- Compounding-active
- 31%
- Re-ranked
- 17%
- Reproducible
- to the commit
Multiple chronic conditions
AI-driven care management for multiple chronic conditions.
She looks stable on every chart. She isn’t. Patient 3-D sees how a person’s conditions compound — and acts before the admission does.
Runs beside everything you own. Replaces nothing.
As her chart sees her
Margaret, 71. Heart failure, kidney disease, diabetes — each one controlled. Three line items. Nothing due.
As Patient 3-D sees her
Her heart failure is straining kidneys her diabetes is already damaging. The diuretic that keeps her breathing is pushing her kidneys down. Her readmission is three weeks away — and her chart has no flag for it.
America has an epidemic nobody scores.
$4.05Ta year — 90 cents of every healthcare dollar — on chronic and mental conditionsSource: CDC · America’s Health Rankings
A patient with heart failure, kidney disease and diabetes is the most expensive person in American medicine — and on every instrument that scores her, she looks like three controlled conditions.
Twelve medications. Nineteen doses a day. One patient.
In 2005, researchers at Johns Hopkins described a 79-year-old woman with five ordinary conditions — osteoporosis, arthritis, diabetes, hypertension, COPD — and followed the national guideline for each one. The guidelines, each written for a single disease, prescribed her twelve medications, nineteen doses a day, at five different times, with interactions no guideline had considered.
Twenty years later nothing has changed in the architecture. Charlson, Elixhauser, ACG, the CMS risk model — every instrument a physician or a CFO relies on adds conditions up. The one that admits conditions interact models five pairs. Five.
Medicine knows her conditions compound. Her chart doesn’t.
Boyd et al., JAMA · CMS-HCC relative-factor tablesMedication list · five guidelines appliedF, 79
12medications
19doses a day
5times a day
Osteoporosisguideline one
Osteoarthritisguideline two
Type 2 diabetesguideline three
Hypertensionguideline four
COPDguideline five
Each guideline written for one disease. She did not have one disease.
We built the instrument that sees what her chart cannot.
Patient 3-D adds the dimension medicine always knew and no instrument computed: how a patient’s conditions interact. Breadth × severity × interaction. Immutable and changeable — age, genetics, behavioral health, social determinants, medications, utilization — resolved into one picture of one person.
1 in 37patients with multiple conditions is compounding in a way no risk score can represent
1 in 58looks stable on every chart — and is on a trajectory the chart cannot see
This is not a higher score. It is the person the additive instrument could not see — found before the admission, not after.
From the first score to the closed loop. Already paid for.
One patient’s path through the platform. Every step is a service already covered — activated for the patients who need it.
She is seen.
Her record arrives — the same record everyone had. The engine reads her three conditions as one compounding trajectory and names what no single-disease guideline was watching for.
Her physician opens the chart.
The protocol is already there: nephrology within 48 hours, a medication reconciliation, a transitional-care visit — fired by her interactions, routed to the roles that own them, documented with the codes that pay for them.
Her home is connected.
A monitoring kit chosen for her profile, not a generic box. Her blood pressure, weight and glucose reach a nurse before they reach an emergency room.
Her care team runs on one queue.
A Care Captain, a nurse triage line that never closes, a community health worker for the ride she couldn’t get — dispatched by the protocol, not by whoever noticed first.
Her care is documented, billed and closed.
Each action acknowledged, completed or disputed, date-stamped. Chronic care management, remote monitoring, transitional care — services already covered, now activated.
Her outcomes are reported — and audited by someone who isn’t us.
Every figure traces to an engine run. The audit lives in a store we write and cannot touch.
She stays home.
That’s the outcome. Everything else is the machinery.
Fourteen agents run this loop — intake to reporting — each with a trigger, a success condition and a rule for what it does when it can’t succeed: it withholds; it never estimates.
Watch it run →
Measured, not promised.
- Compounding-active
- 36%
- Re-ranked
- 21%
- Figures moved
- 0 across five releases
- Checksum
- verified
- Enforced gates
- 40 of 40
- Served
- one unattended run
It replaces nothing you own.
Reads Epic. Reads Cerner. Hands the protocol back into the workflow your clinicians already use. No waiver, no new code, no new payment model — the services were always there. We tell you which patients turn them on.
Health systemsThe admissions you can prevent are already in your record.Health plans & ACOsRisk adjustment sees what was coded. We see what the coding missed.Physicians & care teamsA ranked list, the reason, and the protocol. Not another dashboard.Public programsMeasure the population before you fund the program.
Built by people who ran the systems it fixes.
Twenty years inside government health programs. PMO leadership across twenty-five-plus health plan launches. Delivered with ELEKS, InterSystems and Rhapsody.
Working now with an academic health system, a Midwest county, two state Rural Health Transformation programs, a college of medicine and a regional Blue plan.
The clinical bench · fourteen seats
Two former health-plan chief medical officers · A life and health reinsurance actuary · A practicing family physician and clinical informaticist · A 40-year quality physician executive · A clinical pharmacist · Chronic-care, digital-health and consumer-activation founders · A nurse leader who cut readmissions by a third · Payer-quality, commercialization and market-strategy operators
Named seats and credentials available on request.
How it starts.
A proof of value: one extract under a data use agreement and your clinicians’ judgment, with nothing installed on your side. In production, Patient 3-D runs inside your environment, and your data never leaves it.
One extract under a data use agreement, delivered once.
A flat-file extract you already know how to produce, limited to the fields the analysis needs. We send the column spec; you send the file once.
A sealed U.S. environment.
The proof of value runs in a sealed environment in the United States, with no connection to your systems.
Your clinicians at the review table.
Your named clinical reviewers see every figure before any figure is released.
Results in weeks.
Your population measured in three dimensions — what each patient has, how severe, how it compounds. Weeks, not a program.
Destroyed, with a certificate.
When the work ends the environment is destroyed, and you receive a certificate of destruction.
Every American with multiple chronic conditions, seen in three dimensions, by the end of the decade.
A flat-file extract, a sealed environment, your clinicians at the review table, results in weeks.