ACOs & CINs
Population stratification and gap closure across networks.
Population Health
Population Health Management
We build platforms that turn scattered clinical and claims data into a ranked view of who needs care next — risk stratification, care-gap detection, and value-based-care analytics on a governed FHIR R4 foundation.
HIPAA-ReadyFHIR R4HEDIS-AlignedAudit Logged
Trusted by global innovators
What population health software has to solve
Population health management is a targeting problem: with limited care-management capacity, which patients get outreach first? Answering that means unifying claims, EHR, ADT, lab, and SDOH data, then stratifying the population by risk so the highest-need, most-actionable patients rise to the top. Spreadsheets and disconnected registries can't keep that view current or defensible.
We build population health platforms on a FHIR R4 data foundation where risk stratification and VBC analytics run on governed, traceable data. Care gaps are detected against measure specifications, rising-risk patients are surfaced before they become high-cost, and every list a care manager works can be traced back to the data that produced it.
What it is
Knowing who needs care before they need the ER
Population health management software unifies data across a population and ranks patients by risk and actionability so limited care-management capacity goes where it moves outcomes and cost the most.
It succeeds when the lists it produces are trusted and acted on. We build platforms on governed, traceable data so risk stratification and VBC analytics survive clinical and financial scrutiny.
From raw feeds to a ranked care list
Risk stratification, care-gap detection, and VBC analytics on one governed data layer — so outreach goes where it matters.
What we build into your population health platform
Each capability pairs a population-health outcome with the data standard or model behind it.
Risk stratification & rising-risk models
Predictive and rules-based risk stratification across the population — HCC and clinical risk scores plus rising-risk identification — so care management targets patients before they escalate to high-cost events.
Care-gap detection
Open-measure detection against HEDIS and eCQM specifications, surfacing overdue screenings, uncontrolled conditions, and missed follow-ups with prioritized worklists for outreach teams.
VBC analytics & cost insights
Value-based-care analytics on total cost of care, utilization, and quality performance, tied back to the risk-adjusted population so trends are meaningful rather than raw counts.
FHIR R4 data aggregation
A governed data layer unifying EHR data via FHIR R4, HL7 v2 feeds, claims, ADT event streams, and lab results, with patient matching and lineage so every metric is traceable.
SDOH & equity insights
Social-determinants data integrated into stratification so risk models reflect access, housing, and food-security factors, with equity-stratified reporting for accountable programs.
Registries & outreach workflows
Condition and program registries — diabetes, CHF, hypertension — with campaign and outreach tooling so identified patients move into action, not just a dashboard.
Where it runs
Population health use cases
Health plans
Member risk targeting and Star-measure improvement.
Provider groups
Panel-level risk and care-gap management for clinics.
FQHCs & community health
SDOH-aware outreach for underserved populations.
Chronic disease programs
Diabetes, CHF, and hypertension registries and outreach.
Public health
Population surveillance and program targeting.
Where population health software delivers
Impact comes from targeting the right patients with limited capacity. We build for actionable, traceable stratification — targets are defined against your programs in discovery.
FHIR R4
Governed multi-source data foundation
HCC
Risk-adjusted stratification
HEDIS
Care gaps detected to measure spec
Compliance-First Healthcare App Development Services Backed by Global Standards
15-Minute Scoping Call01
HIPAA
Health Insurance Portability and Accountability Act
Protect PHI with privacy-first architecture, encrypted storage and transmission, strict access controls, and traceable audit logs.
02
GDPR
General Data Protection Regulation
Implement lawful consent flows, data minimization, retention controls, and secure processing for sensitive health data.
03
FHIR
Fast Healthcare Interoperability Resources
Enable standardized health data exchange across apps, care teams, and systems through robust FHIR-ready APIs.
04
HL7
Health Level Seven International
Support enterprise-grade interoperability with HL7-based integrations for records, events, and clinical messaging workflows.
05
HITRUST
Health Information Trust Alliance
Align security programs to healthcare-specific control and risk management practices trusted by providers and ecosystem partners.
06
HITECH
Health Information Technology for Economic and Clinical Health Act
Design with breach notification readiness, digital record safeguards, and operational controls that support regulated care programs.
07
SaMD
FDA Software as a Medical Device
Plan software quality, traceability, and documentation pathways for products that may require SaMD review and submission.
08
MDR (EU)
Medical Device Regulation (European Union)
Prepare EU market-ready processes for risk classification, evidence tracking, and lifecycle governance under MDR expectations.
09
SAMHSA
Substance Abuse and Mental Health Services Administration
Apply confidentiality controls and consent-aware sharing models for behavioral and mental health data experiences.
Standards we build against
Population health standards
FHIRHL7HEDISeCQMHCCHIPAA
Our Process
How we deliver a population health build
Data aggregation, stratification models, and outreach workflows run in parallel toward an actionable platform.
1.
Population & data discovery
We map your populations, programs, and data sources, then design the patient-matching and risk-stratification approach before building.
Population-aware
2.
Data foundation
We build the FHIR R4 data layer aggregating EHR, claims, ADT, and lab feeds, with patient matching and lineage the analytics depend on.
Governed data
3.
Stratification & gaps
Risk models, care-gap detection, and registries, validated against clinical review so the rankings are trusted by the teams that act on them.
Actionable lists
4.
Outreach & go-live
Worklists, outreach tooling, and dashboards, with ongoing tuning as measure specs and programs change.
Always audit-ready
Featured case study
Read Case StudyLera Health: compliant women's health platform
Related proof of compliant delivery: Lera Health isn't a population-health platform, but building its data-driven, personalized care workflow shows how we turn multi-source health data into trustworthy, traceable insight — the same foundation stratification depends on.
Why Partner With Us
15-Minute Scoping CallWhy care organizations pick Agnotic
We bring data-engineering depth, measure fluency, and compliance-first design so your risk lists are trusted and your analytics are defensible.
Governed & Traceable
Every risk score and care gap traces back to source data with lineage — care teams trust lists they can inspect.
Data & Measure Fluency
FHIR aggregation, patient matching, HEDIS, and HCC logic are our baseline, not a research project billed to you.
From Dashboard to Action
We build the outreach and worklist layer so identified patients actually get contacted, not just counted.
Equity-Aware Design
SDOH integrated into stratification so programs target need, not just billing signals.
Our relevant experience
Analytics that move patients into care
Frequently Asked Questions
Cost is driven by data-source count, patient-matching complexity, and the depth of risk and measure logic; a real build typically starts in the mid six figures. We scope against your populations, programs, and available feeds in discovery and share a range.
Ready to target care where it counts?
Tell us your populations and data sources. We'll return a population-health plan with data-foundation scope, stratification approach, and a realistic timeline.
contact@agnotic.com
Partnerships
contact@agnotic.com