Stanford Med · Unit 5B Medicine·Day shift·Mon · 9:42 AM

Inputs & predictions

What data points feed each pillar · how clinical readiness is predicted · what's actually wired

1 · Where data enters

Every signal we evaluate originates in one of these ingestion sources. The protocol column is what we listen to or query.

SourceProtocolWhat it providesDepth
Epic FHIR R4 (primary ADT + clinical ingest)FHIR R4 Subscription + SMART-on-FHIRPrimary admit/discharge/transfer + clinical event ingest for Epic hospitals. FHIR Subscription on Patient, Encounter, Observation, MedicationRequest, ServiceRequest, Condition, AllergyIntolerance.Mock contract
Redox (multi-EHR connector)Redox API (HL7 + FHIR normalized)Cerner, Athena, Meditech connectivity via Redox abstraction layer.UI copy only
HL7 v2 ADT listener (fallback ADT)HL7 v2.x A01/A03/A08 over MLLPFallback admit/discharge/transfer feed for non-Epic / legacy EHRs without FHIR Subscriptions. A01/A03/A08 events over MLLP.UI copy only
Eligibility (X12 270/271)X12 270 request → 271 responseReal-time payer eligibility check via clearinghouse.UI copy only
Surescripts (formulary + benefit)NCPDP SCRIPTReal-time medication formulary, benefit, and pharmacy stock lookup.UI copy only
Naviguide capacity feedNaviguide REST APIReal-time SNF / HH / Hospice / ARU bed + capacity from in-network facilities.UI copy only
DME partner capacity (Lincare, Apria, Inogen)Vendor REST / EDI / portal scrapeDelivery slot availability + inventory from primary DME networks.UI copy only
ModivCare NEMT capacity feed (read)ModivCare RESTInbound capacity feed: wheelchair van + stretcher availability across CA. Paired with modivcare-out for the booking submission.UI copy only
Patient portal eventsInternal SSE + RESTCaregiver preference, SNF rank, transport, education ack, consent.UI copy only
Voalte ack streamVocera/Voalte webhookNurse/PT/Pharmacy task completion acks from existing messaging.UI copy only
Brain tick (scheduled detectors)Inngest cronTime-based detectors — 4pm pharmacy cliff, Fri AM weekend forecast, daily digest.UI copy only

2 · How each pillar consumes data

Six pillars × six input categories. A filled cell means the evaluator for that pillar reads that input category. (Per Phase 7 the "Payer / authorization" pillar was renamed Cost & coverage; the Cost & coverage evaluator considers insurance + charity + manufacturer + waiver paths, not just insurance pre-auth.)

PillarEHR · clinical signalsPT/OT + functionalMedication signalsCoverage & eligibilityResource capacity feedsPatient / caregiver portal
Clinical readiness
····
Functional & equipment readiness
····
Medication readiness
····
Financial readiness
····
Care coordination readiness
····
Patient agreement & support readiness
·····
EHR · clinical signals
Vitals, labs, active diagnoses, comorbidities, sign-off notes — the basis of clinical readiness.
Epic FHIR R4 (primary ADT + clinical ingest)HL7 v2 ADT listener (fallback ADT)Redox (multi-EHR connector)
PT/OT + functional
TUG, FIM, Barthel index, dysphagia screen, mobility status, fall risk — driver of Functional readiness.
Epic FHIR R4 (primary ADT + clinical ingest)Redox (multi-EHR connector)
Medication signals
Active med list, formulary tier, PA status, pharmacy stock, controlled-substance schedule.
Epic FHIR R4 (primary ADT + clinical ingest)Surescripts (formulary + benefit)CoverMyMeds (PBM prior auth)
Coverage & eligibility
X12 270/271 eligibility, SNF/HH benefit windows, PA SLA, denials — all funding paths considered.
Eligibility (X12 270/271)CoverMyMeds (PBM prior auth)Availity (medical PA + EDI)
Resource capacity feeds
SNF / HH / DME / NEMT availability, in-network status, quality rating, distance.
Naviguide capacity feedDME partner capacity (Lincare, Apria, Inogen)ModivCare NEMT capacity feed (read)
Patient / caregiver portal
Preference form, SNF ranking, consent, education completion, transport choice.
Patient portal events

3 · Clinical readiness prediction

The Medical pillar evaluator combines six classes of signal into a deterministic 0–100 score. AI is not in the scoring path; it's only in narrative refresh on demand.

