Abstract: Methods are provided for the surveillance and monitoring of a patient's medical care when the patient is treated at two or more medical organizations having different medical record systems. Patient information is received from a first medical organization and populated into an active risk assessment array that monitors the patient's risk for developing a particular disease or condition. Patient information is then received from a second medical organization and populated into the array. It is determined that actionable criteria have been met, and in response, a notification or alert is sent to the medical organizations indicating that the patient is at risk.

Abstract: Methods, systems, and computer-readable media are provided for building a score plan for a healthcare organization, its providers, its payers, and/or its patients and presenting the results of the score plan on one or more score card user interfaces. Score cards graphically display an entity's progress towards meeting quality measure objectives. The score cards provide information on percentage completion of one or more quality measure objectives by the entity and/or quality measure objectives that may be difficult for the entity to achieve.

Abstract: Systems, methods, and storage media useful in a computer healthcare system to consume clinical quality language queries in a programmatic manner are disclosed. Exemplary implementations may: load a CQL query from a third party; transform the CQL query to a modified structured query language query; load medical data elements from a database record store for each patient in one or more defined patient populations; execute the modified SQL query on medical data elements from the database record store for each patient in one or more defined patient populations; and load results of the modified SQL query.

Abstract: Methods, systems, and computer-readable media are provided for building a score plan for a healthcare organization, its providers, its payers, and/or its patients and presenting the results of the score plan on one or more score card user interfaces. Score cards graphically display an entity's progress towards meeting quality measure objectives. The score cards provide information on percentage completion of one or more quality measure objectives by the entity and/or quality measure objectives that may be difficult for the entity to achieve.

Abstract: Methods are provided for validating theoretical improvements in the decision-support processes facilitating surveillance and monitoring of a patient's risk for developing a particular disease or condition and detecting the disease or condition. Patient information is received from a source and populated into an active risk assessment that monitors the patient's risk for developing Sepsis. At least a first and second set of actionable criteria for determining a patient's risk for developing sepsis are received. For each set of actionable criteria, it is determined that actionable criteria have been met. In some embodiments, software agents, operating in a multi-agent computing platform, perform each determination of whether actionable criteria are met.

Abstract: Methods are provided for the surveillance and monitoring of a patient's medical care when the patient is treated at two or more medical organizations having different medical record systems. Patient information is received from a first medical organization and populated into an active risk assessment array that monitors the patient's risk for developing a particular disease or condition. Patient information is then received from a second medical organization and populated into the array. It is determined that actionable criteria have been met, and in response, a notification or alert is sent to the medical organizations indicating that the patient is at risk.

Abstract: Methods are provided for the surveillance and monitoring of a patient's medical care when the patient is treated at two or more medical organizations having different medical record systems. Patient information is received from a first medical organization and populated into an active risk assessment array that monitors the patient's risk for developing a particular disease or condition. Patient information is then received from a second medical organization and populated into the array. It is determined that actionable criteria have been met, and in response, a notification or alert is sent to the medical organizations indicating that the patient is at risk.

Abstract: Methods are provided for the surveillance and monitoring of a patient's medical care when the patient is treated at two or more medical organizations having different medical record systems. Patient information is received from a first medical organization and populated into an active risk assessment array that monitors the patient's risk for developing a particular disease or condition. Patient information is then received from a second medical organization and populated into the array. It is determined that actionable criteria have been met, and in response, a notification or alert is sent to the medical organizations indicating that the patient is at risk.

Abstract: Systems, methods, and storage media useful in a computer healthcare system to consume clinical quality language queries in a programmatic manner are disclosed. Exemplary implementations may: load a CQL query from a third party; transform the CQL query to a modified structured query language query; load medical data elements from a database record store for each patient in one or more defined patient populations; execute the modified SQL query on medical data elements from the database record store for each patient in one or more defined patient populations; and load results of the modified SQL query.

Abstract: Methods, systems, and computer-readable media are provided for building a score plan for a healthcare organization, its providers, its payers, and/or its patients and presenting the results of the score plan on one or more score card user interfaces. Score cards graphically display an entity's progress towards meeting quality measure objectives. The score cards provide information on percentage completion of one or more quality measure objectives by the entity and/or quality measure objectives that may be difficult for the entity to achieve.

