Abstract: An intelligent continuity of care information system comprises a repository of patient data including clinical and social information associated with a plurality of patients updated and received from a plurality of clinical and social service organizations and data sources, at least one predictive model using clinical and social factors derived from the patient data to extract both explicitly encoded information and implicit information about the patient's clinical and social information, and a user interface operable to present a selected view of the patient data and analysis associated with the at least one particular patient to a user via a computing device, each view being composed of a selected collection of a plurality of widgets each presenting a focused subset of patient data and analysis.

Abstract: A patient care surveillance system comprises a data store operable to receive and store clinical and non-clinical data associated with at least one patient, a user interface configured to receive user input of current information related to at least one patient, a monitor configured to sense at least one parameter associated with at least one patient, and further configured to generate real-time patient monitor data, a data analysis module configured to access the data store and analyze the clinical and non-clinical data, receive and analyze the current information and real-time patient monitor data, and identify at least one adverse event associated with the care of at least one patient, and a data presentation module operable to present information associated with at least one adverse event to a healthcare professional, the information including contextual information associated with the adverse event.

Abstract: A dashboard user interface method comprises displaying a navigable list of at least one target disease, displaying a navigable list of patient identifiers associated with a target disease selected in the target disease list, displaying historic and current data associated with a patient in the patient list identified as being associated with the selected target disease, including clinician notes at admission, receiving, storing, and displaying review's comments, and displaying automatically-generated intervention and treatment recommendations.

Abstract: A clinical predictive and monitoring system comprising a data store operable to receive and store data associated with a plurality of patients selected from medical and health data; and a number of social, behavioral, lifestyle, and economic data; at least one predictive model to identify at least one high-risk patient associated with at least one medical condition; a risk logic module operable to apply the at least one predictive model to the patient data to determine at least one risk score associated the at least one medical condition and identify at least one high-risk patient; a data presentation module operable to present notification and information to an intervention coordination team about the identified at least one high-risk patient; and an artificial intelligence tuning module adapted to automatically adjust parameters in the predictive model in response to trends in the patient data.