Why clinics fill with the wrong patients

Socrates Pre-Op is the Pathways voice agent that takes a structured anaesthetic history from a patient by phone. It is delivered as a secure, time-limited SMS link — no app, no login, no paper questionnaire — and covers 12 clinical domains conversationally, producing structured, severity-tagged findings that feed the risk engine directly.

It is a purpose-built anaesthetic variant rather than a generic intake bot. The distinction matters in practice: a general-purpose intake tool collects answers to the questions it was given, whereas an anaesthetic interview needs to follow up on a positive family history of anaesthetic problems, probe functional capacity when a patient says they are “fine”, and recognise when a described medication is worth photographing.

Completion is tracked, and a finished interview automatically triggers a fresh risk analysis.

How this compares with the two methods it usually replaces — paper questionnaires and telephone pre-assessment — including where each of those still wins.

The Socrates Pre-Op interview covers 12 domains — surgical context, presenting symptoms, prior anaesthetics, systems review, functional capacity and frailty, airway assessment, medications and allergies, social and risk factors, implanted devices, pre-op investigations, a red-flag screen, and safety and shared decisions.

Every domain produces structured, severity-tagged findings rather than free text, which is what allows the risk engine to screen on them directly instead of re-parsing a narrative.

Pathways screens each case with deterministic, versioned rules referenced to perioperative guidelines. Every flag carries a severity tier, the clinical rationale, the triggering evidence, the guideline reference and a recommended action, plus the rule version that produced it. The same inputs always produce the same flags, months later.

Screening covers the domains that drive perioperative outcomes: unstable cardiac symptoms, marked hypertension, diabetes control and SGLT2 management, obstructive sleep apnoea, frailty, malnutrition, functional capacity, smoking and discharge support.

Pathways also states what it does not know. Missing investigations and unconfirmed timings are listed explicitly on every profile, and extraction confidence is shown rather than hidden — a profile that is 86% confident about a patient-reported HbA1c says so.

Yes. Pathways keeps org-wide and per-patient audit logs with full workflow tracing on every risk analysis — the inputs used, the rule version that fired, the output produced, and the human who reviewed it, all timestamped. Logs are exportable for governance committees, M&M review and accreditation.

Because the safety-critical rules are deterministic and versioned, an audit is reproducible rather than merely archived: re-running a case against the rule version recorded at the time produces the same flags. That is the property that lets a decision made in March be examined in September without argument about whether the system “would have said something different”.

They proceed. Every completed profile carries a triage recommendation — anaesthetist review, pre-admission clinic, telephone review, or no further assessment — so clinic slots go to moderate-risk patients and anaesthetist time goes to red flags. Low-risk patients are not routed into a clinic appointment they do not need.

This is the throughput argument, and it runs in both directions. A pre-admission clinic booked out three weeks ahead with mostly healthy ASA 1 patients is not short of capacity so much as misallocating it. Screening every patient at booking makes the queue orderable by risk rather than by whoever called first.

The tracker shows exactly where they stopped — sent, opened, part-way through, or expired — and automated reminders go out without anyone chasing. A link can be resent in one click. Because the status is visible per patient rather than inferred from silence, an incomplete assessment becomes a task on a list instead of a discovery on the day of surgery.

Non-completion is normal and expected — it is why the tracker exists. The failure mode worth designing against is not the patient who does not finish, but the service that does not know they did not finish until the pre-admission clinic.

Patients who genuinely cannot complete a remote assessment are then a known, named group who can be routed to a phone call or a clinic slot deliberately, rather than turning up unassessed.

They are identified as a group rather than missed. The assessment needs only a phone that receives SMS and opens a link — no app, no login, no account. Patients who cannot complete it that way show as incomplete on the tracker, so the service can route them to a telephone assessment or a clinic slot deliberately instead of discovering the gap later.

The design point is that remote assessment does not have to work for every patient to be worth doing. It has to work for enough of them that the clinic’s finite capacity can be pointed at the ones it does not work for — which includes patients without a suitable phone, patients who need an interpreter, and patients who would simply rather come in.

What Pathways changes is that this group is visible in advance and small enough to plan around, instead of being indistinguishable from everyone else on the list.

Most of a Socrates Pre-Op interview is conversational rather than form-filling, and patients complete it from home in their own time rather than in a clinic slot. It can be paused and resumed, and photographing medications happens during the conversation rather than as separate homework. Duration varies with how complex the patient's history is.

The comparison that matters is not against a stopwatch but against what it replaces: a paper questionnaire that arrives in the post and comes back incomplete, or a phone call at a time that suits the service rather than the patient.

Complexity drives length, which is the correct behaviour — a patient with a long medication list and several prior anaesthetics has more to cover than a healthy patient presenting for a day case, and a structured interview should spend the time where the information is.