World-leading Population Health Analytics Software

Our proprietary Patient Need Groups (PNGs) categorize patients into 11 mutually exclusive and clinically relevant groups based on comprehensive health needs – beyond individual diseases – enabling targeted care strategies for every patient type.

Machine learning-powered models forecast health outcomes, predict costs and identify hospitalization risks up to 12 months ahead, allowing proactive intervention for rising-risk patients to improve outcomes and prevent high-cost cases.

Seamlessly combines clinical, claims, pharmacy, lab and social determinants data to create actionable insights that go far beyond traditional medical records.

GeoHealth and Social Need Markers identify geographic and social barriers to care, providing insights that are vital to improving outcomes for vulnerable populations.

Pinpoint actionable intervention opportunities – from substance misuse to frailty and care coordination challenges – that can prevent patients from progressing to higher-risk categories.

The ACG System is a comprehensive population health analytics software that uses structured clinical data to assess patient health needs, predict future health risks and guide resource allocation based on patterns of comorbidity. It helps organizations identify at-risk patients and manage care more effectively and efficiently to impact health outcomes.

The ACG System is used globally by health plans, health systems and other large provider organizations, health care IT/analytics companies, government health agencies, and academic institutions.

The ACG System considers a patient's entire experience across primary, secondary and tertiary care settings over a 12-month observation period. Data may be sourced from claims or electronic medical record data. At a minimum, the ACG System requires: patient demographics (including a unique identifier), diagnosis data (ICD-10, SNOMED, ICPC), medications filled (NDC, ATC, dm+d), and procedure codes or activity data. Additional data input such as lab results (LOINC), social determinants of health (SDoH), and supplementary medical files can further enhance insights.

The ACG System was developed by Johns Hopkins clinicians and researchers and is based on nearly 40 years of published and evidence-based academic research. The ACG System takes a whole-person approach in its methodology — based in patterns of disease, as opposed to a single condition or event. The ACG System is clinically grounded and designed to support a wide range of use cases from population health management to predictive modeling and equity-focused interventions.

The system helps identify high-risk patients, rising-risk individuals and care gaps — enabling more targeted interventions. It supports case-mix adjustment and performance monitoring, resource planning, and risk stratification and segmentation to support strategic population health management decision-making.

Yes, the ACG System is designed to be flexible and the output can be integrated into your existing data warehouse, business intelligence tools or EHR systems.

Organizations using the ACG System have reported improved prioritization and triage of patients for care management programs, reduced hospital readmissions and Emergency Department visits, improved clinical health markers and more equitable resource allocation amongst provider practices. Case studies and peer-reviewed research are available upon request.

The ACG System is updated frequently to reflect the latest clinical codes, model improvements and emerging health care trends. We conduct regular mapping updates to account for new codes to be mapped to our risk markers and new product releases as needed based on new research and to meet evolving industry needs.

Yes. Johns Hopkins HealthCare Solutions offers onboarding, technical support and training, as well as consultation services for implementation and building out use cases tailored to individual customers' needs.