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Solutions
Description
Compatibility Level
Clients
Product Capabilities
Use cases
EHR integrations
Client types
Differentiators
Health equity
Keywords
Media
Company details
Jump to:
Categories
Solutions
Description
Compatibility Level
Clients
Product Capabilities
Use cases
EHR integrations
Client types
Differentiators
Health equity
Keywords
Media
Company details
HealthVision
HealthVision

Categories

Solutions

Description

Product Description:

OnCare360 addresses the patient’s journey between point-of-care visits with a continuous care management platform that captures and transmits daily health data through devices, wearables, and patient interactions. OnCare360 takes a 360-degree approach to managing value-based care by combining Care Management (CCM, RPM, TCM, PCM, RTM), medication, adverse event, and general wellness, clinical communication, and data analytics to create a circle of support between patients, providers and payers.

About OnCare360 Inc.:

OnCare360 addresses the patient’s journey between point-of-care visits with a continuous care management platform that captures and transmits daily health data through devices, wearables, and patient interactions. OnCare360 takes a 360-degree approach to managing value-based care by combining Care Management (CCM, RPM, TCM, PCM, RTM), medication, adverse event, and general wellness, clinical communication, and data analytics to create a circle of support between patients, providers and payers.

Product Description:

HealthVision, the Intelligent Health Management System, is transforming care across health systems and value-based care organizations. HealthVision is made up of three key components:

*The Intelligent Health Record - what if you could see critical information from hundreds of EHR pages in a one-page patient chart and risk summary that serves the entire care team? HealthVision's Patient Spotlight is an easy to digest health profile and risk prediction tool. The Patient Spotlight helps clinicians make sense of the increasingly unwieldy and unmanageable health data in their EMRs in real-time.
*The Intelligent Workflow Solution - who among your patients will have an unplanned admission in the next 90 days? An ED visit in the next 30 days? The Intelligent Workflow Solution includes smart cohorts and rosters that align your scarce clinical, documentation, and administrative resources with the patients who will benefit the most. 

*The Intelligent Analytics Solution - how do your providers' mortality, hospitalizations, infection rates compare? Can your benchmarking system really match apples to apples? The Intelligent Analytics solution matches your population to others outside of your organization with the same baseline risk results. These precise comparisons are an important way to build trust and momentum among providers. 

About Health Data Analytics Institute:

HDAI is a high-growth, visionary company with innovative solutions that free up clinical time, enhance the provider experience, and support outcomes, efficiency, and economic improvement initiatives for health systems and value-based care organizations. 

Compatibility level

Select which hospital or health system you work at and see a personalized compatibility level.

Clients

Select which hospital or health system you work at and see the client list

Product Capabilities

OnCare360 collects a wide range of data, including clinical information such as vital signs, diagnoses, medications, and post-discharge details; care management data like time spent on coordination and care plan updates; and patient-generated health data from RPM and RTM devices. It also gathers social determinants of health (SDOH) data, including housing, transportation, and other socioeconomic factors, along with behavioral health metrics such as mental health screenings and care plans. Preventive care data, such as Health Risk Assessments (HRA), Fall Risk Assessments (FRA), and Advance Care Planning (ACP) directives, are also collected, as well as engagement data from patient portals, communication logs, and reminders. Additionally, OnCare360 tracks billing and compliance data, including CPT codes and audit-ready documentation.

OnCare360 provides advanced analytics to support comprehensive care management and decision-making. These analytics include real-time dashboards for tracking patient outcomes, care plan adherence, and program performance across RPM, CCM, TCM, and other CMS programs. Risk stratification tools identify high-risk patients for targeted interventions, while utilization metrics assess resource efficiency and care delivery effectiveness. The platform also offers insights into social determinants of health (SDOH), highlighting barriers to care and tracking the impact of interventions. Additionally, OnCare360 generates compliance reports, billing accuracy metrics, and CPT code utilization summaries to ensure regulatory alignment and optimize reimbursements. This robust analytics suite enables providers to measure outcomes, improve workflows, and deliver data-driven care.

OnCare360 enables seamless bidirectional communication between healthcare providers, patients, and care teams to enhance coordination and engagement. The platform integrates secure messaging, patient portals, and real-time alerts to facilitate ongoing interactions. Providers can send care plan updates, educational materials, appointment reminders, and alerts to patients directly through the system, while patients can respond with questions, upload health data, or report symptoms via the portal or integrated communication tools. For care teams, OnCare360 supports collaborative workflows, allowing providers, nurses, and social workers to share updates, assign tasks, and communicate in real time. This two-way communication ensures that all stakeholders stay informed and aligned, fostering timely interventions and better care outcomes.

OnCare360 ensures providers can engage eligible patients through cellular-connected devices, eliminating the need for Wi-Fi and enhancing accessibility for underserved populations. For patients with higher technical literacy, OnCare360 offers an intuitive mobile app to streamline access to care plans, reminders, and educational resources. This combination ensures tailored engagement for diverse patient needs.

