Core Concepts
Core Concepts
The Medecision Platform is a modular, API-first healthcare solution built to support end-to-end workflows across care management, utilization management, digital outreach, clinical intelligence, and appeals & grievances. This document outlines the foundational concepts that underpin the platform's architecture, configuration, and real-time automation capabilities.
Member-Centric Design
Medecision structures all data and workflows around a longitudinal member record, enabling teams to deliver proactive, coordinated care. This model ensures that every event, task, or request is contextualized within the full member history.
Key Characteristics:
Each user interaction and automated workflow ties back to a unique member ID
Comprehensive Member View (CMV) consolidates demographics, eligibility, clinical programs, tasks, assessments, outreach, and correspondence
Timeline view provides chronological context across utilization, care, and outreach events
Modular Application Layers
Medecision’s architecture separates capabilities into modular workflow applications that share a common data layer, configuration engine, and extensible integration model.
Major Modules:
Care Management: End-to-end program delivery for chronic, acute, or transitional care
Utilization Management: Intelligent intake, auto-decisioning, TAT monitoring, and correspondence
Appeals & Grievances: Structured routing, review, resolution, and compliance tracking
Digital Outreach: Multi-channel campaigns, journey automation, and engagement reporting
Clinical Intelligence: Rules engine, stratification, risk logic, and predictive analytics
These modules are supported by builders and data platform services described below.
Event-Driven Workflows
Every object and interaction in the platform can be triggered or updated by real-time events. This enables intelligent automation, seamless integration, and consistent auditability.
Event Sources:
ADT feeds, claims files, labs, eligibility and SDOH data
API calls (FHIR, REST)
UI actions (e.g., completing an assessment, updating a request)
Rule engine outputs (e.g., population matching, scoring thresholds)
Event Actions:
Create tasks or programs
Auto-approve or route requests
Trigger correspondence or digital campaigns
Update program status or risk level
Builders and Configurability
Business teams use configuration builders to control platform behavior without code changes. These tools allow clients to implement and maintain logic, pathways, rules, and messaging based on their operational needs.
Builder Tools:
Rules Builder: Conditional logic across modules (triggers, filters, actions)
Program Builder: Eligibility logic, stages, completion rules
Population Builder: Stratification based on data elements (claims, risk, SDOH)
Campaign & Journey Builder: Multi-step outreach and engagement workflows
Assessment Builder: Scoring, branching, and auto-routing assessments
TAT Builder: Turnaround time rules with escalation paths
Each builder maintains versioning, audit history, and can be promoted between environments (e.g., staging to production).
Automation & Intelligence
Automation is central to how the platform reduces administrative burden and improves member outcomes. Rules and builders interact with data feeds and user activity to trigger real-time automation.
Examples:
Auto-create programs for newly admitted members with CHF diagnosis
Route UM requests with insufficient documentation to peer review queue
Auto-generate resolution letters based on decision outcomes
Escalate tasks nearing regulatory deadlines
Predict likelihood of denial based on historical decision models
These rules are executed synchronously with user actions or as asynchronous background processes.
Unified Data Model
All modules use a shared canonical data structure, enabling consistent querying, visualization, and integration.
Data Sources:
Claims, labs, ADT, enrollment/eligibility, assessments, correspondence, SDOH
Integration Options:
Ingestion: Streaming, batch (SFTP), or real-time API
Export: BigQuery, FHIR API, flat file, webhook
API: REST and FHIR-based read/write for member, programs, requests, tasks, and assessments
The platform supports external identity resolution and deduplication, allowing clients to use their own member IDs or link multiple sources to a master member index.
Timeline and Auditability
All events, actions, and user interactions are tracked at the member level, supporting compliance, reporting, and operational visibility.
Timeline View:
Visual timeline in CMV includes tasks, assessments, programs, and requests
Click-through to detail views with change history
Role-based filters and alerts for overdue or escalated items
Audit Trails:
System and user actions logged with timestamps and user ID
Builder changes tracked by version with rollback capability
Governance and Promotion
All platform changes—rule updates, program logic, campaign flows—are governed by environment-based promotion and optional approval workflows.
Key Features:
Support for dev, staging, and production environments
Promotion requests logged and approved through governance workflow
Builders support change sets and rollback for audit and testing
Extensibility & APIs
The platform is designed for full extensibility via APIs and client-specific configurations.
Every UI action is available as a documented API call
Webhook support for outbound triggers (e.g., event to CRM or EMR)
Client-specific branding, workflows, and logic can be configured without affecting core product upgrades
This document is a foundation for understanding how the Medecision Platform is structured. For details on workflow execution, builders, modules, or APIs, refer to the corresponding documentation sections.