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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.

Jonas Kettering

PT-000060 · USC-900109 · EPI-2026-0060

Referral BlockedMedium riskMedicare AdvantageProstate Cancer

Referral CenterReferral CenterSpecialty ReferralAI 58%Pre-Specialty Urology PathwayReferral - BlockedPCMSpecialist Referral

NBA: Resolve documents/intake blocker before outreach

Reason codes: URGENCY_URGENT, DOCS_INCOMPLETE

Outreach

PCM Min.

Paid $

$69

Age / Sex

79 · M

ZIP

90015

Language

English

Payer

Humana Medicare Advantage

Procedure

Robotic Prostatectomy

Surgeon

Dr. Eliot Kashani

Surgery Site

USC Urology Beverly Hills

Surgery Date

Mar 18, 2026

Discharge

Mar 18, 2026

LOS

Status

Referral Blocked

Consent

On file

Episode Timeline

85 events

Workup Ordered · Lipid panel

2026-02-11

Lab

Outreach · Attempt 1 · TCM Accepted

2026-02-11 14:30

Liam Chen

PCM Enrollment · Enrolled · consent signed

2026-02-12

Workup Ordered · Records request

2026-02-12

Records

RPM Enrollment · Weight scale · CPT 99453/99454/99457

2026-02-13

8/30 transmission days

RPM Alert · 1 alert(s) in last 30d

2026-02-13

Weight scale

Program Assignment · PCM · Eligible

2026-02-13 16:00

Accepted (assigned by STF-001)

Program Assignment · Specialist Referral · Eligible

2026-02-13 16:00

Accepted (assigned by STF-001)

Program Assignment · RPM · Eligible

2026-02-13 16:00

Accepted (assigned by STF-001)

Order Set · Pre-Specialty Cardiology Bundle · Activated

2026-02-13 16:00

4 orders

Workup Ordered · 12-lead EKG

2026-02-15

EKG

Workup Scheduled · Lipid panel

2026-02-15

Workup Ordered · BMP

2026-02-15

Lab

Workup Scheduled · BMP

2026-02-17

Steerage · Lab → External

2026-02-19

Pacific Imaging (External)

Workup Scheduled · 12-lead EKG

2026-02-19

Workup Completed · Lipid panel

2026-02-19

Final

Steerage · Procedure → USC

2026-02-21

Keck Hospital of USC

Workup Completed · 12-lead EKG

2026-02-21

Final

Downstream USC Service · Procedure

2026-02-21

PCM Activity · Phone Call · 9m

2026-02-24 11:00

Carmen Ortiz

Steerage · Lab → USC

2026-02-25

USC Norris Cancer Hospital

Workup Completed · BMP

2026-02-25

Final

Downstream USC Service · Lab

2026-02-25

Workup Scheduled · Records request

2026-02-26

Surgery · Robotic Prostatectomy

2026-03-18

Dr. Eliot Kashani

Discharge · LOS 0d

2026-03-18

Intake Trigger · Specialty Referral · Phone

2026-03-18 15:00

Not yet routed

AI Detection · AI score 58%

2026-03-18 15:00

URGENCY_URGENT, DOCS_INCOMPLETE

Program Assignment · PCM · Eligible

2026-03-18 15:00

Not accepted (Pass payer check)

Referral Received · Urology · Recurrent UTI

2026-03-18 15:00

Phone · Inbound Phone Line

Intake Created · Intake REF-0010

2026-03-18 15:00

Urgency: Urgent

PCM Offered · Pre-visit PCM offered

2026-03-18 15:00

Order Set Generated · Pre-Specialty Urology Bundle

2026-03-18 15:00

Program Assignment · Specialist Referral · Eligible

2026-03-19 15:00

Not accepted (Pass payer check)

Workup Ordered · Renal ultrasound

2026-03-20

Imaging

Workup Ordered · Records request

2026-03-20

Records

Outreach Started · First contact attempt

2026-03-20 10:15

2d from referral

Outreach · Attempt 1 · Left Voicemail

2026-03-20 11:45

Jamal Carter

Order Set · Pre-Specialty Urology Bundle · Cancelled

2026-03-20 15:00

4 orders

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

2026-03-21 15:00

Jamal Carter

Exception Opened · Pre-Visit Readiness Blocked

2026-03-21 15:00

Medium · In Progress

Workup Ordered · UA

2026-03-22

Lab

Workup Ordered · PSA

2026-03-22

Lab

Outreach · Attempt 3 · No Answer

2026-03-22 10:00

Liam Chen

Outreach · Attempt 2 · No Answer

2026-03-23 09:00

Jamal Carter

Workup Scheduled · UA

2026-03-24

Workup Scheduled · PSA

2026-03-24

Steerage · Lab → USC

2026-03-25

USC Pasadena Surgery Center

Workup Completed · UA

2026-03-25

Final

Downstream USC Service · Lab

2026-03-25

Workup Ordered · UA

2026-03-26

Lab

Outreach · Attempt 1 · TCM Declined

2026-03-26 11:15

Liam Chen

Program Assignment · PCM · Eligible

2026-03-26 14:45

Accepted (assigned by AI Engine)

