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End-to-End Workflow

From Scheduled Case to Submitted Claim

One connected system across three surfaces. No manual handoffs between charting and billing. No data re-entry. Every step feeds the next.

iPhoneiPadWeb

Six Steps. One Record.

The same case record moves from scheduling through claim submission without re-entry at any handoff point.

01

Scheduled

iPhoneiPad
02

Pre-Op

iPad
03

Intraop

iPhone
04

Post-Op

iPad
05

Billing

Web
06

Paid

Web
01
iPhoneiPad

Case Scheduled

The case board populates itself.

HL7 v2 messages from QGenda arrive before the provider walks in the door. Patient demographics, procedure assignments, and OR room numbers appear on every device automatically — no manual scheduling entry.

  • HL7 v2 / MLLP feed from QGenda — zero manual case creation for scheduled ORs
  • SIU-S12 creates the case, SIU-S14 cancels it, SIU-S15 reschedules it
  • Feed health monitored with 5-minute heartbeat — staff see offline status instantly
  • Manual case creation available when the feed is offline

Providers

Walk in and see the case board fully loaded — no keyboard required

Billing

Patient demographics pre-populated from the schedule, not re-entered at post-op

Leaders

Full OR schedule visible in real time across all facilities

Case Board — OR Schedule

Smith, J. — OR 4

General Adult — ETT

Scheduled

Synced07:30

Torres, M. — OR 7

Spinal — L3/L4

Scheduled

Synced09:15

Chen, R. — OR 2

MAC — Shoulder

Scheduled

Synced10:45

Auto-populated from QGenda feed · HL7 v2

Pre-Op Summary — iPad

Smith, J. — OR 4

General Adult · ETT · 07:30

Allergies

Penicillin — Anaphylaxis

Preset Applied

General Adult — ETT

Drug grid, monitors, and airway loaded

Payer · Rounding Rule

Blue Cross · Ceiling 15 min

Begin Case ▶

02
iPad

Pre-Op on iPad

Everything set before the provider enters the OR.

The anesthesia plan is built on iPad before the case starts. A preset template defaults the drug grid, monitoring configuration, and airway plan. The payer rounding rule is visible on screen before anesthesia start time is locked.

  • 8 preset templates — General Adult, MAC, Spinal, Epidural, OB, and more
  • Allergies displayed in bold red — unmissable visual weight, patient safety requirement
  • Payer rounding rule shown before case start (Hard Constraint #6 from the spec)
  • Pre-op assessment: demographics, current medications, anesthesia plan

Providers

Drug grid pre-sorted for the case type before entering the OR

Billing

Payer confirmed and rounding rule locked before the clock starts

Leaders

Standardized pre-op documentation across all providers and sites

03
iPhone

Intraoperative on iPhone

Two taps. Any critical action. Every time.

The iPhone is the primary charting surface during active cases. A dark display for OR-safe low-light conditions. A drug grid with 72px touch targets designed for gloved hands. Every critical action completable in two taps or fewer — a hard design law, not a guideline.

  • Two-Tap Rule enforced: Tap drug → tap dose → logged with server-side timestamp
  • 72px touch targets — designed for surgical gloves (standard iOS is 44px)
  • ASTM D4774 color coding — on-screen drug color matches the physical syringe label
  • 8-second undo window — reverse fat-finger errors before audit entry is created
  • Offline-first: full charting capability when OR WiFi drops, auto-syncs on reconnect
  • Haptic feedback confirms every medication log without requiring visual confirmation

Providers

Fastest point-of-care charting — both hands stay on the patient, not the screen

Billing

Every event server-timestamped automatically — no provider-entered times, ever

Leaders

Append-only event log with HMAC hash chain — legally defensible at every step

Quick Log — General Adult

Synced
Fentanyl50 mcgOpioids
Rocuronium50 mgNeuromuscular
Propofol200 mgHypnotics
Neostigmine3 mgReversal Agents
Bupivacaine25 mgLocal Anesthetics
Glycopyrrolate0.4 mgAnticholinergics
Ephedrine10 mgVasopressors
Ondansetron4 mgAntiemetics
Fentanyl 50 mcg · IV · 08:32:15
UndoFentanyl 50 mcg logged8s
04
iPad

Post-Op and Chart Completion

A chart can't reach billing with missing fields.

After the case closes, the chart completion checklist enforces every required field before the record moves to billing. ASA units are calculated in real time. The claim readiness score (0–100) shows exactly what's complete and what's blocking.

