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Patient 360

Longitudinal Episode View

Search a synthetic patient or episode to inspect discharge → TCM → PCM → billing → outcomes end-to-end.

Camille Doolittle

PT-000053 · USC-900102 · EPI-2026-0053

Referral BlockedMedium riskCommercialProstate Cancer

Referral CenterReferral CenterSpecialty ReferralAI 61%Pre-Specialty Urology PathwayReferral - BlockedPCMSpecialist Referral

NBA: Resolve documents/intake blocker before outreach

Reason codes: DOCS_INCOMPLETE

Outreach

PCM Min.

Paid $

$69

Age / Sex

67 · F

ZIP

90078

Language

English

Payer

Anthem Blue Cross

Procedure

Robotic Prostatectomy

Surgeon

Dr. Rebecca Lim

Surgery Site

USC Urology Beverly Hills

Surgery Date

Feb 27, 2026

Discharge

Feb 27, 2026

LOS

Status

Referral Blocked

Consent

On file

Episode Timeline

99 events

Billing · PCM Monthly · CPT 99426 · Denied

2026-01-15

$0 / $83

Workup Ordered · Ambulatory cardiac telemetry (ROCT)

2026-01-19

Imaging

Workup Ordered · Troponin

2026-01-19

Lab

Program Assignment · PCM · Eligible

2026-01-19 13:00

Accepted (assigned by STF-010)

Program Assignment · Specialist Referral · Eligible

2026-01-19 13:00

Accepted (assigned by STF-010)

Program Assignment · APCM · Eligible

2026-01-19 13:00

Not accepted (Pass payer check)

Order Set · SOB Cardiology Pre-Visit Bundle · Partially Activated

2026-01-19 13:00

4 orders · review complete

Outreach · Attempt 1 · TCM Accepted

2026-01-19 14:00

Liam Chen

Workup Ordered · BNP

2026-01-21

Lab

PCM Enrollment · Enrolled · consent signed

2026-01-22

Steerage · Imaging → External

2026-01-22

Pacific Imaging (External)

Workup Scheduled · Ambulatory cardiac telemetry (ROCT)

2026-01-22

Workup Completed · Ambulatory cardiac telemetry (ROCT)

2026-01-22

Final

Workup Scheduled · BNP

2026-01-22

Workup Ordered · 12-lead EKG

2026-01-23

EKG

Workup Scheduled · Troponin

2026-01-23

Exception · Referral Documents Missing · Low · In Progress

2026-01-23 12:00

Felix Stone

Exception Opened · Referral Documents Missing

2026-01-23 12:00

Low · In Progress

Steerage · Lab → USC

2026-01-25

USC Urology Beverly Hills

Steerage · Lab → USC

2026-01-25

Keck Hospital of USC

Workup Scheduled · 12-lead EKG

2026-01-25

Workup Completed · BNP

2026-01-25

Final

Workup Completed · Troponin

2026-01-25

Final

Downstream USC Service · Lab

2026-01-25

Downstream USC Service · Lab

2026-01-25

PCM Activity · Phone Call · 10m

2026-01-31 17:30

Carmen Ortiz

Steerage · Procedure → USC

2026-02-04

USC Urology Beverly Hills

Workup Completed · 12-lead EKG

2026-02-04

Final

Downstream USC Service · Procedure

2026-02-04

PCM Activity · Care Plan Review · 20m

2026-02-05 17:30

Carmen Ortiz

Workflow Task · Referral navigation: Pulmonology · Done

2026-02-10 13:00

Intake · RN

Billing · PCM Monthly · CPT 99426 · Pending

2026-02-15

$0 / $71

Surgery · Robotic Prostatectomy

2026-02-27

Dr. Rebecca Lim

Discharge · LOS 0d

2026-02-27

Workup Ordered · Records request

2026-02-27

Records

Outreach · Attempt 1 · Left Voicemail

2026-02-27 10:45

Liam Chen

Intake Trigger · Specialty Referral · Community PCP

2026-02-27 11:00

Not yet routed

AI Detection · AI score 61%

2026-02-27 11:00

DOCS_INCOMPLETE

Program Assignment · PCM · Eligible

2026-02-27 11:00

Accepted (assigned by AI Engine)

Referral Received · Nephrology · Proteinuria workup

2026-02-27 11:00

External System · South Bay Family Practice

Intake Created · Intake REF-0003

2026-02-27 11:00

Urgency: Routine

PCM Offered · Pre-visit PCM offered

2026-02-27 11:00

Order Set Generated · Pre-Specialty Urology Bundle

2026-02-27 11:00

Outreach Started · First contact attempt

2026-02-27 17:15

0d from referral

Workup Ordered · UA

2026-02-28

Lab

Workup Ordered · PSA

2026-02-28

Lab

Workup Ordered · Renal ultrasound

2026-02-28

Imaging

Program Assignment · Specialist Referral · Eligible

2026-02-28 11:00

Not accepted (Pass payer check)

Outreach · Attempt 3 · TCM Accepted

2026-03-01 16:30

Jamal Carter

Order Set · Pre-Specialty Urology Bundle · Cancelled

2026-03-02 11:00

4 orders

Outreach · Attempt 2 · Left Voicemail

2026-03-02 16:30

Sofia Diaz

Program Assignment · RPM · Eligible

2026-03-02 18:30

Accepted (assigned by AI Engine)

PCM Enrollment · Enrolled · consent signed

2026-03-03

PCM Enrolled · Patient enrolled in PCM

2026-03-03

Workup Ordered · Troponin

2026-03-03

Lab

Exception · Pre-Visit Readiness Blocked · Low · In Progress

2026-03-03 13:00

Derek Mensah

Exception Opened · Pre-Visit Readiness Blocked

2026-03-03 13:00

Low · In Progress

Outreach · Attempt 1 · TCM Accepted

2026-03-03 17:30

Sofia Diaz

Program Assignment · PCM · Eligible

2026-03-03 18:30

Accepted (assigned by AI Engine)

