Primary Care / Family Medicine

Own the panel. Close the gaps. Keep the savings.

Primary care is the engine of value-based care. You hold the attributed lives, you are accountable for the quality measures, and you bear the financial risk. But most EHRs give you a patient chart — not a population view. Glance gives you both: the patient in front of you and the 2,000 behind them.

11 HEDIS care gaps tracked automatically. HCC coding with suspected conditions. AWV scheduling with pre-visit prep. Financial dashboards that show your shared savings trajectory in real time.

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Glance — Panel Overview
Dr. Martinez — Panel Summary
Attributed
2,147
Open Gaps
312
AWVs Due
87
RAF Score
1.08
Today's Patients with Open Gaps
Johnson, R. — 9:30am
A1c overdue · Retinal exam · Statin Rx
3 gaps
Patel, S. — 10:15am
BP control · Mammogram due
2 gaps
Williams, D. — 11:00am
AWV scheduled · HCC review
AWV

Purpose-built for the PCP in value-based care

Every feature addresses a workflow that primary care physicians face daily — the Monday morning huddle, the pre-visit chart review, the end-of-quarter quality push.

Care Gap Dashboard

All 11 HEDIS measures in one view: A1c control, BP control, statin therapy, breast cancer screening, colorectal cancer screening, cervical cancer screening, retinal exams, nephropathy screening, depression screening, medication adherence, and AWV completion. Filter by provider, payer, risk tier, or due date. See exactly which patients need what, and when.

HCC Risk Coding

Surface suspected conditions from claims history, problem lists, and lab results that should be coded but are not. RAF score trending by patient and across your panel. Identify patients with declining RAF scores who need condition recapture at their next visit. Pre-visit HCC review sheets for every scheduled appointment.

AWV Scheduling & Prep

Identify every Medicare patient who has not had an Annual Wellness Visit this year. Automated outreach lists sorted by gap count (so the patients with the most to gain get scheduled first). Pre-visit preparation with health risk assessment, medication reconciliation, and open care gaps pre-populated for the visit.

Population Health Dashboard

Risk-stratify your entire panel. See the distribution of high, medium, and low-risk patients. Identify rising-risk patients before they become high-cost. Track utilization patterns — ED visits, inpatient admissions, specialist referrals — across your attributed population. Drill down from population trends to individual patient actions.

Financial Analytics

PMPM cost tracking against benchmarks. Shared savings projections based on current quality scores and utilization trends. FFS rate analysis to identify underpayment. VBC readiness scoring to evaluate new contract opportunities. Total cost of care trending by patient cohort. See exactly where your revenue is coming from and where it is leaking.

Workflows that fit your day

Glance integrates into the rhythms of primary care practice — morning huddles, pre-visit planning, point-of-care decision support, and end-of-day wrap-up.

Morning Huddle

Pull today's schedule with care gaps and HCC opportunities pre-loaded. Your care coordinator sees which patients need labs drawn, which need screening orders, and which have AWV components to complete — before the patient walks in the door.

Point-of-Care via SMART on FHIR

Launch Glance directly from your EHR during the patient visit. See open care gaps, due screenings, medication adherence scores, and suspected HCC conditions without leaving your chart. Close gaps in real time as you address them during the encounter.

Outreach & Panel Management

Generate worklists for your care team: patients overdue for A1c, patients with lapsed mammograms, patients who have not picked up their statin. Assign outreach tasks, track completion, and measure the impact on your quality scores week over week.

Quarterly Performance Review

Provider-level scorecards with quality measure rates, RAF score trends, utilization benchmarks, and financial performance against VBC contract targets. Compare across providers in your group to identify best practices and coaching opportunities.

Quality measures that drive your revenue

In value-based care, quality scores directly determine your shared savings, bonus payments, and penalty avoidance. These are the measures that matter most for primary care.

A1c

Diabetes Control

HbA1c <8% (HEDIS CDC). Track every diabetic in your panel. Surface patients overdue for testing or above threshold.

BP

Hypertension Control

BP <140/90 (HEDIS CBP). Identify uncontrolled patients, track medication changes, flag those lost to follow-up.

BCS

Cancer Screening

Breast, colorectal, and cervical cancer screening rates. Outreach lists for patients due or overdue for screening.

PDC

Medication Adherence

Proportion of Days Covered for statins, antihypertensives, and oral diabetes medications. Identify non-adherent patients before they fall off therapy.