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Care coordination failures include missed referrals, lost follow-ups, fragmented communication, and incomplete transitions between primary and specialty care. These failures can delay diagnosis, weaken continuity, and increase avoidable utilisation. Existing detection approaches often depend on manual review, retrospective audits, or simple rule-based flags. Such approaches are poorly suited to capture the relational complexity of patient, provider, referral, messaging, and encounter networks. This article develops a conceptual graph-based machine learning model for predicting care coordination failures. The model represents patient–provider referral networks enriched with follow-up status, patient message activity, specialty access delays, and provider communication patterns. The proposed approach uses a heterogeneous graph neural network in which patients and providers are nodes. Referral, encounter, and messaging relationships are represented as edges, while node and edge features encode follow-up adherence, message frequency, wait-time signals, and communication context. Conceptually, the model would identify high-risk referral edges that combine delayed access, incomplete follow-up, weak messaging activity, or limited provider communication. These predictions would support coordinator review before a referral becomes a documented care gap. A graph-based model could shift care coordination from reactive tracking toward predictive prevention. By identifying fragile referral relationships early, it could support more timely outreach and safer continuity of care.

Preventive care delivery remains inconsistent despite well-established recommendations for cancer screening, immunization, and chronic disease monitoring. Missed preventive services create avoidable downstream morbidity, delayed diagnosis, and inefficient use of primary care resources. Current preventive care gap closure strategies are often reactive, fragmented, and dependent on manual review. Primary care clinicians cannot feasibly reconstruct every patient’s eligibility status, prior reminders, portal behavior, and visit timing during brief encounters. This article proposes an artificial intelligence system that continuously analyzes primary care records, applies screening eligibility rules, integrates reminder logs and patient portal activity, and detects upcoming visit opportunity windows. The system would surface a personalized preventive care gap list before or during clinical contact. The framework includes a rules engine for guideline-based eligibility, an engagement module that interprets reminder history and portal behavior, a visit opportunity detector, and a prioritization engine. Together, these components would rank preventive actions by clinical relevance, timing feasibility, and patient readiness. The system would transform routine primary care encounters into targeted preventive care opportunities by delivering the right recommendation at the right moment. By combining eligibility logic with engagement and visit context, it could support proactive care without relying solely on clinician memory. A proactive, AI-enhanced preventive care system could narrow the gap between evidence-based recommendations and real-world delivery. Its value would depend on transparent rule design, workflow-sensitive implementation, and careful prospective evaluation.

Asynchronous digital communication with patients has become a routine component of modern healthcare delivery. The rapid growth of patient portals, chatbots, and digital front-door tools has created opportunities for more responsive care, while also increasing communication workload for clinical teams. This systematic review examined artificial intelligence applications in digital patient communication from 2017 to 2026. The review focused on portal message triage, chatbot support, care navigation, automated response drafting, and patient engagement analytics. A PRISMA 2020-compliant review was conducted using structured searches of PubMed, Scopus, IEEE Xplore, and Web of Science. Records were screened by two reviewers, with data extracted on communication domain, AI approach, clinical setting, evaluation strategy, safety reporting, and implementation maturity. The literature was dominated by studies of chatbot support and portal message triage, with a growing body of work on large language model-enabled response drafting. Care navigation and patient engagement analytics were less frequently evaluated, and most studies emphasized technical performance, user satisfaction, or feasibility rather than health outcomes or workload reduction in real-world settings. AI for patient communication appears technically promising in isolated tasks, particularly message classification, chatbot interaction, and draft response generation. However, evidence remains limited regarding safe, equitable, and effective deployment across integrated communication workflows.