BucketAI · Population health

You have 22,000 patients. Who do you call first?

Most hospitals sit on years of patient records and treat them as an archive. BucketAI reads that archive as a worklist — sorting every person into health buckets, ranking who needs contact this week, and telling the front desk exactly what to offer them.

Your patient list is a waiting room. BucketAI decides the order.

BucketAI · Today
8 models live · drift-monitored

47 patients need attention this week. Reaching all of them is ₹4.2 L in addressable care.

Critical₹2.1 L
Cardio follow-up overdue 12 high-risk cardiac patients with no visit in 60+ days Open worklist →
High₹1.4 L
Diabetic retinopathy screening due 23 patients eligible, none screened in the last 12 months Open worklist →

See all 14 cohorts →

How it works

Four steps, and then it does it again.

Every patient runs the same loop — and the loop closes, which is the part most population-health tools skip.

1Read the record

Chart, labs, prescriptions, lifestyle inputs, family history, age and location — whatever the record actually holds for that person.

2Score 27 buckets

Each patient gets a 0–1 score for every possible health bucket, from cardiovascular risk to a sleep study to an overdue dental check.

3Assign and recommend

The top-scoring buckets become that patient's care plan, with the specific service to offer and a reason a human can read aloud on the phone.

4Learn from the outcome

When the service happens, the result is labelled and fed back. Confirmed buckets reinforce; refuted ones correct. The list gets sharper every cycle.

Explainability

Every bucket comes with its reasons.

A score nobody can interrogate is a score nobody should act on. Open any patient and BucketAI shows which facts pushed them into a bucket, and by how much — so a doctor can overrule it in ten seconds if it's wrong.

  • Contributing factors, weighted — the actual chart values that moved the score, each with its own contribution.
  • A plain-language next action — not "risk score 0.88", but "schedule a cardiology consult this week, and here is why".
  • Confidence on the face of it — low-confidence cases are routed to a clinician for review rather than dialled by the call centre.
  • Care plan you can hand over — the whole bucket set for a patient, printable, ready for the follow-up call or the family conversation.
Ramesh IyerM · 58 · MRN-10421 · last visit 12 Mar
Cardio 0.88

What to do next. Schedule a cardiology consult this week — high LDL, stage-2 hypertension and a family history of MI.

LDL 168 mg/dL+0.21
BP 148/94+0.18
Father · MI at 61+0.14
Diabetic + age+0.12
BMI 29.1+0.09
Non-smoker−0.04
Confidence 0.947 buckets identified for this patient

The buckets

Twenty-seven ways a patient can need you next.

A bucket is not a diagnosis — it is a reason to make contact. Each patient is scored 0–1 against every one of them, and the ones that clear the threshold become their care plan. Most people land in three to seven.

Critical · 612 patients · contact this week High · 3,280 · contact this month Watch · 7,544 · monitor Lifestyle · 6,108 · programme Preventive · 4,497 · annual
Bucket family CriticalHigh WatchLifestylePreventive Cardiovascular Post-MIUncontrolled BPLipidsSedentaryScreening Metabolic DKA historyHbA1c > 8Pre-diabeticWeightFasting panel Renal DialysiseGFR fallingProteinuria—Annual eGFR Oncology screening —Family historyAge band—Due screen Women's health High-risk ANCPost-natalCycle issuesBone healthCervical screen Respiratory & sleep COPD exac.Asthma controlSTOP-BANGSmokingSpirometry Mental health Risk flagPHQ-9 highFollow-up dueStress— Preventive & dental ——OverdueVisionAnnual panel
Highest-yield cohort Strong signal Moderate Low Not applicable

The loop that closes

Most population tools stop at step three.

Finding cohorts is the easy half. What separates a working programme from a dashboard is whether the outcome of the call comes back and changes the next list.

1Read

Chart, labs, prescriptions, lifestyle inputs, family history, age. Whatever the record actually holds — no separate data warehouse.

268 features
2Score

A 0–1 score against all 27 buckets, with the contributing chart values weighted and kept for display.

27 scores / patient
3Recommend

Top buckets become a care plan with a specific service and a reason a receptionist can say out loud.

3–7 buckets typical
4Act

Outreach books a real appointment on the real calendar against the real UHID. No CSV, no re-keying.

Booked in HIS
5Learn

Service rendered, outcome labelled, fed to the next training cycle. Confirmed reinforces; refuted corrects.

Back to step 1
Identified Whole panel

Every registered patient scored, not a sample. The cohorts you never knew you had are the point.

Contacted & booked Conversion

Tracked per cohort, so you learn which reasons people actually say yes to — and which scripts to retire.

Delivered The only number

Care actually rendered, traced back to the cohort that generated it. Everything before this is a promise.

Guardrails

A recall engine is one bad prompt away from being a sales list.

Population health done badly is upselling with a stethoscope on. These are the rules that keep it clinical.

Clinical need drives rankingCohorts are ordered by risk and overdue interval — never by margin on the service Always
Low confidence never gets dialledAmbiguous cases route to a clinician for review instead of to the call centre Always
Every recommendation is explainableThe chart values that produced the score are shown, weighted, on the patient record Always
A clinician can overrule in one clickWith the reason recorded, and fed back as a training signal Always
Patient opt-out is honoured everywhereOne withdrawal removes them from every cohort, not just the one they were called about Always
Revenue figures are never shown to clinical staffThe value of a cohort is a planning number for administrators, not a nudge on a doctor's screen Never shown

Model operations

It tells you when it is getting worse.

Any model degrades as your population changes. The difference is whether it admits it. BucketAI watches its own drift, queues the cases it isn't sure about, and asks a clinician instead of guessing.

/ 01

A fleet, not a black box

Eight specialty models behind one router, each versioned, each with its own accuracy tracked separately — so "the model is accurate" can be broken down to which bucket, this month — and which one is drifting.

/ 02

Drift monitoring

Population shift is measured per bucket against the training distribution. Cross the threshold and the model is flagged for retraining before its recommendations quietly rot.

/ 03

Ambiguous cases go to a human

Cases the model is genuinely unsure about are queued for clinician labelling rather than pushed to a call list. Those labels are also the most valuable training data you have.

/ 04

Outcomes close the loop

After the service is rendered, the bucket is confirmed or refuted. That confirm rate — reported per bucket, not as one flattering average — is how you judge whether to keep trusting it.

The funnel

Identified. Booked. Actually delivered.

Population health is judged on care delivered, not on cohorts discovered. BucketAI reports the whole funnel, including the part that didn't convert.

IdentifiedEvery eligible patient

Sorted into buckets across the full panel, with the addressable care quantified per cohort.

BookedContacted and scheduled

Outreach from the recommendation itself — appointment booked, care plan sent, no re-keying.

RealizedService completed

The only number that counts, tracked back to the cohort that generated it — and fed to the next training cycle.

Interface vignettes show illustrative data, not real patients or records. Cohort sizes and values shown are examples, not results from a named hospital.

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