Health Insights

Population analytics across 2,847 patients

+2.1%

94.2%

Controlled BP

+4.3%

87.8%

Medication Adherence

-0.2%

7.1%

Avg A1C

-0.8%

3.2%

30-Day Readmission Rate

Trends Over Time

89%

Sep

90%

Oct

91%

Nov

90%

Dec

92%

Jan

94%

Feb

BP Control Rate

81%

Sep

82%

Oct

83%

Nov

84%

Dec

86%

Jan

88%

Feb

Adherence Rate

5.8k

Sep

5.9k

Oct

5.6k

Nov

5.4k

Dec

6.1k

Jan

6.4k

Feb

Avg Daily Steps

4.8%

Sep

4.5%

Oct

4.2%

Nov

4.0%

Dec

3.6%

Jan

3.2%

Feb

30-Day Readmission Rate

Cohort Breakdown

4 cohorts

Diabetes

847 patients

7.1% Avg A1C

82% Adherence

12 Alerts

Hypertension

1,203 patients

128/82 Avg BP

94% Controlled

8 Alerts

Cardiac

392 patients

23 AF Episodes

74 Avg HR

5 Alerts

Respiratory

285 patients

47 Reports

96% SpO2 Avg

3 Alerts

Risk Stratification

2,847 patients

4.5%

10%

66.4%

19.1%

High Risk

Uncontrolled conditions, frequent ED visits

127 patients

Rising Risk

Declining metrics, adherence drops

284 patients

Moderate

Stable with active management

1,891 patients

Low Risk

Well-controlled, self-managing

545 patients

Wearable Analytics

847 devices

Apple Watch

462

Dexcom

213

Withings

Other

6,420 Avg Daily Steps

6.8h Avg Sleep Quality

68 Avg Resting HR

Device Sync Rate: 98.2% — All systems operational

Cohort Alerts & Recommendations

4 active

12 diabetic patients showing upward A1C trend — Consider outreach

Flu season spike: 8% increase in respiratory symptoms reported

34 patients with declining medication adherence this month

Sleep quality declining in cardiac cohort — avg down 0.5h this month

Top At-Risk Patients

Showing top 10

Patient	Risk Score	Primary Condition	Key Alert	Trend	Action
Robert Johnson MRN: 847291	92	Atrial Fibrillation	AF episodes 3x/week, increasing	Worsening	View Twin
Maria Garcia MRN: 592847	89	Hypertension	BP 185/110 sustained	Worsening
James Williams MRN: 738492	87	Type 2 Diabetes	Recurrent hypoglycemia <55 mg/dL	Worsening
Susan Miller MRN: 592018	85	CHF	Weight gain +8lbs in 2 weeks	Worsening
Emily Davis MRN: 629481	78	Cardiac	Chest tightness + SOB pattern	Rising
Michael Brown MRN: 847261	76	Cardiac	Potential warfarin interaction flagged	Stable
Patricia Moore MRN: 418293	74	Type 2 Diabetes	A1C trending upward 7.2 → 7.8	Rising
David Lee MRN: 305718	72	Type 2 Diabetes	Medication adherence dropping (GI issues)	Rising
Jennifer Taylor MRN: 692014	70	Autoimmune	Complex symptom pattern — fatigue, rash	Evaluating
Thomas Anderson MRN: 841027	68	Hypertension	Borderline BP control, sleep declining	Improving

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