Patient 360
Longitudinal Episode View
Search a synthetic patient or episode to inspect discharge → TCM → PCM → billing → outcomes end-to-end.
Nestor Okonkwo
PT-000064 · USC-900113 · EPI-2026-0064
NBA: Close loop with referring provider
Reason codes: URGENCY_URGENT, CARDIO_RISK, RPM_CANDIDATE, IPC_CANDIDATE
Outreach
4
PCM Min.
0
Paid $
$0
Age / Sex
61 · M
ZIP
90040
Language
English
Payer
Medicare FFS
Procedure
Robotic Prostatectomy
Surgeon
Dr. Rebecca Lim
Surgery Site
USC Urology Beverly Hills
Surgery Date
Jan 17, 2026
Discharge
Jan 17, 2026
LOS
0d
Status
Referral Closed
Consent
On file
Episode Timeline
70 eventsProgram Assignment · PCM · Eligible
2026-01-11 08:00Accepted (assigned by AI Engine)
Program Assignment · Specialist Referral · Eligible
2026-01-12 08:00Accepted (assigned by STF-010)
Outreach · Attempt 1 · TCM Accepted
2026-01-13 11:45Sofia Diaz
PCM Enrollment · Enrolled · consent signed
2026-01-14Program Assignment · PCM · Eligible
2026-01-15 09:45Not accepted (Pass payer check)
Surgery · Robotic Prostatectomy
2026-01-17Dr. Rebecca Lim
Discharge · LOS 0d
2026-01-17Program Assignment · Specialist Referral · Eligible
2026-01-17 09:45Accepted (assigned by STF-002)
Program Assignment · RPM · Eligible
2026-01-17 09:45Accepted (assigned by STF-002)
Order Set · Pre-Specialty Cardiology Bundle · Activated
2026-01-17 09:454 orders
Intake Trigger · Specialty Referral · Independent PCP
2026-01-17 12:15Routed at 2026-01-19 09:30
AI Detection · AI score 60%
2026-01-17 12:15URGENCY_URGENT, CARDIO_RISK, RPM_CANDIDATE, IPC_CANDIDATE
Program Assignment · PCM · Eligible
2026-01-17 12:15Not accepted (Pass payer check)
Program Assignment · Specialist Referral · Eligible
2026-01-17 12:15Accepted (assigned by STF-008)
Program Assignment · RPM · Eligible
2026-01-17 12:15Accepted (assigned by STF-008)
Referral Received · Cardiology · Palpitations
2026-01-17 12:15External System · Westwood Primary Care
Intake Created · Intake REF-0014
2026-01-17 12:15Urgency: Urgent
PCM Offered · Pre-visit PCM offered
2026-01-17 12:15Order Set Generated · Pre-Specialty Cardiology Bundle
2026-01-17 12:15RPM Enrollment · Cardiac monitor · CPT 99453/99454/99457
2026-01-1928/30 transmission days
Workup Ordered · BMP
2026-01-19Lab
Outreach Started · First contact attempt
2026-01-19 09:302d from referral
Program Assignment · IPC · Eligible
2026-01-19 12:15Not accepted (Pass payer check)
Outreach · Attempt 1 · No Answer
2026-01-19 15:15Jamal Carter
Workup Ordered · 12-lead EKG
2026-01-20EKG
Workup Ordered · Lipid panel
2026-01-20Lab
Workflow Task · Referral navigation: Nephrology · Done
2026-01-20 08:00Intake · RN
Outreach · Attempt 1 · TCM Accepted
2026-01-20 10:15Jamal Carter
Order Set · Pre-Specialty Cardiology Bundle · Activated
2026-01-20 12:154 orders
Outreach · Attempt 2 · TCM Accepted
2026-01-20 12:45Felix Stone
Workup Scheduled · 12-lead EKG
2026-01-21Workup Ordered · 12-lead EKG
2026-01-22EKG
Workup Scheduled · BMP
2026-01-22Workup Ordered · Records request
2026-01-22Records
Exception · Referral Documents Missing · Low · Open
2026-01-22 13:45Sofia Diaz
