Cohorts
Population health worklist
Risk-stratified cohorts with open care gaps, ordered by impact and patient outreach status.
Panel size
1,284
Open care gaps
312
Rising-risk patients
48
Overdue · 90d+
19
Active cohorts
- Diabetes · A1c not measured 12mo42 pts64% outreach
- Hypertension · BP > 140/90 last visit71 pts48% outreach
- CKD stage 3 · ACEi/ARB not on regimen18 pts22% outreach
- ASCVD · statin not prescribed26 pts35% outreach
- Colon cancer screening overdue (50–75)88 pts71% outreach
- Annual wellness visit not scheduled67 pts55% outreach
Today's outreach queue
- M. ChenA1c overdue · last 14mo
- R. SinghBP 152/94 · titrate
- L. BrooksColonoscopy overdue
- T. NguyenStatin candidate · ASCVD 18%