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CKD Care Orchestration — Demo Framework

A teaching demonstration of care orchestration across the full CKD-to-ESKD journey.

This is a demonstration of care orchestration — a working illustration, not a product. It shows how a semi-standalone orchestration layer would look sitting alongside existing EHRs: fed by AI-reviewed HIE records, ADT feeds, and delayed claims; organizing a patient's decade-long kidney journey; and tracking not just what should happen next, but whether the last recommendation actually happened — and why not. Everything here is synthetic. The point is to make three habits of mind concrete: judge systems by what data they realistically receive; read patients as trajectories, not snapshots; and know when to put the data down and ask what this person is actually capable of. HIE = health information exchange (records shared between organizations) · ADT = hospital admission/discharge/transfer messages.

🎯 What this demo teaches

1 · What orchestration can — and cannot — do. An orchestration layer sits beside the EHR. It sequences work, tracks whether recommendations were acted on, and coordinates across organizations. It does not replace clinical judgment, and it cannot act on data it never receives.
2 · Change over time beats snapshots. CKD is a decade-long trajectory. The unit of insight is the delta — eGFR slope, proteinuria trend, and the gap between what was recommended last visit and what actually happened (the Fourth Gate). A single encounter viewed in isolation is almost always misleading.
3 · Data is not the patient. Sometimes the right move is to step back and ask what the patient is truly capable of — function, cognition, literacy, transportation, caregiver support, finances, goals — not what the record says.
🔒 No live AI runs in this demo — every AI output you'll see was authored in advance and frozen in, so the demo is reproducible.

🚀 How to Use This Demo

  1. Choose a patient — open 👥 Patients to browse the eighteen cases; each has a unique clinical arc from early CKD to its outcome.
  2. See their narrative journey — 📖 Patient Narratives tells the whole story start to finish: encounters, labs, decisions, care team, and agentic opportunities in sequence.
  3. Get into the details — ★ Patient Journey gives the encounter-by-encounter view: timeline, care snapshot, checklist findings, and care-team coordination for each visit.
  4. Look at the checklists in detail — Checklist mode walks the seven CKD Care Categories; enter values to activate next-best-action logic and surface critical gaps.
  5. Review references and trigger thresholds — ⚡ Reference & Triggers holds the evidence library and the thresholds that drive each alert.
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18 AI-Generated Patient Cases

Realistic longitudinal histories spanning up to 11 years — from early CKD through hemodialysis, peritoneal and home dialysis, transplant, conservative management, and death before ESKD.

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Full Care Journey Visualization

Each encounter is plotted on an eGFR timeline with CKD stage transitions, care team coordination gaps, and HIE data availability shown in real time.

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Evidence-Based Checklists

Seven CKD Care Categories map the framework's checklist logic to each encounter — the underlying items drive next-best-action and gap identification.

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Multi-Disciplinary Care Team

Each case includes a full care team across fragmented EHR systems, showing coordination gaps, HIE limitations, and value-based care context.

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Episodes, Events & Illness Threads

Each history is organized as a clinical construct — encounters, events (turning points), illness threads (with acuity, chronicity & progression), and episodes, shown as Acts, that group them.

CKD Progression Pathway — eGFR-Staged Decision Framework
G3a ≥45 G3b 30–44 G4 15–29 G5 <15 60 45 30 25 20 15 10 5 eGFR ml/min ← declining eGFR CKD Education & Monitoring Structured CKD edu · Modality counseling · Transplant options · Goals of care DIALYSIS HD Access Planning AV Fistula / Graft Referral ICHD / HHD PD Pathway PD Cath. Peritoneal Dialysis TRANSPLANT Eval / Listing Transplant Evaluation Waitlist Kidney Transplant CONSERVATIVE Kidney Mgmt Conservative Kidney Management (CKM) Palliative / Hospice Palliative / Hospice Stage G4 eGFR ≤30 Goals of Care Modality + Tx Access Prep eGFR ≤20 ESKD Zone eGFR ≤15 ← Earlier CKD (G3a–G3b) ESKD / active treatment →
How each journey is organized — episodes, events & illness threads
EncounterA single visit or contact — the points plotted on the eGFR timeline above.
EventA turning point — a new diagnosis, an acute illness, a hospitalization, or a medication change.
Illness threadA condition running through time, each carrying its own acuity, chronicity, and progression.
Episode (Act)A chapter grouping the encounters and events of one phase — pre-dialysis, dialysis, transplant, and so on.
Disease chronicity is tracked on three independent axes: acuity (acute vs. chronic), chronicity (self-limited · persistent · relapsing), and progression (improving · stable · progressive) — so an illness can remain “chronic” while its trajectory changes from year to year.
⚠️ DEMONSTRATION ONLY — NOT FOR CLINICAL USE. This tool is a conceptual prototype for stakeholder and design review. It has not been validated, regulated, or approved for patient care. All patient data is AI-generated and entirely fictional. Clinical decisions must be made by qualified clinicians using current evidence and guidelines.
DEMONSTRATION ONLY — NOT FOR CLINICAL USE — CKD Care Orchestration Framework v0.1 Demo
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CKD not yet confirmed
Downstream action-oriented modules operate in informational-only mode until CKD designation is confirmed. See item 1.1.
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Demo Case
Encounter:
🔄 Encounter loaded
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Draft Clinical Note — CKD Care Category 1 Summary

Click to expand ▾
✓ Copied!

👥 Demo Patient Profiles

18 demo patients — load any into the Narrative, Patient Journey, or Checklist