Synthetic data prototype — no PHI. Numbers, names, and IDs are fabricated for design review only.
Patient Journey
On-Ramp Funnels — Generalist · Specialist · Office-Based
Stage-by-stage conversion across the three EPIC on-ramps. Click any patient to open Patient 360.
Filters
Generalist Hospital-Initiated
ED & inpatient ADT → AI detection → routing → discharge → longitudinal
20 cohort45% end-to-end
ADT / EHR Signal20
AI Detection10↳ 50%
Condition Routing20↳ 200%
Program Assignment19↳ 95%
Order Set Activated5↳ 26%
Discharge Planning20↳ 400%
TCM / RPM / Referral19↳ 95%
Longitudinal Transition9↳ 47%
Blocked patients16
Specialist Post-Surgical
Surgery → discharge → TCM → DME → PCM → monthly billing & RWE
20 cohort35% end-to-end
Surgery Schedule20
Discharge List20↳ 100%
TCM Outreach Reached17↳ 85%
TCM Encounter14↳ 82%
Post-Acute / DME18↳ 129%
Follow-Up → PCM2↳ 11%
PCM Enrollment12↳ 600%
Monthly Mgmt (Billable)7↳ 58%
Blocked patients18
Office-Based Provider
Panel upload → stratify → APCM/PCM → consent → monthly mgmt → IPC/RPM → billing
10 cohort30% end-to-end
Panel Upload10
Risk Stratification9↳ 90%
PCM / APCM Assigned10↳ 111%
Outreach / Consent9↳ 90%
Care Plan Active3↳ 33%
Monthly Management4↳ 133%
IPC / RPM Layer10↳ 250%
Billing / RWE3↳ 30%
Blocked patients7
Next Best Actions — Generalist Hospital-Initiated
Click a patient to open Patient 360
| Patient | Stage | Next Best Action | Blocker | Tasks |
|---|---|---|---|---|
| William KimEPI-2026-0010 | Triggered | Ship RPM device + activate transmissions | Initiate TCM (NP) | 5(5 overdue) |
| Karen ParkEPI-2026-0015 | Longitudinal | Ship RPM device + activate transmissions | Initiate TCM (NP) | 4(4 overdue) |
| Anthony WalkerEPI-2026-0022 | Routed - Outreach | Ship RPM device + activate transmissions | Initiate TCM (NP) | 4(4 overdue) |
| Kenneth GarciaEPI-2026-0032 | Triggered | Schedule TCM visit within 14d | Initiate TCM (NP) | 4(4 overdue) |
| Dennis ZimmermanEPI-2026-0050 | Routed - Outreach | Schedule TCM visit within 14d | Initiate TCM (NP) | 4(4 overdue) |
| Denise JohnsonEPI-2026-0009 | Routed - Outreach | Ship RPM device + activate transmissions | Initiate TCM (NP) | 2(2 overdue) |
| Charles MitchellEPI-2026-0012 | Routed - Outreach | Continue care plan; no urgent action | Initiate TCM (NP) | 2(2 overdue) |
| James EllisEPI-2026-0030 | Routed - Outreach | Ship RPM device + activate transmissions | Initiate RPM (NP) | 2(2 overdue) |
Next Best Actions — Specialist Post-Surgical
Click a patient to open Patient 360
| Patient | Stage | Next Best Action | Blocker | Tasks |
|---|---|---|---|---|
| Maria AlvarezEPI-2026-0001 | Longitudinal | Verify DME delivery + patient education | Initiate TCM (NP) | 4(4 overdue) |
| Patricia EvansEPI-2026-0005 | Routed - Outreach | Verify DME delivery + patient education | Initiate TCM (NP) | 3(3 overdue) |
| Barbara LawsonEPI-2026-0011 | Longitudinal | Verify DME delivery + patient education | Initiate DME (Ops Coordinator) | 3(3 overdue) |
| Susan NguyenEPI-2026-0013 | Longitudinal | Verify DME delivery + patient education | Initiate DME (Ops Coordinator) | 3(3 overdue) |
| Donald OwensEPI-2026-0014 | Longitudinal | Verify DME delivery + patient education | Initiate TCM (NP) | 3(3 overdue) |
| Helen ReyesEPI-2026-0017 | Longitudinal | Continue care plan; no urgent action | Initiate TCM (NP) | 3(3 overdue) |
| Thomas BennettEPI-2026-0002 | Longitudinal | Verify DME delivery + patient education | Initiate TCM (NP) | 2(2 overdue) |
| Robert DavisEPI-2026-0004 | Longitudinal | Verify DME delivery + patient education | Initiate Post-Acute (NP) | 2(2 overdue) |
Next Best Actions — Office-Based Provider
Click a patient to open Patient 360
| Patient | Stage | Next Best Action | Blocker | Tasks |
|---|---|---|---|---|
| Ellen GreeneEPI-2026-0007 | Longitudinal | Ship RPM device + activate transmissions | Initiate APCM (RN) | 2(2 overdue) |
| Nancy JacobsEPI-2026-0035 | Routed - Outreach | Continue care plan; no urgent action | Initiate PCM (RN) | 2(2 overdue) |
| Michelle TanakaEPI-2026-0019 | Routed - Outreach | Continue care plan; no urgent action | Initiate PCM (RN) | 1(1 overdue) |
| Sandra VargasEPI-2026-0021 | Longitudinal | Ship RPM device + activate transmissions | Initiate RPM (NP) | 1(1 overdue) |
| Howard CarterEPI-2026-0028 | Longitudinal | Continue care plan; no urgent action | Initiate PCM (RN) | 1(1 overdue) |
| Laura HayesEPI-2026-0033 | Routed - Outreach | Continue care plan; no urgent action | Initiate PCM (RN) | 1(1 overdue) |
| Zachary VelascoEPI-2026-0046 | Care Plan Active | Confirm PCM consent + enroll | Initiate IPC (NP) | 1(1 overdue) |
| Irene DelgadoEPI-2026-0029 | Care Plan Active | Confirm PCM consent + enroll | — | 0 |