Synthetic data prototype — no PHI. Numbers, names, and IDs are fabricated for design review only.

Patient 360

Longitudinal Episode View

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James Ellis

PT-000030 · USC-900030 · EPI-2026-0030

OutreachLow riskMedicare AdvantageBladder Cancer

Generalist Hospital-InitiatedGeneralist Acute CareADT ED ArrivalAI 90%Syncope / Arrhythmia PathwayRouted - OutreachTCMRPMIPCSpecialist Referral

NBA: Ship RPM device + activate transmissions

Reason codes: RECENT_FALL, PRIOR_COMPLICATION

Outreach

PCM Min.

Paid $

Age / Sex

57 · M

ZIP

90014

Language

English

Payer

Humana Medicare Advantage

Procedure

Cystectomy

Surgeon

Dr. Sofia Marchetti

Surgery Site

USC Norris Cancer Hospital

Surgery Date

Jan 07, 2026

Discharge

Jan 14, 2026

LOS

Status

Outreach

Consent

On file

Episode Timeline

18 events

Surgery · Cystectomy

2026-01-07

Dr. Sofia Marchetti

Program Assignment · RPM · Eligible

2026-01-11 00:00

Accepted (assigned by AI Engine)

Program Assignment · Specialist Referral · Eligible

2026-01-11 00:00

Accepted (assigned by STF-002)

Intake Trigger · ADT ED Arrival · Keck ED ADT Feed

2026-01-11 17:15

Routed at 2026-01-12 00:00

Program Assignment · TCM · Eligible

2026-01-12 00:00

Not accepted (Pass payer check)

Program Assignment · IPC · Eligible

2026-01-12 00:00

Accepted (assigned by AI Engine)

Order Set · Syncope Monitoring Bundle · Activated

2026-01-13 00:00

3 orders · review complete

Discharge · LOS 7d

2026-01-14

Outreach · Attempt 1 · Call Back Requested

2026-01-15 09:30

Jamal Carter

RPM Enrollment · BP cuff · CPT 99453/99454/99457

2026-01-17

14/30 transmission days

RPM Alert · 3 alert(s) in last 30d

2026-01-17

BP cuff

Outreach · Attempt 1 · TCM Accepted

2026-01-17 17:00

Felix Stone

Outreach · Attempt 2 · No Answer

2026-01-18 16:00

Jamal Carter

Workflow Task · Initiate Specialist Referral · Done

2026-01-20 00:00

Intake · NP

IPC Consult · Nephrology · CPT 99445

2026-01-21 00:00

Report complete

Utilization · Readmission · Hematuria

2026-01-22 04:10

In-network

TCM Encounter · Phone · CPT 99495

2026-01-28

Note pending

Steerage · Pharmacy → USC

2026-01-29

USC Pasadena Surgery Center

Outreach Attempts

ID	Attempt	Datetime	Outcome	Staff	Min
OUT-0066	#1	2026-01-15 09:30	Call Back Requested	Jamal Carter	2
OUT-0067	#2	2026-01-18 16:00	No Answer	Jamal Carter	2
OUT-0120	#1	2026-01-17 17:00	TCM Accepted	Felix Stone	11

TCM Encounters

ID	Encounter	Type	CPT	Doc Complete	Note → USC	Staff
TCM-0031	2026-01-28	Phone	99495	No	No	Sofia Diaz

Actionable Chat

Synthetic

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Next Best Actions

Rule-based recommendations derived from the patient's current state.

Send TCM note to USC EHR
High
Documentation completed but note not transmitted
Owner: RN
Activate RPM device
Medium
BP cuff transmitting only 14/30 days — confirm setup
Owner: RN
Resolve RPM alert(s)
High
3 unresolved BP cuff alert(s) in last 30d
Owner: RN
Complete TCM documentation for billing
Medium
TCM encounter logged but documentation flagged incomplete; CPT 9949x cannot bill.
Owner: NP
Backfill PROMs RWE
Low
PROMs only 45% complete
Owner: Ops Coordinator