Patent attributes
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.