OnCare360 offers pre-built, condition-specific care plans and pathways that are fully customizable to meet the unique needs of each patient. These templates are designed to support clinical decision-making and streamline patient engagement, providing actionable guidance for care delivery. Integrated directly into the platform, these care plans align with automated workflows, ensuring seamless implementation while enabling providers to personalize interventions, enhance adherence, and optimize outcomes with ease.

OnCare360 seamlessly integrates with existing EHR systems, supporting both HL7 file-based integration and SMART on FHIR protocols. This interoperability ensures smooth data exchange, enabling providers to synchronize patient information, care plans, and clinical workflows directly within their EHR environment. By leveraging industry-standard frameworks, OnCare360 enhances operational efficiency and reduces duplication of effort, allowing healthcare teams to focus on delivering high-quality, coordinated care.

OnCare360 streamlines logistics management, staff training, patient onboarding, and ongoing tech support to enhance the clinician and patient experience. The platform provides intuitive workflows that simplify patient onboarding, ensuring smooth enrollment in care programs with minimal administrative effort. Staff training modules offer step-by-step guidance on using OnCare360’s features, enabling care teams to adopt the platform quickly and effectively. Additionally, the system includes robust tech support, with dedicated resources to address patient and provider needs, reducing disruptions and ensuring seamless operation.

OnCare360 leverages AI-based assistants, tailored learning content, and educational materials to engage patients and support behavior change. The platform delivers personalized insights, automated reminders, and easy-to-understand resources, empowering patients to track progress, set goals, and stay motivated in achieving better health outcomes.

Use Cases

Description:

• A primary care practice is overwhelmed with the administrative burden of managing a large population of patients with chronic conditions like diabetes and hypertension. Care plans are outdated, follow-ups are missed, and staff struggle to accurately track time for billing compliance with Chronic Care Management (CCM) services. This results in poor patient outcomes and underutilization of reimbursement opportunities.

• A cardiology practice focuses on managing patients with advanced heart conditions but faces challenges in coordinating Principal Care Management (PCM) for these high-risk individuals. Providers find it difficult to track detailed interactions, update care plans, and collaborate with primary care teams, leading to gaps in care and reduced efficiency in managing a single complex condition.

• A regional hospital experiences high readmission rates and struggles to optimize patient length-of-stay due to ineffective Transitional Care Management (TCM). Many patients discharged after acute care fail to schedule follow-ups, adhere to discharge instructions, or receive timely medication reconciliation. Additionally, inefficient discharge planning leads to extended hospital stays, straining resources and affecting patient flow. Without a centralized system to monitor post-discharge care, track follow-up visits, and coordinate transitions, the hospital faces challenges in improving recovery outcomes, reducing readmissions, and achieving value-based care benchmarks.

• A rural health clinic struggles to monitor patients with chronic diseases due to limited access to in-person care and delayed identification of worsening symptoms. Patients are often unaware of their health trends, leading to avoidable complications. The clinic needs a solution to integrate FDA-approved RPM devices and deliver real-time insights for timely interventions.

• A payvider serving a diverse population finds that many patients face significant social determinants of health (SDOH) barriers, such as transportation challenges, food insecurity, and housing instability. These barriers prevent patients from adhering to care plans and attending follow-ups, resulting in increased healthcare costs and poor outcomes. The organization lacks tools to systematically capture and address these non-medical factors.

Pediatric use cases:

None provided

Users:

Physician Practices, Hospitals, Health Systems, Accountable Care Organizations, Primary Care Providers, Speciality Providers

Description:

Continuity of care, care management, and care optimization; clinical operations, clinical performance, pre-visit and pre-surgery planning; post-acute network management; network, market, and financial performance and insights; population health management and value-based care; quality and safety: 

*Embedded EHR predictors enterprise-wide (ambulatory and inpatient settings) 

*Hundreds of predictive models built on HDAI’s baseline risks​ - delivery of baseline, encounter-based risks 

*Ambulatory clinical decision support​ - risk predictions for patients with consult visits to support decisions about the right clinical next step

*Discharge planning​ - evaluating discharge and next-site-of-care decisions, including SNF/HHA performance insights

*Post-discharge follow-up protocols​ - ensuring the highest-risk patients receive an appropriate share of support after discharge​

*Peri-operative adverse event risk management - focus visits around a patient’s areas of highest risk to enable optimization that improves expected surgical outcomes​

*Contracting and network design support​ - sophisticated network analytics to support decisions for provider performance, recruitment, and network optimization

*ACO patient targeting​ - smart cohorts focused on demonstrated areas of highest opportunity to enable high-ROI, precise interventions by care managers​

*Collaborate on diagnostic-grade models​ - partnership between data science teams to leverage new data sets to build diagnostic-grade models 

Pediatric use cases:

None provided

Users:

Clinicians, clinical care teams, and care managers; C-suite executives; Innovation and Quality leaders; Chief Medical Officers; Population Health leaders; Chief Nursing Officers; support/office staff 

EHR Integrations

Integrations:

Acute care EMR, Ambulatory EMR, ADT, Website / public online sources

EMR Integration & Relevant Hardware:

Recommended, but not required

EMRs Supported:

Epic, Cerner, eClinicalWorks, Allscripts, Meditech, NextGen, Athenahealth

Hardware Compatibility:

Desktop, Mobile / Tablet (web optimized), Mobile / Tablet (native app), Other

Integrations:

Acute care EMR, Ambulatory EMR, Ancillary EMR

EMR Integration & Relevant Hardware:

Use case dependent

EMRs Supported:

Epic

Hardware Compatibility:

None provided

Client Types

Differentiators

Differentiators vs EHR Functionality:

OnCare360 enhances care management by addressing key gaps:

1. Comprehensive Care Management: Specialized tools for CMS programs like CCM, RPM, TCM, and SDOH, including workflows, time tracking, and care plan templates.