Abstract: Methods are provided for validating theoretical improvements in the decision-support processes facilitating surveillance and monitoring of a patient's risk for developing a particular disease or condition and detecting the disease or condition. Patient information is received from a source and populated into an active risk assessment that monitors the patient's risk for developing Sepsis. At least a first and second set of actionable criteria for determining a patient's risk for developing sepsis are received. For each set of actionable criteria, it is determined that actionable criteria have been met. In some embodiments, software agents, operating in a multi-agent computing platform, perform each determination of whether actionable criteria are met.

Abstract: Methods, systems, and computer-readable media are provided for building a score plan for a healthcare organization, its providers, its payers, and/or its patients and presenting the results of the score plan on one or more score card user interfaces. Score cards graphically display an entity's progress towards meeting quality measure objectives. The score cards provide information on percentage completion of one or more quality measure objectives by the entity and/or quality measure objectives that may be difficult for the entity to achieve.

Abstract: Methods, systems, and computer-readable media are provided for building a score plan for a healthcare organization, its providers, its payers, and/or its patients and presenting the results of the score plan on one or more score card user interfaces. Score cards graphically display an entity's progress towards meeting quality measure objectives. The score cards provide information on percentage completion of one or more quality measure objectives by the entity and/or quality measure objectives that may be difficult for the entity to achieve.

Abstract: Methods, systems, and computer storage media are provided for generating simulation graphs using real-time clinical data. A user may indicate one or more scenario variables to apply to an area of interest. A simulation graph is then generated that includes at least an indication of a scenario status. The scenario status indicates an expected result based on the one or more scenario variables selected by the user. The simulation graph may also include a baseline status indicating an expected result should no changes be made to a current environment. Multiple simulation graphs for varying areas of interest may be generated and compared to one another such that a user is able to quickly identify efficient solutions.

Abstract: Methods, systems, and computer storage media are provided for generating simulation graphs using real-time clinical data. A user may indicate one or more scenario variables to apply to an area of interest. A simulation graph is then generated that includes at least an indication of a scenario status. The scenario status indicates an expected result based on the one or more scenario variables selected by the user. The simulation graph may also include a baseline status indicating an expected result should no changes be made to a current environment. Multiple simulation graphs for varying areas of interest may be generated and compared to one another such that a user is able to quickly identify efficient solutions.

Abstract: Methods, systems, and computer storage media are provided for generating simulation graphs using real-time clinical data. A user may indicate one or more scenario variables to apply to an area of interest. A simulation graph is then generated that includes at least an indication of a scenario status. The scenario status indicates an expected result based on the one or more scenario variables selected by the user. The simulation graph may also include a baseline status indicating an expected result should no changes be made to a current environment. Multiple simulation graphs for varying areas of interest may be generated and compared to one another such that a user is able to quickly identify efficient solutions.

Abstract: A readmission risk prediction model is generated and used for identifying patients having elevated risk of readmission and determining inpatient treatment and outpatient activities based on readmission risk. Readmission risk prediction models may be generated for a variety of different clinical conditions using logistic regression techniques. When a patient is admitted to a hospital, the patient's condition is identified and a corresponding readmission risk prediction model is employed to identify the patient's risk of readmission. The readmission risk may be presented to a clinician and employed to recommend interventions intended to treat the patient and reduce the probability of readmission for the patient. The patient's readmission risk may also be calculated after the patient has been discharged and used for planning outpatient activities for the patient.

Abstract: A readmission risk prediction model is generated and used for identifying patients having elevated risk of readmission and determining inpatient treatment and outpatient activities based on readmission risk. Readmission risk prediction models may be generated for a variety of different clinical conditions using logistic regression techniques. When a patient is admitted to a hospital, the patient's condition is identified and a corresponding readmission risk prediction model is employed to identify the patient's risk of readmission. The readmission risk may be presented to a clinician and employed to recommend interventions intended to treat the patient and reduce the probability of readmission for the patient. The patient's readmission risk may also be calculated after the patient has been discharged and used for planning outpatient activities for the patient.

Abstract: Methods, systems, and computer-readable media are provided for organizational management of population health. A network management service builds and maintains data stores of organizational data associated with one or more healthcare organizations. A population health management service receives raw data from disparate sources, creates a reference record for each raw data source, and generates patient-centric longitudinal population records using the reference records. Programs for managing population health utilize both the organizational data and the population records to generate condition-specific or objective-specific solutions.

Abstract: Methods, systems, and computer-readable media are provided for automatically and without human intervention identifying providers and/or patient population segments eligible for one or more outreach events and executing the outreach event. An outreach event is an action or communication by a healthcare organization or its providers to contact providers or patients regarding one or more quality measures.