AUSTIN (KXAN) — The City of Austin reports our communities of color experience higher rates of many diseases, including cancer, diabetes and heart disease.

KXAN has also reported on how COVID-19 has disproportionately impacted the city’s people of color.

One Austin-based company just won a year-long, national competition to help doctors close that health gap, by using artificial intelligence.

“Our hypothesis was that it wasn’t just clinical or the diagnostic or the prescriptions that made someone high risk… but rather that it was a combination of both clinical and social,” said Dr. Jim Walton, president and CEO of Genesis Physicians Group in Dallas.

He said where and how you live can tell doctors a lot about your health risk. For example, you may be more likely to skip a doctor visit if you don’t have access to transportation or child care.

Walton is working to find out what those top challenges are for nearly 30,000 Medicaid patients in Dallas. He’s using, Inc. — an Austin-based artificial intelligence company.

“We take mountains of medical records and other data about people and use that to learn patterns and predict who’s going to get sick and who’s going to have bad outcomes,” explained Dave DeCaprio,, Inc.’s chief technology officer and cofounder.

From there, Walton said his staff reaches out to those patients to help address any challenges they may have in accessing health care.

“They use our platform to outreach to people, and we help reduce barriers to care,” said Carol McCall,, Inc.’s chief analytics officer.

“Looking for, if you will, the needle in a haystack, right? The top 1 to 2% most risky people who, by virtue of both their clinical and their social circumstances, would move them to the top of the list of the people we would reach out to to address social issues on behalf of their doctor,” Walton explained.

His group works with about 57 independent physicians.

The Centers for Medicare & Medicaid Services just awarded ClosedLoop $1.6 million for its work in a national, year-long competition. The company said it’ll use the prize money to expand operations and are now looking to hire 30 people in the next 30 days.

But more importantly, they hope the competition helped more health care leaders realize the benefits of artificial intelligence.

“We predict the future so that you can change it,” said McCall.

Walton is also using ClosedLoop’s artificial intelligence software to predict who’s most at risk of COVID-19 complications, so staff can reach out to those patients, educate them about vaccines and provide access to shots.

How the platform works

“How old a person is, what gender, where they live by address — if I provide that information, then ClosedLoop can access data that they have that’s publicly available with regards to the patient’s environment and the community in which they live,” explained Walton.

But his team also collects two new kinds of data for the platform: An interview with the patient or patient’s parent about the social issues they face and which organization his team refers them to for that help.

“When we make a referral to a community-based organization to address a social issue like food insecurity or transportation issues, that information is also fed into the database,” he said.

Walton hopes all that data will feed back into the platform and ‘train’ it to predict even more.

“Which of those patients are most likely to miss a primary care appointment, which one of those patients is most likely, if they have a behavioral health diagnosis, to not get the kind of care that they need in order to maintain the medication regiment to keep them stable…” he explained.

Walton hopes the platform will next be able to tell them which of their outreach strategies is working best.

“‘Hey, this is the intervention that’s making the most difference… and here’s the one that’s not,'” said Walton, who hopes to have an impact study in another year.