Software as a service (SAAS) services featuring software for healthcare entities which enables structured data capture, recording, reconciliation, stratification, computation, analysis, prediction, application of artificial intelligence and machine learning, for uses in the nature of care coordination, chronic care management, care management, population health, case management, readmission reduction, transitional care management, wellness programs, annual wellness visits, remote patient marketing, care plan creation and adherence, social determinants of health, and community-based coordination