Exception Opened · Referral Documents Missing
2026-01-22 13:45Low · Open
Workup Ordered · Lipid panel
2026-01-23Lab
Workup Ordered · BMP
2026-01-23Lab
Workup Ordered · Records request
2026-01-23Records
Steerage · Lab → USC
2026-01-24USC Urology Beverly Hills
Workup Scheduled · Lipid panel
2026-01-24Workup Completed · Lipid panel
2026-01-24Final
Workup Scheduled · Records request
2026-01-24Downstream USC Service · Lab
2026-01-24Workup Scheduled · Records request
2026-01-25Workup Scheduled · Lipid panel
2026-01-25Workup Scheduled · BMP
2026-01-25Steerage · Other → External
2026-01-26Community Health LA (External)
Workup Scheduled · 12-lead EKG
2026-01-26Workup Completed · Records request
2026-01-26Final
PCM Activity · Med Reconciliation · 16m
2026-01-27 09:15Elena Rivera
Steerage · Lab → USC
2026-01-28USC Pasadena Surgery Center
Workup Completed · BMP
2026-01-28Final
Downstream USC Service · Lab
2026-01-28Steerage · Lab → USC
2026-01-29USC Urology Beverly Hills
Workup Completed · BMP
2026-01-29Final
Downstream USC Service · Lab
2026-01-29Steerage · Procedure → USC
2026-01-30USC Urology Beverly Hills
Workup Completed · 12-lead EKG
2026-01-30Final
Downstream USC Service · Procedure
2026-01-30Specialist Visit Scheduled · Cardiology appointment
2026-01-3114d from referral
Steerage · Procedure → USC
2026-02-01Keck Hospital of USC
Workup Completed · 12-lead EKG
2026-02-01Final
Downstream USC Service · Procedure
2026-02-01Steerage · Other → External
2026-02-03Pacific Imaging (External)
Workup Completed · Records request
2026-02-03Final
Steerage · Lab → External
2026-02-04Pacific Imaging (External)
Workup Completed · Lipid panel
2026-02-04Final
Workflow Task · Referral navigation: Cardiology · Done
2026-02-04 12:15Intake · Ops Coordinator
Readiness Updated · Score 71% · In Progress
2026-02-16 12:15PCM enrolment; RPM device activation
Outreach Attempts
| ID | Attempt | Datetime | Outcome | Staff | Min |
|---|---|---|---|---|---|
| OUT-0144 | #1 | 2026-01-19 15:15 | No Answer | Jamal Carter | 2 |
| OUT-0145 | #2 | 2026-01-20 12:45 | TCM Accepted | Felix Stone | 18 |
| OUT-0183 | #1 | 2026-01-20 10:15 | TCM Accepted | Jamal Carter | 6 |
| OUT-0222 | #1 | 2026-01-13 11:45 | TCM Accepted | Sofia Diaz | 9 |
TCM Encounters
No TCM encounter yet
Actionable Chat
SyntheticNext Best Actions
Rule-based recommendations derived from the patient's current state.
Schedule TCM encounter
HighPatient accepted 77d ago, encounter not yet completed
Owner: NP
Log additional PCM time this month
MediumCurrent month at 0m; need 30m more to bill 99426
Owner: RN
Review exception: Referral Documents Missing
LowLow severity · 72d open
Owner: RN
Backfill Pre-Visit Readiness RWE
LowPre-Visit Readiness only 42% complete
Owner: Ops Coordinator
Backfill Pre-Visit Readiness RWE
LowPre-Visit Readiness only 40% complete
Owner: Ops Coordinator
Obtain PCM consent
MediumPatient is PCM-eligible but consent has not been captured
Owner: RN
Close RWE data gaps
Low5 domain(s) with completeness gaps
Owner: Ops Coordinator
Open Exceptions
- Low
Referral Documents Missing
72d open · Open