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Cohort Watch
Built for Rep. Ronnie Jackson · U.S. Representative (TX-13) (R) · Physician
A population-health tracker — see a cohort's risk, screening gaps, and where one intervention helps most.
Aggregate onlyEvery cohort here is a count and a set of percentages — there is no person-level field anywhere in this app. This is a check before you decide: a signal to act, never a diagnosis. Not medical advice.
Population-Health Decision Check
Where does one intervention help most?
Act here firstHighest risk-weighted closable gap across 6 cohorts
Rural seniors 65+
One action — Mail FIT kits to everyone overdue — reaches 5,925 at-risk people who are currently overdue for colorectal screening.
29,625
priority score
46%
screening gap
34/100
cohort risk
Intervention priority by cohort
30k
23k
17k
12k
6.5k
1.9k
Score = severity × (size × prevalence × gap). The tallest bar is where a single action closes the biggest risk-weighted gap.
At a glance
74,300
people under watch
14,808
reachable by top actions
Cohorts improving vs worsening (latest period)
6/6 narrowing their average gap
1
Rural seniors 65+TX-13 Panhandle · 18,400 people
Top action: Mail FIT kits to everyone overdue · reaches 5,925 at-risk
29,625
priority
-2pp
improving
2
Diabetes registryCounty-wide · 9,300 people
Top action: Reflex A1c for at-risk patients at intake · reaches 2,883 at-risk
23,064
priority
-1pp
improving
3
Agricultural workers 30–55Rural counties · 12,100 people
Top action: Refer eligible smokers to low-dose CT · reaches 2,386 at-risk
16,702
priority
-1pp
improving
4
Young adults 19–34District-wide · 22,500 people
Top action: Add a PHQ-2 to the intake form · reaches 2,309 at-risk
11,545
priority
-1pp
improving
5
Veterans (county VA panel)County VA · 7,800 people
Top action: Refer eligible smokers to low-dose CT · reaches 927 at-risk
6,489
priority
-1pp
improving
6
Expectant & postpartumDistrict-wide · 4,200 people
Top action: Add a PHQ-2 to the intake form · reaches 378 at-risk
1,890
priority
-1pp
improving
Decision-support for population health, not a clinical or individual-care tool. Aggregate sample data; no patient identifiers are collected, stored, or displayed. Intervention priority is a transparent signal to investigate — not a diagnosis and not medical advice. Consult clinical and public-health professionals before committing resources.
Showcase demo for the America's Future 80th Anniversary Summit. Showcase · best home: Nonprofit / constituent service. Seeded with realistic sample data; runs payment-dark (no billing). Not a production system.