🏥 1 patient, 100 front doors

Fragmented care. Virtual-first entry points. And one ambient layer that can document all of it.

Blake Madden Jun 29th, 2026 Read in browser

In partnership with Happy Monday, Hospitalogists! When CMS’s ACCESS Model goes live July 1, a wave of 150+ tech-enabled organizations are about to need ambient documentation capability they don't have. That's just the policy-level version of a bigger structural problem: patients are fragmenting their care across virtual-first and in-person settings, and the ambient documentation layer hasn't caught up. Nabla has been quietly building for exactly this. Today I'm breaking down why Nabla's bet on true adaptability — with consistency across care settings, EHR stacks, and patient access points — positions them well for where this market is heading. I’ll also share why it matters for primary care, FQHCs, and anyone trying to serve a patient who walks through more than one front door. One Patient, A Hundred Front Doors Why Nabla built for flexibility before the rest of healthcare admitted it had to. TL;DR: One of the biggest themes in health tech this year is ambient AI’s evolution and expansion across different care settings. What first started at the big health system is now permeating throughout all healthcare services. Patients now assemble their own care across a PCP, a DTC weight-loss brand, a virtual menopause clinic, and other modalities. But often virtual first. As AI expands, Nabla's bet is on adaptability for what their partners need. Nabla Echo keeps documentation consistent whether the visit happens in an exam room or over video or by phone. Nabla Connect, its connective API customers love, enables rural providers and other groups to engage and build meaningfully in ambient capabilities. CMS's ACCESS Model goes live July 1 and pulls a wave of tech-enabled entrants into Medicare, putting a premium on virtual-first documentation and the onus back on primary care — an area of multi-modality Nabla excels in. Allow Me to Reintroduce Nabla Last year I wrote about Nabla restoring the joy of medicine and what they as a team stand for. The Product Love Slack channel, four years of fine-tuning against real clinic workflows, the whole approach pointed at the clinician instead of the buyer. All of that is still true, but what's changed (drastically) since I wrote it is the shape of the patient given the prevalence of consumer AI. In primary care, patients are acting more like consumers than they ever have before, and this shift will only continue. Someone keeps a PCP inside a health system, fills GLP-1 scripts through a telehealth brand they saw on TV, books a virtual menopause clinic advertised on the subway. A meaningful share of mental health visits happen over video now. Care across these accessible modalities and virtual first entry points is fragmenting. Patients Built Their Own Care Networks. Records Didn't Follow. This fragmentation creates a unique problem for both the health system but really any provider trying to meaningfully engage a patient longitudinally (PCPs, etc.). Each patient touchpoint generates documentation, and almost none of it talks to the rest. A menopause script doesn't exist in a vacuum. It interacts with everything else you're taking. But the note describing it has to actually reach the PCP for any of that to matter. Most ambient AI went to market targeting the enterprise first with integrations and EHR alignment. Vendors went straight at large health systems, often selling to someone who isn't in clinic on a given Tuesday, and assumed the encounter happens in a brick-and-mortar room wired into Epic or Cerner. And there’s nothing wrong with this approach. It’s a fine market with ARR for the taking. But the virtual-first brands capturing all this fragmented demand aren't running Epic, nor are the rural health providers. Most of these guys are running systems that were never built to handle the complexity of what they're now being asked to do. So as ambient has evolved, and as primary care has fragmented, we’re seeing a real need for accessible ambient documentation across virtual-first and rural settings. Adaptability Is Nabla’s Bread and Butter The ambient world is a dog fight, and everyone wants the scrap the butcher tossed out behind the shop. Nabla has quietly focused its team on adaptability for whatever their customer is looking for. Their original differentiator was tenacious focus on the end user — the physician or clinician — and customization at this clinician level. An ER doc wants exhaustive capture. A PCP wants the opposite — contextualized, current information with concise takeaways. Problem-oriented, in and out. Every physician or clinician, across care settings, across specialties, wants something different. Every. Single. One. So Nabla took that same flexibility instinct and doubled down on it, infusing this adaptability into its platform. Nabla’s tech keeps telehealth documentation consistent with in-person care, so the note looks and behaves the same no matter where the visit happened. Echo captures the video visit (it is not the video platform itself) and keeps the documentation coherent across whatever channel the care arrives