Overview
A regional hospital network was facing rising costs from preventable 30-day readmissions, particularly among heart failure and COPD patients. They needed a predictive system that could flag high-risk patients before discharge, giving care teams time to intervene with targeted follow-up plans.
We built a machine learning pipeline that ingests EHR data — demographics, diagnosis codes, lab results, prior admissions, and social determinants of health — to generate a real-time risk score for every patient approaching discharge. The model integrates directly into the hospital’s existing care coordination workflow.
How It Works
1. Data Ingestion & Feature Engineering
- Automated ETL pipeline pulls from Epic EHR system via HL7 FHIR APIs
- 47 clinical features extracted including comorbidity indices, medication counts, length of stay, and prior utilization
- Social determinant overlays from census and claims data
- Real-time data validation and missing value imputation
2. Predictive Model
- Gradient-boosted ensemble (XGBoost) trained on 3 years of historical discharge data (~45,000 encounters)
- Explainable AI layer (SHAP values) so clinicians understand why a patient is flagged
- Calibrated probability outputs, not just binary classification
- Monthly model retraining with drift detection alerts
3. Clinical Integration
- Risk scores surface directly in the Epic discharge planning workflow
- Color-coded alerts: green (<20%), yellow (20-50%), red (>50% readmission probability)
- Automated care plan suggestions based on top risk factors
- Daily digest reports for care coordination managers
Architecture & Infrastructure
Data Layer
Epic FHIR APIs, HL7 integration, HIPAA-compliant data lake on AWS S3
ML Pipeline
SageMaker training, feature store, model registry, automated retraining
Inference
Real-time scoring API via Lambda, <3min end-to-end latency
Monitoring
CloudWatch dashboards, model drift detection, A/B testing framework
Performance
Sensitivity (Recall)
82%
Specificity
91%
Positive Predictive Value
74%
Model Retraining Cycle
Monthly
Interested in a similar solution for your organization?
Request a Consultation