Complex Multi-Disease Framework

A panel of specialist agents — not a checklist

A data-gathering agent kicks off on the ADT event, pulls the record, and drafts a synopsis. Then each module is a specialist agent that files one standard report, and a coordinator agent synthesizes them into a single prioritized worklist for the nurse or NP.

1 · Trigger & lens Trigger ADT admit/discharge · or nurse opens case Lens VBC RN/NP · post-discharge / CHE 2 · Data-gathering & monitoring agent — runs first Data-gathering & monitoring agent ingests available records · flags the triggers it finds · drafts a synopsis to review · keeps watching for new data 3 · Specialist agents — woken by the flagged triggers Fluid Arrhythmia Diabetes Falls + 13 more each agent: intake recent events · review what's known · test data + context · file a report 4 · Every agent files ONE standard report — the contract No concern Needs data Needs context Actionable+ confidence Coordinator agent dedupe cross-module signals · resolve conflicts · rank by urgency × certainty 5 · One prioritized worklist — reviewed by the human Urgentescalate now Gatherdata / context, by role ActNBA, certainty-scaled Clearedno concern blue = data-gathering & monitoring · teal = specialist agent · purple = coordinator · gray/amber/green/red = report + priority status

The data agent runs first on the ADT event and hands the nurse a synopsis; the specialists each report; the coordinator synthesizes; the human reviews and can deep-dive into any agent.

The agents, and who does what

What kicks things off, what each agent does, how often they run, and what stays the human's job.

Data-gathering & monitoring agent

Runs first, then keeps watching

Kicks off before anyone opens the chart. On an ADT admit/discharge (or when the nurse opens the case) it:

  • ingests whatever records are available — discharge summary, labs, meds, prior notes, claims
  • flags the triggers it finds in the record, as suggestions
  • drafts a one-screen synopsis for the nurse to review
  • keeps monitoring for new ADT events and new data, and re-triggers the pipeline
Each module agent

Reviews one problem area

A specialist for its disease or risk (fluid, arrhythmia, diabetes, falls…). On its slice of the record it:

  • intakes the recent hospital events
  • reviews what's already known
  • tests whether it has enough data and enough context to reason
  • files findings, next-best-actions with a confidence, urgent escalations, and cross-module signals
Cadence & triggers

Wakes on events, not constant polling

Agents sit idle until something changes. The pipeline re-runs when:

  • an ADT event posts (admit or discharge)
  • new records land (labs, claims, care-gap feed)
  • the nurse opens or refreshes the case
  • a data gap gets filled — re-waking that agent and the coordinator

Post-discharge: fires on the ADT event. CHE: fires across all records when the annual review opens.

Coordinator agent

Keeps the running picture

Listens to every agent's report and re-synthesizes whenever one changes. It:

  • dedupes the shared threads (one syncope, not four problems)
  • resolves conflicts (anticoagulate the AF vs. hold for the bleed → surface, don't decide)
  • ranks by urgency × certainty into one worklist
  • labels each item: cleared / needs data / needs context / actionable
The human

Reviews and decides

The nurse or NP starts at the synopsis and the coordinator's output, not the raw modules. They:

  • act on urgent escalations first
  • fill the requested data/context — certainty rises live as they do
  • deep-dive into any agent to see its reasoning and evidence
  • accept or override every suggestion

The system routes and gathers; the human decides.

Walk through a real case

Demo case: an in-center HD patient is discharged after a syncopal episode. The ADT event fires the data agent; a VBC nurse then works the case. Watch the pipeline fill in.

Step 1 of 12

Live pipeline state
Data agent — idle
Falls
asleep
Arrhythmia
asleep
Fluid
asleep
Diabetes
asleep
Coordinator — idle
Prioritized worklist
— appears once the coordinator has run —

What's a mock today, what's real in production

The report contract is the durable part. The reasoning engine behind each agent swaps without changing anything downstream.

This mock. The data agent's synopsis and each specialist are deterministic rules over the module's declared data/context needs. Great for showing the flow and the contract.
Production. The data agent ingests live ADT/records; each specialist becomes an LLM agent with tool access to the chart, labs, and claims — emitting the same report contract.
Unchanged either way. The coordinator, the worklist, the human review, and the deep-dive all read the contract, not the engine. That's the v2 → v3 path.

Companion explainer for the Complex Multi-Disease Framework · designed to serve as the tool's opening screen.