through. Tia Health is a good example of Nabla’s partnership. A women's-health model that runs hybrid and virtual, and purpose built this way by design. They cut clinical note submission time by 50% on Nabla — proof a non-traditional, non-Epic care model can stand the ambient layer up and have it actually work. Enterprise Logos, FQHC Math One thing I genuinely appreciated in talking with the team: Nabla cares, plain and simple. They aren't only chasing enterprise ARR. Yes, of course if they had it their way they would want to win every big IDN that rolls through with an RFP. But really when sitting down with the Nabla team for this piece, they shared a stat that stuck with me from a community health center. An FQHC. After rolling out Nabla, revenue cycle compressed from 40 days to 7. They surfaced roughly $250K that had been leaking out the back through unclosed notes and staff turnover. Think about a clinic running at a loss to potentially breakeven, implementing new tech, and finding $250K more to work with on an annual basis. This kind of result with technology is why I’m optimistic about rural health transformation despite the entirety of the talking heads in the industry bemoaning the state of rural hospitals. Here’s a solution with promise. Do something about it. Across the spectrum of care delivery, Nabla is there. A tiny safety net clinic. A virtual startup's homegrown stack. University of Iowa Health Care, where Nabla has generated north of 798,000 encounter notes at a 75% week-over-week engagement score. Nabla is flexible because it was built by people paying attention to the clinician, not the buyer. Two points that make this case: Clinician-first mentality — A product shaped around individual clinician preference is structurally more adaptable than one shaped around a single EHR’s API. Product Love Channel — A vendor that tracks product love at the individual clinician level (not NPS, not renewal rates) is organized around a different signal than its competitors. A Note On ACCESS ACCESS demands virtual first by virtue of payment alone. The model goes live July 1 — a 10-year, outcomes-aligned program paying tech-enabled organizations to manage chronic conditions like hypertension, diabetes, MSK pain, and depression. A lot of the participating orgs have never served Medicare beneficiaries. They’ve never documented in a way anyone outside their own four walls would read. ACCESS pays referring and primary care clinicians a co-management fee to review updates flowing from these new entrants. So a note generated inside some wearables company now has to land, legibly and on time, inside a primary care workflow. And Medicare is cutting the check for it. Coordination between unlikely bed partners just got written into the payment model, and the writing is on the wall for future alternative payment models or anything else CMS/CMMI tries. They’re saying “you guys need to talk to each other, so prepare accordingly.” Here’s the rub: Many of the 150+ tech organizations CMS has already approved know how to monitor and generate clinical data. They do not know how to generate a note. There’s a significant difference between a blood pressure trend chart and a clinical update with appropriate context that a PCP can review, co-sign, and get paid for in under two minutes. ACCESS’s co-management fee assumes a level of note quality (an ambient layer that documents on their end and communicates on the other) that doesn’t exist for the organization yet. This is exactly the gap Connect and Echo were built for. From the Encounter To the Intelligence Layer Here's the longer game, and something I touched on very recently. Master the encounter first as a wedge — the cleanest, most portable record across every front door a patient walks through — then move upstream and downstream of this stack. I've spent a good chunk of 2026 arguing this is the year the clinical intelligence layer gets real, and the encounter is the wedge into it. Whoever owns documentation that actually travels, consistent across in-person and virtual, enterprise and startup, with the governance discipline to not store or train on patient data along the way, is positioned for whatever the next phase turns out to be. And it’s not going to be a winner take all market. So choose the right partner, or AI strategy, for you. Whatever the case, considering Nabla is worth your time. Restoring the joy of medicine was chapter one. Keeping that joy intact while the patient scatters across a dozen front doors is the harder chapter. It's also the one that matters now. Nabla built for it before most of the market saw it coming. This essay is a sponsored post in partnership with Nabla. I write these posts for companies with products or missions I believe can provide value-adds for Hospitalogy subscribers, many of whom work with/for ACOs, FQHCs, integrated health systems, health plans, and other risk-bearing organizations that want to learn more about potential value-based care partners. If you’re interested in a sponsored deep dive, please reach out to blake@workweek.com! Thanks for the read! Let me know what you thought by replying back to this email. — Blake

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