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From first principles

Every piece of care has a job. Start there.

Each piece of the health industry exists to do one job for a person. Set aside the form it grew into, ask what the job actually needs, and build that. Here is how this portfolio would rebuild nine pieces.

This is a design. Each piece states what runs today and what comes next. Nothing here is for sale, nothing unsigned is called approved, and Boulder (co-op.care) is the first node, still being built. Each piece carries its own Today line. The same map is published for agents at /first-principles.json.

Under all nine

Three rules

  • The person keeps the record.

    The person is the only one present at every visit, so the record starts with them and institutions see what they choose to share.

  • A machine may draft. A named, licensed person signs or declines.

    Drafting has become cheap and accountability has not. Unsigned work is never called approved.

  • The people who do the work own it.

    Whoever owns a care system decides whom it serves; when caregivers and families own it, the value stays with them.

The map

Nine pieces

  1. 01 · Paying for care

    Get the right care paid for, without the family fighting the paperwork.

    What it grew into
    A third party decides after the fact, and a stack of forms, codes and denials sits between the family and their own money.
    From first principles
    Much of the care an aging person needs is paid by the family, often from accounts set aside for health costs. What opens that money for a specific need is a physician's judgment on that one case.
    Rebuilt
    A physician reviews the family's case and signs a letter of medical necessity or declines it. The family keeps the letter and the receipts together.

    A machine may draft. A named, licensed person signs or declines.The person keeps the record.

    Designed

    Today: The review flow is built and runs on test cases only. Letters are not open yet.

    Where: ComfortCard · ClinicalSwipe

  2. 02 · The physician's signature

    A licensed person stands behind a clinical decision.

    What it grew into
    Physician time drains into documentation. AI now drafts more of it, and it is getting harder to tell who actually decided.
    From first principles
    Drafting has become cheap. Accountability has not. The scarce thing is a named person who reviewed this case and put their name on it.
    Rebuilt
    A machine drafts. A named, licensed physician signs or declines, and the signature becomes a record anyone can check.

    A machine may draft. A named, licensed person signs or declines.

    Designed

    Today: Runs in a sandbox on synthetic cases.

    Where: HarnessHealth

  3. 03 · Hands-on care at home

    Someone skilled and steady helps at home.

    What it grew into
    Agencies place caregivers they pay little and keep briefly, so the relationship, which is the real product, starts over each time someone leaves.
    From first principles
    Care is a relationship. Whatever makes caregivers stay is the product.
    Rebuilt
    A cooperative in which caregivers are worker-owners and families are members, so the value stays with the people who create it.

    The people who do the work own it.

    Being built

    Today: Boulder is Node One. Sign-ups, a family assessment and a time bank run today; paid care begins once it is licensed and staffed.

    Where: co-op.care

  4. 04 · The health record

    Remember the person across every visit.

    What it grew into
    Each clinic, hospital and agency keeps its own slice. The family carries the rest in their heads and a kitchen drawer.
    From first principles
    The person is the only one present at every visit. The record should start with them.
    Rebuilt
    The record lives on the person's own device, and institutions see what the person chooses to share.

    The person keeps the record.

    On your device

    Today: ComfortCard's family file keeps papers on the family's own device. chanio runs on the founder's own Mac, not yet for members.

    Where: ComfortCard · chanio

  5. 05 · Getting paid for surgery

    A surgeon is paid correctly for work that was done.

    What it grew into
    Coders, clearinghouses and vendors sit between the operative note and the claim. Each takes a share, and each is a place for errors.
    From first principles
    The operative note already says what was done. The work is translation, and the surgeon is the one accountable for it.
    Rebuilt
    Software reads the surgeon's own note, a rules engine checks it, and the surgeon signs or strikes each line under their own number.

    A machine may draft. A named, licensed person signs or declines.

    Designed

    Today: The receipt runs on sample notes. Nothing is for sale.

    Where: SurgeonValue

  6. 06 · Getting ready

    A person understands what is about to happen to them.

    What it grew into
    Handouts, a portal and a rushed visit.
    From first principles
    Understanding shows when someone can explain it back, not when they have been handed a pamphlet.
    Rebuilt
    Short classes with sources cited on the page, and a check of what you know that stays on your device.

    The person keeps the record.

    Live

    Today: Live. No account and nothing to buy.

    Where: JointClass · SurgeryProcess

  7. 07 · Between visits

    Know whether recovery is on track before the next appointment.

    What it grew into
    Patients wait weeks for a visit to find out something went wrong.
    From first principles
    Recovery happens at home, so that is where to measure it, with a licensed clinician reading what comes in.
    Rebuilt
    A phone camera tracks movement at home. A licensed physical therapist reviews it and sends the summary on to the surgeon.

    A machine may draft. A named, licensed person signs or declines.The person keeps the record.

    Being built

    Today: Built, and the recovery summary already passes to the surgeon's side. The first patients come next, with a licensed physical therapist.

    Where: JointCoach

  8. 08 · The end of life

    A person's wishes are known and honored.

    What it grew into
    Forms signed once, filed, and not found when they matter.
    From first principles
    Wishes come out of a conversation, and the family is who carries them.
    Rebuilt
    The conversation happens in tap cards and is written down in the family's own words, kept by them.

    The person keeps the record.

    Live

    Today: Live. The answers stay on the device.

    Where: CareGoals · Quality Death

  9. 09 · Owning it

    Pay for the system and decide whom it serves.

    What it grew into
    Outside owners hold the system, so the returns, and the decisions, leave the community.
    From first principles
    Whoever owns it decides whom it serves. Rural America got electric power when communities owned the lines.
    Rebuilt
    Member-owned cooperatives, federated so each community runs its own node on a shared, open protocol.

    The people who do the work own it.

    Being built

    Today: co-op.care is a filed Colorado cooperative. Boulder is Node One; this is not yet a national grid.

    Where: co-op.care · Vimty

What this map leaves alone

Hospitals, drug makers and device makers are not rebuilt here. The aim is that a person needs the hospital less often, and arrives with their own record when they do.

Two doors