DocChart

Population Health

PHM worklist

Loading action queue

Loading matching patients, saved rows, and evidence layers.

Building the scoped worklist view

PHM worklist

HbA1c overdue

Import: docchart_synthetic_population_300.json | Diabetes | showing the first 8 patients for fast loading.
Queue mode: Last saved list.

PHM

Cohort

Ask

Patient scope

Import: docchart_synthetic_population_300.json

Counts are unique patients. Import scopes can overlap when several uploaded files contain the same patient.

All patients

9 unique / 403

docchart_synthetic_population_300.json

8 here / 300

docchart_synthetic_population_300.json

8 here / 300

synthetic-100-longitudinal.xml

None here / 100

sample-omd.xml

None here / 0

What This List Is

HbA1c evidence missing in the last 6 months.

high

Structured fact

Needs review

8, active workflow rows

Queued for:

HbA1c overdue

How selected:

Deterministic rule + clinician review

Where saved:

PHM workflow rows; escalations become Flags & Tasks.

When updated:

Create queue adds new matches; existing decisions stay saved.

Priority & AI-CDS Evidence

Priority score from the configured PHM rule: base priority plus modifiers such as open flags, age, linked care gaps, or follow-up gaps. Scores are capped at 100.

It is a sorting signal, not a diagnosis. The score combines the rule base priority with modifiers such as open flags, age, overdue visits, or linked care gaps.

Quality Standards:

CEP resources:

Workflow

Save a work queue, then use each patient card to record what happened next.

Build cohort

Ask AI

1. Match

DocChart finds patients who match this rule.

2. Queue

patients are waiting for action.

3. Act

Record call, recall, flag, book, snooze, or close.

4. AI-CDS

Use AI/CDS or cohorts when you need more context.

Current view: Patients from the most recent saved queue run.

Most staff work from Active saved rows after saving today's list.

Prediabetes and Type 2 DiabetesQuality Standard linked through AI-CDS guidance retrieval

Patients

Showing 8 of 8 visible rows from 8 matched patients.

8, shown

Brian Little

66y | unknown | English

Priority ,85

new

3, flag,s

Care team: Amina Farah
Last touch: 2026-05-09

4 evidence layers

Structured fact

DocChart PHM rule

HbA1c overdue 2026.05

HbA1c evidence missing in the last 6 months.

DocChart flags

3 open clinical flags

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Prediabetes and Type 2 Diabetes

Evidence details (2)

Workflow state

new

Created from PHM workbench for clinician review. Saved queue row retained even though the current live rule no longer matches.

Matched by:

structured PHM rule

Strengthen with:

fresh labs, recent visit note, or confirmed OpenMed fact.

False positive risk:

stale imported record, resolved condition, duplicate note mention, or missing exclusion.

Evidence freshness:

last touch 2026-05-09

Chart

More actions

Carl Lloyd

90y | M | Portuguese

Priority ,85

new

3, flag,s

Care team: Eric Lavoie
Last touch: 2025-09-24

4 evidence layers

Structured fact

DocChart PHM rule

HbA1c overdue 2026.05

HbA1c evidence missing in the last 6 months.

DocChart flags

3 open clinical flags

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Prediabetes and Type 2 Diabetes

Evidence details (2)

Workflow state

new

Created from PHM workbench for clinician review. Saved queue row retained even though the current live rule no longer matches.

Matched by:

structured PHM rule

Strengthen with:

fresh labs, recent visit note, or confirmed OpenMed fact.

False positive risk:

stale imported record, resolved condition, duplicate note mention, or missing exclusion.

Evidence freshness:

last touch 2025-09-24

Chart

More actions

Eric Mendoza

74y | M | English

Priority ,85

new

5, flag,s

Care team: Melinda Chu
Last touch: 2026-04-30

4 evidence layers

Structured fact

DocChart PHM rule

HbA1c overdue 2026.05

HbA1c evidence missing in the last 6 months.

DocChart flags

5 open clinical flags

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Prediabetes and Type 2 Diabetes

Evidence details (2)

Workflow state

new

Created from PHM workbench for clinician review. Saved queue row retained even though the current live rule no longer matches.

Matched by:

structured PHM rule

Strengthen with:

fresh labs, recent visit note, or confirmed OpenMed fact.

False positive risk:

stale imported record, resolved condition, duplicate note mention, or missing exclusion.

Evidence freshness:

last touch 2026-04-30

Chart

More actions

Jerry Noble

58y | M | French

Priority ,85

new

4, flag,s

Care team: Amina Farah
Last touch: 2026-05-03

4 evidence layers

Structured fact

DocChart PHM rule

HbA1c overdue 2026.05

HbA1c evidence missing in the last 6 months.

DocChart flags

4 open clinical flags

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Prediabetes and Type 2 Diabetes

Evidence details (2)

Workflow state

new

Created from PHM workbench for clinician review. Saved queue row retained even though the current live rule no longer matches.