Order Set · SOB Cardiology Pre-Visit Bundle · Activated

2026-03-03 18:30

4 orders · review complete

Workup Scheduled · UA

2026-03-04

Workup Scheduled · PSA

2026-03-04

Workup Scheduled · Renal ultrasound

2026-03-04

Program Assignment · Specialist Referral · Eligible

2026-03-04 18:30

Accepted (assigned by AI Engine)

Steerage · Lab → External

2026-03-05

Community Health LA (External)

Steerage · Lab → USC

2026-03-05

USC Norris Cancer Hospital

Workup Completed · PSA

2026-03-05

Final

Workup Completed · Troponin

2026-03-05

Final

Downstream USC Service · Lab

2026-03-05

Outreach · Attempt 2 · Call Back Requested

2026-03-05 13:15

Felix Stone

Outreach · Attempt 3 · TCM Accepted

2026-03-05 13:30

Jamal Carter

Steerage · Imaging → USC

2026-03-06

Keck Hospital of USC

Workup Completed · Renal ultrasound

2026-03-06

Final

Workup Ordered · 12-lead EKG

2026-03-06

EKG

Workup Ordered · Ambulatory cardiac telemetry (ROCT)

2026-03-06

Imaging

Downstream USC Service · Imaging

2026-03-06

RPM Enrollment · Pulse oximeter · CPT 99453/99454/99457

2026-03-07

16/30 transmission days

RPM Alert · 1 alert(s) in last 30d

2026-03-07

Pulse oximeter

Workup Ordered · BNP

2026-03-07

Lab

PCM Enrollment · Enrolled · consent signed

2026-03-08

Steerage · Lab → External

2026-03-08

Community Health LA (External)

Workup Completed · UA

2026-03-08

Final

Workup Scheduled · Troponin

2026-03-08

Workup Scheduled · 12-lead EKG

2026-03-09

PCM Activity · Med Reconciliation · 13m

2026-03-09 09:15

Naomi Reyes

Workup Scheduled · Ambulatory cardiac telemetry (ROCT)

2026-03-10

Readiness Updated · Score 57% · Blocked

2026-03-11 11:00

1 pending workups; Outside records

Workup Scheduled · BNP

2026-03-12

Billing · PCM Monthly · CPT 99426 · Paid

2026-03-15

$69 / $69

Steerage · Imaging → External

2026-03-15

Pacific Imaging (External)

Workup Completed · Ambulatory cardiac telemetry (ROCT)

2026-03-15

Final

Steerage · Procedure → USC

2026-03-16

USC Pasadena Surgery Center

Workup Completed · 12-lead EKG

2026-03-16

Final

Downstream USC Service · Procedure

2026-03-16

PCM Activity · Care Plan Review · 14m

2026-03-17 15:30

Brandon Lee

Steerage · Lab → USC

2026-03-18

Keck Hospital of USC

Workup Completed · BNP

2026-03-18

Final

Downstream USC Service · Lab

2026-03-18

PCM Activity · Patient Education · 19m

2026-03-19 15:30

Brandon Lee

Outreach Attempts

ID	Attempt	Datetime	Outcome	Staff	Min
OUT-0125	#1	2026-02-27 10:45	Left Voicemail	Liam Chen	5
OUT-0126	#2	2026-03-02 16:30	Left Voicemail	Sofia Diaz	4
OUT-0127	#3	2026-03-01 16:30	TCM Accepted	Jamal Carter	11
OUT-0166	#1	2026-01-19 14:00	TCM Accepted	Liam Chen	7
OUT-0203	#1	2026-03-03 17:30	TCM Accepted	Sofia Diaz	13
OUT-0204	#2	2026-03-05 13:15	Call Back Requested	Felix Stone	4
OUT-0205	#3	2026-03-05 13:30	TCM Accepted	Jamal Carter	9

TCM Encounters

No TCM encounter yet

Actionable Chat

Synthetic

I can answer questions about this patient's EPIC workflow, intake trigger, pathway, programs, order set, tasks, and billing evidence. Try one of the suggested prompts below.

Next Best Actions

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

Schedule TCM encounter
High
Patient accepted 36d ago, encounter not yet completed
Owner: NP
Log additional PCM time this month
Medium
Current month at 0m; need 30m more to bill 99426
Owner: RN
Rework denied claim(s)
Medium
$83 in denials across 1 claim(s)
Owner: Ops Coordinator
Review exception: Referral Documents Missing
Low
Low severity · 71d open
Owner: RN
Review exception: Pre-Visit Readiness Blocked
Low
Low severity · 32d open
Owner: Ops Coordinator
Route intake trigger
High
Specialty Referral from Community PCP not yet routed
Owner: Ops Coordinator
Resolve RPM alert(s)
High
1 unresolved Pulse oximeter alert(s) in last 30d
Owner: RN
Request missing referral documents
High
Referring office has not sent required clinical documents
Owner: Ops Coordinator
Schedule records: Records request
Medium
Workup ordered but not yet scheduled
Owner: MA
Mitigate leakage risk
High
Referral flagged as at-risk for leaving the USC network
Owner: Ops Coordinator
Close RWE data gaps
Low
7 domain(s) with completeness gaps
Owner: Ops Coordinator

Open Exceptions

Referral Documents Missing
71d open · In Progress
Low
Pre-Visit Readiness Blocked
32d open · In Progress
Low

Longitudinal Episode View

Camille Doolittle

Episode Timeline

Outreach Attempts

TCM Encounters

Actionable Chat

Chat QA Checklist

Next Best Actions

Open Exceptions