  1. Vitals + labs (FHIR Observations) checked against service-line discharge criteria — CHF: diuresis target + BNP trend; sepsis: lactate clearance; ortho: pain control.
  2. Active diagnoses + comorbidities matched against the comorbidity-interactions library (CHF + CKD triggers nephrology follow-up; CHF + DM triggers carb-counting education).
  3. Hospitalist attestation("medically ready") — explicit timestamp on the medical-ready clock.
  4. IMM delivery for Medicare patients (42 CFR §405.1206 + CMS-10049). Initial within 2 days of admit, 2nd within 2 days of discharge.
  5. Med reconciliation completion (TJC NPSG.03.06.01) — discharge med list reconciled against home med list.
  6. Discharge plan written — the actual plan document exists in the chart (not a placeholder).

Each check has status PASS / PENDING / FAIL with a citation. The score is a weighted aggregation; a single blocking FAIL forces the pillar to BLOCKED regardless of overall percentage.

4 · Operational readiness planning

Operational readiness is composite — four pillars (Medication + Cost & coverage + Resources + Patient agreement) each compute independently and the dispatcher re-runs them on every event. There is no single "operational score"; the operational state is the conjunction of those four pillars.

  1. Medication — discharge med list + formulary tier + PA status + pharmacy stock + meds-to-beds delivery window.
  2. Cost & coverage — every needed service evaluated against all 9 funding paths (insurance pre-auth, charity 501(r), manufacturer assistance, Medicaid HCBS waiver, self-pay accepted, plan exception). Pillar fails when ANY service has no confirmed funding path.
  3. Resources — bed / DME / NEMT match identified, in-network confirmed, quality ≥ 3★, capacity open, backup warmed.
  4. Patient agreement — preference form sent, rankings captured, consent + education completed.

The dynamic engine (src/lib/engine/dispatcher.ts) re-evaluates all four on every event — task complete, payer decision, vendor callback, portal submit, simulated FHIR observation. The EventFeed shows the per-pillar diffs (Medication 50 → 72, +22) so day-by-day evolution is visible.

5 · What's actually wired (honest depth)

Per CLAUDE.md house rules: every integration is classified. 0 live wires (real fetch/SDK against real vendor), 6 mock-contract modules (typed code exists in src/lib/integrations/ with mockSend + Submission audit row), and 31 UI-only entries (described in architecture copy but no module yet).

ComponentLayerDepth
Epic FHIR R4 (primary ADT + clinical ingest)INGESTIONMock contract
Voalte ONE (secure clinician messaging)OUTBOUNDMock contract
TigerConnect (paging / on-call routing)OUTBOUNDMock contract
Twilio Programmable Messaging (SMS outreach)OUTBOUNDMock contract
Epic MyChart (portal push + tasks)OUTBOUNDMock contract
CoverMyMeds (PBM prior auth)OUTBOUNDMock contract
Redox (multi-EHR connector)INGESTIONUI copy only
HL7 v2 ADT listener (fallback ADT)INGESTIONUI copy only
Eligibility (X12 270/271)INGESTIONUI copy only
Surescripts (formulary + benefit)INGESTIONUI copy only
Naviguide capacity feedINGESTIONUI copy only
DME partner capacity (Lincare, Apria, Inogen)INGESTIONUI copy only
ModivCare NEMT capacity feed (read)INGESTIONUI copy only
Patient portal eventsINGESTIONUI copy only
Voalte ack streamINGESTIONUI copy only
Brain tick (scheduled detectors)INGESTIONUI copy only
Six-Dimension Readiness EngineCOREUI copy only
PaCHE barrier ontology + FSMCOREUI copy only
Brain detectorsCOREUI copy only
AI agent layer (Claude via runAgent)COREUI copy only
Resource matcher (graph)COREUI copy only
Task orchestratorCOREUI copy only
Audit spine (AgentInference + Submission)COREUI copy only
Event bus (Inngest workflows)COREUI copy only
EHR writebackOUTBOUNDUI copy only
Availity (medical PA + EDI)OUTBOUNDUI copy only
Naviguide e-referralOUTBOUNDUI copy only
Parachute Health (DME orders)OUTBOUNDUI copy only
ModivCare NEMT booking submission (write)OUTBOUNDUI copy only
Twilio + Vapi/Retell (voice agents)OUTBOUNDUI copy only
Documo (e-fax fallback)OUTBOUNDUI copy only
Notification busOUTBOUNDUI copy only
CM ConsoleUIUI copy only
MD Widget (Epic Sidebar)UIUI copy only
Patient + Family PortalUIUI copy only
Voalte-style task feedUIUI copy only
Admin / Throughput dashboardUIUI copy only
Demo data · no PHI · mocked Epic + payer endpoints