Workup Scheduled · Records request

2026-03-27

Workup Ordered · Renal ultrasound

2026-03-27

Imaging

Outreach · Attempt 2 · TCM Accepted

2026-03-27 11:15

Jamal Carter

Workup Ordered · PSA

2026-03-28

Lab

Workup Ordered · Records request

2026-03-28

Records

Program Assignment · Specialist Referral · Eligible

2026-03-28 14:45

Accepted (assigned by AI Engine)

PCM Enrollment · Enrolled · consent signed

2026-03-29

Workup Scheduled · Renal ultrasound

2026-03-29

Order Set · Pre-Specialty Urology Bundle · Activated

2026-03-29 14:45

4 orders

Steerage · Lab → External

2026-03-30

Pacific Imaging (External)

Workup Completed · PSA

2026-03-30

Final

Workup Scheduled · UA

2026-03-30

Workup Scheduled · Records request

2026-03-30

Steerage · Imaging → USC

2026-03-31

USC Norris Cancer Hospital

Workup Completed · Renal ultrasound

2026-03-31

Final

Specialist Visit Scheduled · Urology appointment

2026-03-31

13d from referral

Downstream USC Service · Imaging

2026-03-31

PCM Activity · Phone Call · 22m

2026-04-01 10:15

Naomi Reyes

Readiness Updated · Score 43% · Blocked

2026-04-01 15:00

2 pending workups; Outside records; PCM enrolment

Workup Scheduled · PSA

2026-04-02

Steerage · Other → USC

2026-04-03

USC Urology Beverly Hills

Workup Completed · Records request

2026-04-03

Final

Downstream USC Service · Other

2026-04-03

Steerage · Lab → USC

2026-04-04

USC Pasadena Surgery Center

Workup Completed · UA

2026-04-04

Final

Downstream USC Service · Lab

2026-04-04

PCM Activity · Med Reconciliation · 13m

2026-04-07 17:15

Naomi Reyes

Steerage · Lab → External

2026-04-09

Community Health LA (External)

Workup Completed · PSA

2026-04-09

Final

Billing · PCM Monthly · CPT 99426 · Paid

2026-04-15

$69 / $69

Workflow Task · Referral navigation: Urology · Done

2026-04-22 14:45

Intake · RN

Outreach Attempts

ID	Attempt	Datetime	Outcome	Staff	Min
OUT-0138	#1	2026-03-20 11:45	Left Voicemail	Jamal Carter	1
OUT-0139	#2	2026-03-23 09:00	No Answer	Jamal Carter	3
OUT-0140	#3	2026-03-22 10:00	No Answer	Liam Chen	2
OUT-0177	#1	2026-02-11 14:30	TCM Accepted	Liam Chen	11
OUT-0216	#1	2026-03-26 11:15	TCM Declined	Liam Chen	2
OUT-0217	#2	2026-03-27 11:15	TCM Accepted	Jamal Carter	8

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 17d ago, encounter not yet completed
Owner: NP
Review exception: Pre-Visit Readiness Blocked
Low
Medium severity · 14d open
Owner: RN
Route intake trigger
High
Specialty Referral from Phone not yet routed
Owner: Ops Coordinator
Activate RPM device
Medium
Weight scale transmitting only 8/30 days — confirm setup
Owner: RN
Resolve RPM alert(s)
High
1 unresolved Weight scale alert(s) in last 30d
Owner: RN
Request missing referral documents
High
Referring office has not sent required clinical documents
Owner: Ops Coordinator
Obtain PCM consent
Medium
Patient is PCM-eligible but consent has not been captured
Owner: RN
Schedule imaging: Renal ultrasound
Medium
Workup ordered but not yet scheduled
Owner: MA
Expedite delayed records
High
External lab slow turnaround
Owner: RN
Expedite delayed records
High
External lab slow turnaround
Owner: RN
Resolve low readiness items
High
Readiness score 43% — 2 pending workups; Outside records; PCM enrolment
Owner: RN
Mitigate leakage risk
High
Referral flagged as at-risk for leaving the USC network
Owner: Ops Coordinator

Open Exceptions

Pre-Visit Readiness Blocked
14d open · In Progress
Medium

Longitudinal Episode View

Jonas Kettering

Episode Timeline

Outreach Attempts

TCM Encounters

Actionable Chat

Chat QA Checklist

Next Best Actions

Open Exceptions