Chapter Two

Put Your VBC Data to Work

Your warehouse should not end in another dashboard.

DAX's application layer helps value-based care teams act on the clinical, claims, payer, ADT, and operational intelligence created by the data foundation.

The application runs on top of infrastructure your organization owns.

See It Against Your Data Start With the Foundation

How it works

Data → Insight → Workflow → Outcome

Every capability is organized the same way. If a capability cannot be traced from a data source to an operational outcome, it does not belong in the application.

Transitions of care

Data: ADT discharge event + clinical history + claims
Insight: Readmission risk scored on the discharge, with the TCM compliance clock running
Workflow: Episode lands in the care team's worklist, prioritized by risk
Action: Interactive contact inside the required window, then the face-to-face visit
Outcome: Fewer avoidable readmissions and defensible TCM billing

Risk adjustment

Data: Claims diagnosis history + clinical documentation + encounter schedule
Insight: Suspected conditions surfaced with the evidence they were drawn from
Workflow: Coders confirm or dismiss; confirmed suspects route to the provider
Action: Provider documents at the next visit; coder validates support
Outcome: Accurate RAF capture that holds up under audit

Quality gap closure

Data: Labs, diagnoses, procedures, and payer gap files
Insight: Open measures by patient, provider, and contract
Workflow: Gaps drive outreach campaigns and point-of-care lists
Action: Staff schedule and complete the qualifying service
Outcome: Measured performance with provider attestation on file

Contract performance

Data: Normalized claims across payers + attribution + benchmarks
Insight: PMPM, utilization trend, and risk-versus-cost segmentation
Workflow: Drill from an executive dashboard down to the patient driving it
Action: Operational intervention while the performance year is still open
Outcome: Fewer surprises at settlement

Capabilities

What the application covers

Each of these resolves to a work queue, an alert, or a report somebody owns — not to a tile on a landing screen.

Population health analytics

Executive dashboards and population snapshot
KPI monitoring with real-time metrics
Risk stratification across the attributed population
Drill-down from any measure to the patient level

Patient Hub

A 360° longitudinal record across clinical, claims, and ADT
Conditions, medications, labs, vitals, encounters, allergies
Risk score, open care gaps, and financial summary in one view
Unified activity timeline with deep links into every workflow

Care coordination

One prioritized work queue across every workflow
Risk-based prioritization so the highest-impact work surfaces first
Assignment, ownership, and SLA tracking
Bulk actions for high-volume outreach

Quality measurement & gap closure

HEDIS and contract quality measure tracking
Care gap identification, closure, and provider attestation
Measure-year tracking with standardized value sets
Outreach outcome capture tied back to the measure

Care planning

Structured care plan authoring
Goals, interventions, and problem lists
Care team assignment and progress tracking

Risk adjustment (HCC)

Condition suspecting from claims and clinical documentation
RAF capture and recapture tracking by model year
Evidence-linked coding support with clinician confirm or dismiss
Every suggestion traceable to the record it came from

Transitions of care

Discharge tracking from real-time hospital events
TCM compliance windows with the clock visible to the team
Interactive contact and face-to-face visit tracking
Readmission risk scoring, including LACE

Patient outreach & engagement

Campaign workflows built on cohorts you define
Configurable trigger rules without engineering involvement
SMS, voice, and email with delivery tracking
Consent and quiet-hours handling built in
Call outcome capture with clinical context for the caller

Access & scheduling

Online booking against live provider availability
Appointment hold and waitlist management
Two-way calendar sync with the EHR
No-show tracking and follow-up

Patient self-service

Identity-proofed portal access
Self-scheduling
Secure messaging

Membership, eligibility & attribution

Enrollment, eligibility, and roster management
Member 360 with payer and line-of-business views
Attribution across Medicare Advantage, Medicaid, commercial, and duals

Cost & utilization analytics

PMPM and total cost of care trending
Risk-versus-cost segmentation
Readmission and utilization analysis
Cohort cost and outcome comparison

Provider & staff performance

Staff productivity and caseload views
Provider scorecards including wRVU
SLA attainment and period-over-period comparison
Outreach yield and effectiveness, exportable for review

Governance

Access control that survives an audit

Every screen in the application enforces the same rules, because they are applied at the data layer rather than in the interface.

Role-based access control
Patient-level row security
HIPAA access logging and full audit trail
Hierarchy filtering: organization → payer → line of business → practice → provider
EHR-agnostic and all-payer by design

The hierarchy

The application consumes the foundation. It does not own it.

This is the part that matters when you are three years into a contract and your priorities have changed. If the application owns the data, replacing the application means rebuilding everything underneath it. If the foundation is yours, replacing the application is a procurement decision, not a migration project.

So: run DAX's application if it fits. Run the BI stack your analysts already know. Build something internally. Point an AI agent at it later. The foundation does not care, and neither do we — that is the whole point of building it this way.

Compare this to the alternatives

Bring your own data to the demo.

Generic demos are easy to make look good. Show us a contract you are accountable for and we will talk about what the workflow would actually look like on your data.

Discuss Your Data Environment Reference Architecture