Matched by:

structured PHM rule

Strengthen with:

fresh labs, recent visit note, or confirmed OpenMed fact.

False positive risk:

stale imported record, resolved condition, duplicate note mention, or missing exclusion.

Evidence freshness:

last touch 2026-05-03

Chart

More actions

Noah Vasquez

62y | M | English

Priority ,85

new

4, flag,s

Care team: Amina Farah
Last touch: 2026-01-01

4 evidence layers

Structured fact

DocChart PHM rule

HbA1c overdue 2026.05

HbA1c evidence missing in the last 6 months.

DocChart flags

4 open clinical flags

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Prediabetes and Type 2 Diabetes

Evidence details (2)

Workflow state

new

Created from PHM workbench for clinician review. Saved queue row retained even though the current live rule no longer matches.

Matched by:

structured PHM rule

Strengthen with:

fresh labs, recent visit note, or confirmed OpenMed fact.

False positive risk:

stale imported record, resolved condition, duplicate note mention, or missing exclusion.

Evidence freshness:

last touch 2026-01-01

Chart

More actions

Phillip Eaton

43y | M | English

Priority ,85

new

2, flag,s

Care team: Wole Oduntan
Last touch: 2026-05-17

4 evidence layers

Structured fact

DocChart PHM rule

HbA1c overdue 2026.05

HbA1c evidence missing in the last 6 months.

DocChart flags

2 open clinical flags

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Prediabetes and Type 2 Diabetes

Evidence details (2)

Workflow state

new

Created from PHM workbench for clinician review. Saved queue row retained even though the current live rule no longer matches.

Matched by:

structured PHM rule

Strengthen with:

fresh labs, recent visit note, or confirmed OpenMed fact.

False positive risk:

stale imported record, resolved condition, duplicate note mention, or missing exclusion.

Evidence freshness:

last touch 2026-05-17

Chart

More actions

Richard Brown

40y | M | French

Priority ,85

new

1, flag,

Care team: Eric Lavoie
Last touch: 2025-07-14

4 evidence layers

Structured fact

DocChart PHM rule

HbA1c overdue 2026.05

HbA1c evidence missing in the last 6 months.

DocChart flags

1 open clinical flag

Possible diabetes monitoring care gap | medium | new | structured

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Prediabetes and Type 2 Diabetes

Evidence details (2)

Workflow state

new

Created from PHM workbench for clinician review. Saved queue row retained even though the current live rule no longer matches.

Matched by:

structured PHM rule

Strengthen with:

fresh labs, recent visit note, or confirmed OpenMed fact.

False positive risk:

stale imported record, resolved condition, duplicate note mention, or missing exclusion.

Evidence freshness:

last touch 2025-07-14

Chart

More actions

Stephen Moore

69y | M | English

Priority ,85

new

9, flag,s

Care team: Eric Lavoie
Last touch: 2026-04-26

4 evidence layers

Structured fact

DocChart PHM rule

HbA1c overdue 2026.05

HbA1c evidence missing in the last 6 months.

DocChart flags

9 open clinical flags

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Prediabetes and Type 2 Diabetes

Evidence details (2)

Workflow state

new

Created from PHM workbench for clinician review. Saved queue row retained even though the current live rule no longer matches.

Matched by:

structured PHM rule

Strengthen with:

fresh labs, recent visit note, or confirmed OpenMed fact.

False positive risk:

stale imported record, resolved condition, duplicate note mention, or missing exclusion.

Evidence freshness:

last touch 2026-04-26

Chart

More actions

8, shown

Brian Little

66y | unknown | English

Priority ,85

new

3, flag,s

Care team: Amina Farah
Last touch: 2026-05-09

4 evidence layers

Structured fact

DocChart PHM rule

HbA1c overdue 2026.05

HbA1c evidence missing in the last 6 months.

DocChart flags

3 open clinical flags

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Prediabetes and Type 2 Diabetes

Evidence details (2)

Workflow state

new

Created from PHM workbench for clinician review. Saved queue row retained even though the current live rule no longer matches.

Matched by:

structured PHM rule

Strengthen with:

fresh labs, recent visit note, or confirmed OpenMed fact.

False positive risk:

stale imported record, resolved condition, duplicate note mention, or missing exclusion.

Evidence freshness:

last touch 2026-05-09

Chart

More actions

Carl Lloyd

90y | M | Portuguese

Priority ,85

new

3, flag,s

Care team: Eric Lavoie
Last touch: 2025-09-24

4 evidence layers

Structured fact

DocChart PHM rule

HbA1c overdue 2026.05

HbA1c evidence missing in the last 6 months.

DocChart flags

3 open clinical flags

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Prediabetes and Type 2 Diabetes

Evidence details (2)

Workflow state

new

Created from PHM workbench for clinician review. Saved queue row retained even though the current live rule no longer matches.

Matched by:

structured PHM rule

Strengthen with:

fresh labs, recent visit note, or confirmed OpenMed fact.

False positive risk:

stale imported record, resolved condition, duplicate note mention, or missing exclusion.

