Healthcare Ontology

Comprehensive domain knowledge for healthcare organizations, including hospitals, clinics, health systems, and telehealth providers.

Overview

The Healthcare ontology equips AI agents with deep understanding of healthcare operations:

• Patient Management: Registration, scheduling, care coordination
• Clinical Workflows: Orders, results, documentation
• Revenue Cycle: Billing, claims, collections
• Compliance: HIPAA, regulatory reporting
• Quality & Safety: Metrics, incident reporting

Ontology Layers

Role Layer

roles:
  - name: Patient Services Agent
    responsibilities:
      - Handle appointment scheduling
      - Process registration updates
      - Answer patient inquiries
      - Manage referrals
    permissions:
      - read: demographics, appointments, insurance
      - execute: schedule, reschedule, send_reminder
    phi_access: limited  # Only what's needed for task

  - name: Clinical Support Agent
    responsibilities:
      - Process order requests
      - Track results delivery
      - Manage clinical documentation
    permissions:
      - read: orders, results, notes
      - execute: flag_critical, notify_provider
    phi_access: clinical  # Full clinical context

  - name: Revenue Cycle Agent
    responsibilities:
      - Process claims
      - Handle denials
      - Manage patient billing
    permissions:
      - read: claims, payments, balances
      - execute: submit_claim, appeal_denial, payment_plan
    phi_access: billing  # Financial and demographic only

Domain Layer

Key Entities

Entity	Description	Key Attributes
Patient	Healthcare recipient	MRN, Name, DOB, Insurance, PCP
Encounter	Care episode	ID, Type, Date, Provider, Facility
Provider	Clinician	NPI, Name, Specialty, Credentials
Order	Clinical request	ID, Type, Status, Urgency, Results
Claim	Billing submission	ID, Amount, Payer, Status, Codes
Appointment	Scheduled visit	ID, Time, Type, Provider, Status

Entity Relationships

erDiagram
    PATIENT ||--o{ ENCOUNTER : has
    PATIENT ||--o{ APPOINTMENT : schedules
    PATIENT ||--o{ INSURANCE : covered_by
    ENCOUNTER ||--o{ ORDER : contains
    ENCOUNTER ||--o{ DIAGNOSIS : documents
    ENCOUNTER ||--|| PROVIDER : seen_by
    ENCOUNTER ||--o{ CLAIM : generates
    ORDER ||--o| RESULT : produces

Interaction Layer

Common Workflows

Appointment Scheduling

sequenceDiagram
    participant P as Patient
    participant A as Agent
    participant S as Scheduling
    participant E as EHR

    P->>A: Request Appointment
    A->>E: Check Patient Status
    E-->>A: Patient Record
    A->>S: Find Available Slots
    S-->>A: Available Times
    A->>P: Offer Options
    P->>A: Select Time
    A->>S: Book Appointment
    S-->>A: Confirmation
    A->>P: Send Confirmation

Clinical Order Processing

graph LR
    A[Order Placed] --> B{Urgent?}
    B -->|Yes| C[Priority Queue]
    B -->|No| D[Standard Queue]
    C --> E[Process Order]
    D --> E
    E --> F[Perform Test]
    F --> G[Results Available]
    G --> H{Critical?}
    H -->|Yes| I[Immediate Alert]
    H -->|No| J[Standard Notification]

Regulatory Compliance

Regulation	Scope	Agent Actions
HIPAA	Protected Health Info	Access logging, minimum necessary, encryption
HITECH	EHR meaningful use	Audit trails, breach notification
CMS CoP	Hospital conditions	Quality reporting, safety protocols
Joint Commission	Accreditation	Documentation standards
State Laws	Varies by state	Consent management, reporting

HIPAA Considerations for AI Agents

const hipaaGuardrails = {
  // Minimum Necessary Rule
  dataAccess: {
    principle: "minimum_necessary",
    enforce: true,
    auditAll: true
  },

  // PHI Handling
  phi: {
    neverLog: ["ssn", "full_dob", "credit_card"],
    maskInLogs: ["mrn", "name", "address"],
    encryptAtRest: true,
    encryptInTransit: true
  },

  // Access Controls
  access: {
    requireAuthentication: true,
    requireAuthorization: true,
    logAllAccess: true,
    breakGlassAudit: true
  }
};

Prompt Templates

Patient Inquiry

You are a patient services agent for {organization_name}.

Patient Context:
- Name: {patient_name}
- MRN: {mrn}
- Upcoming appointments: {appointments}
- Outstanding balance: {balance}

Patient Question: {question}

Guidelines:
1. Be empathetic and professional
2. Only share information the patient is authorized to access
3. For clinical questions, direct to their care team
4. For urgent symptoms, advise ER/urgent care

Respond helpfully while maintaining HIPAA compliance.

Appointment Management

You are a scheduling agent processing an appointment request.

Request Details:
- Patient: {patient_name} (MRN: {mrn})
- Requested service: {service_type}
- Preferred times: {preferences}
- Insurance: {insurance}

Provider Availability:
{available_slots}

Find the best appointment option considering:
1. Patient preferences
2. Clinical urgency
3. Insurance requirements
4. Travel/accessibility needs

Integration Points

EHR Systems

System	Capabilities	Agent Actions
Epic	Full EHR	MyChart messages, scheduling, orders
Cerner	Full EHR	Patient portal, results, documentation
Athenahealth	Cloud EHR	Scheduling, billing, messaging
Meditech	Hospital EHR	ADT, orders, results

Healthcare APIs

Standard	Purpose	Use Case
HL7 FHIR	Data exchange	Patient records, clinical data
HL7 v2	Messaging	ADT, orders, results
X12 EDI	Claims	837/835 transactions

Metrics & KPIs

Metric	Description	Agent Monitoring
Patient Wait Time	Avg time to appointment	Alert if > 14 days
No-Show Rate	Missed appointments	Alert if > 10%
Clean Claim Rate	First-pass acceptance	Alert if < 95%
Patient Satisfaction	Survey scores	Alert if < 85%

Sample Agent Configuration

const healthcareAgent = {
  name: "Patient Services",
  ontology: "healthcare-v1",
  autonomyLevel: "L2", // Supervised

  capabilities: {
    scheduling: true,
    patientInquiries: true,
    insuranceVerification: true,
    referralManagement: true
  },

  guardrails: {
    hipaaCompliance: "strict",
    phiHandling: "minimum_necessary",
    requireApprovalFor: [
      "cancel_appointment",
      "update_demographics",
      "share_records"
    ],
    blockedActions: [
      "clinical_advice",
      "diagnosis_discussion",
      "medication_changes"
    ]
  },

  integrations: [
    "epic_mychart",
    "insurance_eligibility",
    "scheduling_system"
  ]
};

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HIPAA Compliance

All healthcare agents must operate under strict HIPAA guidelines. Ensure proper Business Associate Agreements (BAAs) are in place and all PHI access is logged and auditable.

Getting Started

To deploy a Healthcare agent:

1. Select the Healthcare ontology during workspace setup
2. Configure EHR integration (FHIR preferred)
3. Enable HIPAA-compliant audit logging
4. Start with L1 (Assisted) autonomy for clinical workflows