Synthesize knowledge and analyze large, complex care-related data sets to identify those at risk. Manage information that spans multiple stakeholders, including wellness, health and social care organizations. Deliver proactive, individualized care that eliminates unnecessary and preventable inpatient hospital admissions and readmissions. Highlight the most effective evidence-based care protocols for greater economic value and reduced waste. Collaborate over boundaries, including organizational, bureaucratic and technological, to enable individual and population health. Provide coordinated care to individuals as citizens, patients and consumers.