Evidence freshness:

last touch 2025-09-24

Chart

More actions

Eric Mendoza

74y | M | English

Priority ,85

new

5, flag,s

Care team: Melinda Chu
Last touch: 2026-04-30

4 evidence layers

Structured fact

DocChart PHM rule

HbA1c overdue 2026.05

HbA1c evidence missing in the last 6 months.

DocChart flags

5 open clinical flags

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Prediabetes and Type 2 Diabetes

Evidence details (2)

Workflow state

new

Created from PHM workbench for clinician review. Saved queue row retained even though the current live rule no longer matches.

Matched by:

structured PHM rule

Strengthen with:

fresh labs, recent visit note, or confirmed OpenMed fact.

False positive risk:

stale imported record, resolved condition, duplicate note mention, or missing exclusion.

Evidence freshness:

last touch 2026-04-30

Chart

More actions

Jerry Noble

58y | M | French

Priority ,85

new

4, flag,s

Care team: Amina Farah
Last touch: 2026-05-03

4 evidence layers

Structured fact

DocChart PHM rule

HbA1c overdue 2026.05

HbA1c evidence missing in the last 6 months.

DocChart flags

4 open clinical flags

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Prediabetes and Type 2 Diabetes

Evidence details (2)

Workflow state

new

Created from PHM workbench for clinician review. Saved queue row retained even though the current live rule no longer matches.

Matched by:

structured PHM rule

Strengthen with:

fresh labs, recent visit note, or confirmed OpenMed fact.

False positive risk:

stale imported record, resolved condition, duplicate note mention, or missing exclusion.

Evidence freshness:

last touch 2026-05-03

Chart

More actions

Noah Vasquez

62y | M | English

Priority ,85

new

4, flag,s

Care team: Amina Farah
Last touch: 2026-01-01

4 evidence layers

Structured fact

DocChart PHM rule

HbA1c overdue 2026.05

HbA1c evidence missing in the last 6 months.

DocChart flags

4 open clinical flags

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Prediabetes and Type 2 Diabetes

Evidence details (2)

Workflow state

new

Created from PHM workbench for clinician review. Saved queue row retained even though the current live rule no longer matches.

Matched by:

structured PHM rule

Strengthen with:

fresh labs, recent visit note, or confirmed OpenMed fact.

False positive risk:

stale imported record, resolved condition, duplicate note mention, or missing exclusion.

Evidence freshness:

last touch 2026-01-01

Chart

More actions

Phillip Eaton

43y | M | English

Priority ,85

new

2, flag,s

Care team: Wole Oduntan
Last touch: 2026-05-17

4 evidence layers

Structured fact

DocChart PHM rule

HbA1c overdue 2026.05

HbA1c evidence missing in the last 6 months.

DocChart flags

2 open clinical flags

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Prediabetes and Type 2 Diabetes

Evidence details (2)

Workflow state

new

Created from PHM workbench for clinician review. Saved queue row retained even though the current live rule no longer matches.

Matched by:

structured PHM rule

Strengthen with:

fresh labs, recent visit note, or confirmed OpenMed fact.

False positive risk:

stale imported record, resolved condition, duplicate note mention, or missing exclusion.

Evidence freshness:

last touch 2026-05-17

Chart

More actions

Richard Brown

40y | M | French

Priority ,85

new

1, flag,

Care team: Eric Lavoie
Last touch: 2025-07-14

4 evidence layers

Structured fact

DocChart PHM rule

HbA1c overdue 2026.05

HbA1c evidence missing in the last 6 months.

DocChart flags

1 open clinical flag

Possible diabetes monitoring care gap | medium | new | structured

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Prediabetes and Type 2 Diabetes

Evidence details (2)

Workflow state

new

Created from PHM workbench for clinician review. Saved queue row retained even though the current live rule no longer matches.

Matched by:

structured PHM rule

Strengthen with:

fresh labs, recent visit note, or confirmed OpenMed fact.

False positive risk:

stale imported record, resolved condition, duplicate note mention, or missing exclusion.

Evidence freshness:

last touch 2025-07-14

Chart

More actions

Stephen Moore

69y | M | English

Priority ,85

new

9, flag,s

Care team: Eric Lavoie
Last touch: 2026-04-26

4 evidence layers

Structured fact

DocChart PHM rule

HbA1c overdue 2026.05

HbA1c evidence missing in the last 6 months.

DocChart flags

9 open clinical flags

AI-CDS guidance

1 Quality Standard / 0 CEP resources

Prediabetes and Type 2 Diabetes

Evidence details (2)

Workflow state

new

Created from PHM workbench for clinician review. Saved queue row retained even though the current live rule no longer matches.

Matched by:

structured PHM rule

Strengthen with:

fresh labs, recent visit note, or confirmed OpenMed fact.

False positive risk:

stale imported record, resolved condition, duplicate note mention, or missing exclusion.

Evidence freshness:

last touch 2026-04-26

Chart

More actions