  • 9 Tier 1 universal blockers — hard stops that prevent billing submission
  • 7 Tier 2 contextual blockers — payer-specific requirements enforced automatically
  • Claim readiness score 0–100 — weighted across all required fields
  • Cases below threshold are blocked from claim generation until resolved
  • Clinical review routing assigns incomplete charts to the right provider

Providers

Clear checklist — no guessing which fields are missing or why

Billing

Every chart arrives pre-validated — billing team reviews clean data, not raw charts

Leaders

Late completion queue surfaces cases that haven't cleared the checklist by shift end

Chart Completion — iPad

Smith, J. — OR 4

General Adult · 2h 14m

87

Claim Readiness

  • Anesthesia start/end times
  • CPT code assigned
  • ASA physical status
  • Supervising NPI
  • Estimated blood loss

1 blocker remaining before billing submission

ASA Unit Calculation

Base Units

CPT 00840

7

Time Units

134 min ÷ ceil/15

9

QC Units

No qualifying circumstance

0

Total Units

16

Modifiers Derived

AAQKQS

Derived from supervision model and case context

837P Generated

Submitted to Availity clearinghouse

SV2 loop · SSE-KMS archived to S3

05
Web

Billing Pipeline

ASA units calculated. Modifiers derived. Claim generated.

Once a chart clears the completion checklist, the billing engine takes over. ASA units are calculated from the case timestamps using the payer-specific rounding rule that was locked at pre-op. All six anesthesia modifiers are derived from clinical context — none are entered manually.

  • ASA formula: Base Units + Time Units (payer rounding) + Qualifying Circumstance Units
  • All 6 modifiers (AA, QK, QX, QZ, AD, QS) derived from clinical context — never manual
  • 837P claim generated in SV2 loop format for Availity or Waystar clearinghouse
  • Every submitted claim archived to S3 with SSE-KMS encryption
  • Batch submission — billing staff review queue and submit in bulk

Providers

Nothing to do — billing runs from the chart, not a second form

Billing

No manual unit calculation, no modifier lookup — the engine derives everything

Leaders

Fixed monthly cost regardless of claim volume — no per-case billing surprises

06
Web

Adjudication and Correction

Denials don't disappear into a queue — they get assigned.

The clearinghouse returns 999 functional acknowledgments, 277CA transport acknowledgments, and 835 remittance advice. Rejected claims are automatically classified by denial reason and routed to the correct person for correction. The remediation workspace surfaces the exact field that caused the rejection.

  • 999 structural acknowledgment — catches format errors before payer processing
  • 277CA transport acknowledgment — confirms payer accepted the claim for adjudication
  • 835 remittance — payment confirmation or denial with reason codes
  • Rejection router classifies denial reason and assigns correction responsibility
  • Remediation workspace shows the exact field causing the rejection with inline editing

Providers

Clinical corrections requested with specific context — no vague billing callbacks

Billing

Field-level rejection guidance in the same workspace as claim review

Leaders

Parity dashboard compares AIMS unit totals to legacy system — proves billing accuracy

Smith, J. — OR 4

Paid

16 units · $487.20 · Blue Cross

Torres, M. — OR 7

Denied

CO-97 — Benefit not covered under plan

42

Readiness

Assigned to Billing — Remediation

Missing supervising NPI for QK supervision model. Add NPI to resubmit.

Running Through Every Step

Tamper-Evident Audit Trail

Every action at every step — case scheduled, medication logged, timestamp locked, correction made, claim submitted — is recorded in an append-only audit log. Nothing is deleted. Nothing is overwritten.

HMAC-SHA256 Hash Chain

Each audit record includes the HMAC of the previous record. Any modification breaks the chain — independently detectable.

7-Year Retention

Meets HIPAA record retention requirements. Every event from every case is retained and exportable.

5 Event Classes

Access, Mutation, Privileged, Integration, and Submission — all captured with source tags (Tap, OCR, Voice, Scan, System).

FaceID on Corrections

Corrections require biometric confirmation. Provider identity, original value, corrected value, and reason code are all recorded.

Original Always Preserved

Corrections append a new record with a correction_of reference. The original event is never altered or deleted.

Legal-Grade Export

The full audit log is exportable for malpractice defense, payer audits, and compliance reviews.

Correction model: Corrections create new events with correction_of references to the original. The original is never altered. Every correction records the provider identity, timestamp, and FaceID confirmation.

HIPAA CompliantSOC 2 Type IIInfrastructure by AptibleData Owned by Your Organization

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