Small Town,
Big Impact

The Challenge

By 2020, BCHC had launched its population health program, but data access and accuracy quickly became barriers to success. Extracting information from their Oracle Health CommunityWorks (Cerner) system was difficult, cumbersome, and time-consuming.

“We needed data we could trust and use in real time. Our providers doubted the accuracy of what they were seeing, and that made it hard to act on performance metrics or track patient outcomes confidently.”

Beverly Nelson, RN - Clinical Quality and Population Health Manager at BCHC. 

The hospital relied on manual Excel spreadsheets to track metrics like A1C levels, blood pressure, and preventive screenings for Blue Cross Blue Shield (BCBS) and MSSP (Medicare Shared Savings Program) programs. Staff would enter each patient’s data by hand, a process that consumed hours each week and limited the organization’s ability to scale value-based initiatives.

With multiple payers, overlapping quality measures, and growing demands for real-time reporting, BCHC needed a unified, automated system that could provide reliable, actionable data across all populations.

The Solution

In 2022, BCHC partnered with i2i Population Health, an Azara Healthcare company, to bring structure and scalability to its population health efforts. Implementing i2iTracks®, BCHC gained a centralized platform to manage quality performance, coordinate care, and 
translate data into daily action across its primary care clinics.

i2iTracks integrates seamlessly with Oracle Health’s CommunityWorks EHR, providing a single view of patient and population health data. The platform supports hundreds of clinical measures and streamlines frontline workflows by surfacing actionable insights, flagging high-risk patients, and helping staff close care gaps efficiently, all within existing clinical routines.

Working closely with the i2i and Oracle Health teams, BCHC designed an implementation that prioritized automation, standardization and visibility. The goal: to replace manual chart reviews and disconnected spreadsheets with a unified, data-driven workflow that informed every patient encounter.

Using i2iTracks, BCHC developed Patient Visit Summaries for Pre-Visit Planning, a pivotal tool that allowed staff to close care gaps using real-time data rather than manual chart reviews. This approach decreased preparation time for visits and ensured patients were up to date on screenings, lab work, and chronic condition follow-up. “It didn’t just give us data, it gave us structure,” said Nelson.

Initially deployed to support BCBS quality measures and MSSP ACO (Accountable Care Organization) metrics, BCHC has since expanded its use of i2iTracks into a payer-agnostic model, allowing the same workflows and dashboards to support all populations. This shift has streamlined data tracking, risk stratification, and quality reporting across the enterprise, laying the groundwork for consistent, system-wide improvement. 

The Results

Since adopting the i2iTracks platform, BCHC has redefined what’s possible for a small rural hospital, transforming its approach to population health from reactive, spreadsheet-driven tracking to proactive, real-time management. Staff can instantly see 
where each patient stands on key measures, and leadership can track performance across all payers with a single click. “Before i2i, we had to hunt for information across multiple systems,” said Nelson. “Now, everything we need for a patient visit is at our fingertips. It’s transformed how we prepare for appointments and follow through on care.” The result is not only operational efficiency but also 
measurable clinical and financial impact.

Significant highlights include:

• Perfect BCBS quality scorecards and increased shared savings through ACO contracts, validating the return on investment for BCHC’s population health strategy.
• Dramatic efficiency gains, freeing care teams from hours of manual data entry and enabling them to focus on direct patient care.
• Significant quality improvement across major measures from 2022 to 2024 as seen to the right.
• Strengthened provider confidence in data accuracy and timeliness, driving broader engagement in quality improvement initiatives.
• A culture shift toward proactive care management—turning data into a daily decision-making tool rather than an end-of-quarter report.

Looking Ahead

BCHC continues to expand its partnership with i2i and Oracle Health to support broader goals around risk stratification, referral management, and population-level cost tracking. Plans to deploy i2iPRiZiM® analytics will enable leadership to further align clinical and financial performance while supporting payer-agnostic reporting.

Building on its success, BCHC is expanding its partnership with i2i and Oracle Health to unlock even deeper insights across the continuum of care. Focused on risk stratification, referral management, and population-level cost tracking, the next phase of their 
population health strategy will help BCHC proactively identify high-risk patients, manage utilization, and reduce avoidable costs. 

The organization also plans to integrate i2iPRiZiM® analytics to strengthen payer-agnostic reporting and align clinical quality with financial performance. By pairing actionable data with local care team leadership, BCHC aims to translate analytics into measurable 
community impact. 

Our goal is simple. Use data to drive smarter care, support our clinicians, and make sure every patient gets the right care at the right time. With i2i, we finally have the infrastructure to make that happen. The next step is using that foundation to push 
preventive care even further and keep our communities healthy for generations to come.

Beverly Nelson, RN - Clinical Quality and Population Health Manager at BCHC. 

As BCHC moves forward, its data journey demonstrates how even the most rural hospitals can use technology, teamwork, and trusted data to deliver big-city performance with small-town heart.