The Future of Chronic Care

A Focus on Outcomes

Healthcare can only be reinvented by changing what we measure. Success should reflect how a patient's health actually changes, not visits completed or codes billed. The current system optimizes for throughput (more appointments, more procedures, more documentation) while the metrics that actually matter to patients go untracked: Is my A1C improving? Am I sleeping better? Can I walk further than I could six months ago?

Recent breakthroughs in AI make it possible to track outcomes continuously and offload work to systems that deliver personalized care at scale. For the first time, we can monitor a patient's trajectory between visits, detect early warning signs, and intervene before problems escalate, all without adding hours to a clinician's day.

The future of care is asynchronous, personalized, and continuous. Rather than snapshots taken during quarterly appointments, patients and providers share a living picture of health that evolves in real time.

Conversations as a new Medical Record

Medical records are shifting from episodic documentation to a continuous flow of interactions. The Conversation model is our approach to this evolution, treating every meaningful exchange as a first-class clinical event, not just the ones that happen in exam rooms.

A Conversation can be:

• •A full in-person appointment: intake, transcription, discharge, follow-ups
• •An asynchronous clinical interaction: medication check-ins, dietary guidance, symptom monitoring, care plan adjustments, or responding to patient questions

For clinicians, an autonomous Health Agent initiates conversations when it needs information or requires approval to take action: writing data to the system, adjusting a care plan, or messaging a patient on their behalf. For patients, Health Agents reach out to deliver care: routine check-ins, personalized guidance, and data gathering that happens naturally, in their own time.

Every conversation becomes part of the clinical record, creating continuity that episodic visits could never achieve.

Aligned Incentives for Patients, Providers, and Payers

Payments tied to patient outcomes. Revenue shared among clinicians based on their contribution to a patient's care. Conversations become the primitive for tracking and attributing impact, finally creating a clear link between the work clinicians do and the results patients experience.

This isn't incremental improvement. A generational shift in digital health is now possible: a system that aligns incentives between patients, providers, and payers. When everyone benefits from better health rather than more services, the economics of care fundamentally change.