Intelligent continuity of care information system and method

An intelligent continuity of care information method, comprising:

• receiving real-time patient data including clinical and social information associated with a plurality of patients from a plurality of clinical and social service organizations;
• providing a set of 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 to identify patients requiring medical care and/or social services;
• accessing the patient data associated with the plurality of patients, pre-processing the patient data, and applying the predictive model to analyze the patient data for at least one particular patient;
• and
• presenting one of a selected customizable clinical, social, or patient view of the patient data and analysis associated with the at least one particular patient to a plurality of healthcare providers, social service providers, and patients via an electronic device, where each view being composed of a selected collection of a plurality of widgets each focusing on a subset of patient data.

An intelligent continuity of care information system, comprising:

• at least one data source configured to generate and store 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;
• a computer configured to access the patient data associated with the plurality of patients, pre-process, extract information, and analyze the patient data for at least one particular patient;
• and
• a user interface configured to present a selected view of the patient data and analysis associated with at least one particular patient to an authorized user via a computing device, each view being composed of a selected collection of a plurality of widgets each presenting a focused and configurable subset of patient data, the order in which the plurality of widgets are displayed being configurable by the user.