2. Automated Compliance: Built-in CPT code tracking and billing workflows ensure accurate reimbursements and CMS compliance.

3. Patient Engagement: Offers portals, reminders, and secure messaging for proactive communication and improved adherence.

4. Advanced Analytics: Real-time dashboards track care outcomes, program performance, and at-risk patients.

5. SDOH Integration: Dedicated tools to assess and address social barriers to care, linking patients to resources.

OnCare360 complements EHR systems by focusing on care delivery, compliance, and patient-centric tools.

Differentiators vs Competitors:

OnCare360 stands out with its comprehensive, integrated platform designed to streamline workflows and improve patient outcomes:

1. All-in-One Platform: Combines tools for RPM, CCM, TCM, PCM, AWV, SDOH, ACP, and more, eliminating the need for multiple systems.

2. Program-Specific Features: Tailored workflows, care plan templates, and automated time tracking for each CMS program ensure ease of implementation and compliance.

3. Patient Engagement Tools: Secure portals, reminders, and educational resources promote adherence and satisfaction, surpassing basic communication solutions offered by competitors.

4. Compliance Automation: Preloaded CPT codes, billing accuracy checks, and audit-ready documentation reduce errors and maximize reimbursements.

5. SDOH and Holistic Care: Advanced tools to assess and address non-medical factors, linking patients to resources and improving health equity.

6. Scalability and Flexibility: Suitable for small practices, large health systems, and ACOs, with customizable workflows for diverse needs.

7. Real-Time Insights: Analytics dashboards provide actionable data on care outcomes, performance metrics, and patient risks.

OnCare360 delivers unmatched versatility, compliance, and patient engagement features.

Differentiators vs EHR Functionality:

HDAI uses GPT/LLM and AI predictive models to dynamically canvas the EHR to extract, synthesize, and risk prioritize the most relevant information. HealthVision™ allows clinicians to effectively focus on care planning instead of searching the EHR. 

The EHR has changed the way we practice medicine, burdening clinicians with mountains of data and forcing them to spend their precious time in front of computers instead of with their patients. When the healthcare industry first transitioned paper records to electronic, the intention was to have all patient data accessible in one place, alleviating the healthcare system of cumbersome physical storage spaces for medical records and administrative staff to manage it. ​

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However, the EHR has overburdened clinicians with documentation tasks that were once allocated to administrative professionals ​and has clinicians combing through an inordinate amount of disparate and disorganized data to find relevant patient information. 

Differentiators vs Competitors:

HealthVision is the first and only enterprise-wide, AI-powered intelligent health management system and is currently being used by Houston Methodist and other leading healthcare systems and ACOs. The platform has a broad range of capabilities which combined create a unique ability to address healthcare challenges across the care continuum (outpatient, inpatient, post-acute, etc.).

It simplifies information retrieval for clinicians, distilling hundreds of pages and notes for an individual patient in a typical electronic health record into an AI-synthesized one-page, individually configurable view that summarizes a patient’s medical history and granular risk profile. ​

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It allows a health system or risk bearing provider entity to identify and proactively manage patients at high risk of dozens of adverse events and excess utilization, including readmissions, extended length of stay and mortality. ​

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It enables sophisticated performance and network analysis. Using the nation’s largest longitudinal dataset (140 million patients, 0.5 trillion records), we have developed detailed performance profile on every physician and health care facility in the country.​

In addition to running Generative-AI and 100s of predictive models in real-time within the EHR environment, HealthVision is also designed to enable rapid deployment of local institutional models allowing agile and cost-effective real-time implementations of internally developed AI solutions.​

Health Equity

To avoid complex sources of bias, we do not include social drivers of health and race information in our AI models. Instead, we leverage our models and our digital twinning methodology to detect bias and identify differences in outcomes and performance related to health equity and access. This information allows us to quantify biases in current practice and help organizations address it in the future.

HDAI leverages controls from NIST, HIPAA, and ISO 27001 frameworks to build our Information Security Program (ISP.) The company maintains annual SOC2-Type II and bi-annual HITRUST CSF r2 Validated audit certificates to verify the strength of our program. The most recent HITRUST CSF version completed is v11.0 (both reports available upon request.)

HDAI's customer success team is the primary support for our end users. Responses are fielded and addressed asap and product updates are released and communicated in a timely fashion.

Keywords

Images

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Videos

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OnCare360 TCM Patient Education Video.mp4

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The Intelligent Health Record

Downloads

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OnCare360 CCM.pdf

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Company Details

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