For hospitals

Your readmission penalty is being decided in clinics you don't control.

We partner with the primary care practices your discharged patients actually go home to. You get a real closed loop, not a fax confirmation, not a "we tried to call." Documented, attributable, HRRP‑aligned.

Discharge → PCP, not into the void.

Every discharge in your catchment shows up on a named clinician's worklist within 24 hours, with risk score and SDOH context attached.

7‑day visit + 30‑day check, tracked.

TCM-aligned milestones, surfaced as overdue/due, with a single pane the hospital case management team can audit.

HRRP‑aligned reporting.

Cohort-level readmission deltas by condition, by site, by PCP panel. Not a marketing dashboard - the numbers your CFO actually quotes.

What you get

A clean operational picture, not another dashboard to ignore.

Hospital edition: discharge queue, ED revisit list, HRRP cohort view, ROI calculator
Single‑signature ROI / LOI templates designed for fast partner review
BAA‑ready, no PHI leaves the partner clinic without explicit ROI
30 / 60 / 90‑day pilot with a defined exit if numbers don't move

Epic & EHR integration

Built to plug into Epic, without a six‑month IT project.

We meet hospitals where their integration team actually is. Three doors in, pick whichever your team can sign off on this quarter.

Production path

SMART‑on‑FHIR (Epic, Cerner, Meditech)

Standard OAuth2 + FHIR R4. Reads Patient, Encounter, Condition, MedicationRequest, DocumentReference. Writes back the post‑discharge note as a DocumentReference. Launches inside Epic Hyperspace or standalone, no second login.

Real‑time trigger

ADT feed (HL7v2 or FHIR Subscription)

We accept A03 (discharge) and A08 (update) over your existing Mirth / Rhapsody / Corepoint interface, or via Epic Bridges. The PCP worklist updates the moment the patient leaves the building.

Pilot fallback

Daily CSV / SFTP drop

If FHIR app review will take a quarter, we start with a signed daily discharge file over SFTP. Same workflow on day one, swap to FHIR when App Orchard / Showroom clears.

What we don't do: overstate our App Orchard / Epic Showroom status. We are an active developer with a working SMART‑on‑FHIR client and are happy to share our security posture, BAA, and reference architecture under NDA. For pilots, the CSV path gets us live in days while the full marketplace path runs in parallel.

See the LOI we use with hospital partners.

Plain English, single signature, ninety‑day exit. Most CMOs read it in one sitting.

Request the LOI