Abstract: A dashboard user interface method includes displaying a navigable list of patients each associated with a target disease with a calculated risk level, displaying historic and current data associated with a selected patient in the patient list identified as being associated with the target disease, displaying an identification of key factors in the selected patient's health data that contribute to the risk level for the selected patient with respect to the target disease, receiving and displaying care management notes for transitional care intervention for the selected patient, 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.

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 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.