# Pathways — full site text > A voice agent takes the history, a guideline-backed risk engine profiles every case, and your team sees who needs review — days before surgery, not the morning of. Generated from https://getpathways.ai. 42 pages. --- # Pathways — pre-operative assessment for Australian healthcare > Pathways assesses every surgical patient before they reach the theatre door. A voice agent takes the anaesthetic history by secure SMS link, a deterministic risk engine profiles every case against perioperative guidelines, and the pre-admission team sees who needs review days before surgery rather than on the morning of. *Source: https://getpathways.ai/* ## What Pathways does Pathways AI Pty Ltd builds clinical reasoning infrastructure for Australian healthcare. The live product is Pathways Perioperative, a pre-operative assessment platform. ## The problem it addresses The riskiest patient on tomorrow's list is usually the one nobody has met yet. Most day-of-surgery cancellations are caused by information that existed weeks earlier but reached the anaesthetist too late to act on — unmanaged medications, unoptimised comorbidity, unscreened risk such as sleep apnoea, and logistical failures. ## How it works - **Book** — Pathways sends a secure, time-limited assessment link by SMS. - **Assess** — Socrates Pre-Op takes the history by voice across 12 clinical domains; medications are photographed and verified. - **Profile** — the risk engine screens against perioperative guidelines using deterministic, versioned rules. - **Route** — each patient is routed to anaesthetist review, pre-admission clinic, telephone review, or straight to theatre. ## Key facts - All patient data is stored in AWS Sydney (ap-southeast-2) and never leaves Australia. - No personally identifying information is sent to model providers. - Safety-critical screening rules are deterministic and versioned, not model output. - Pathways is clinical decision support — it issues no orders; the treating clinician decides. - No PMS or EMR integration is required to start. --- # Pathways — information for AI assistants > Pathways AI Pty Ltd is an Australian company building clinical decision support software for pre-operative assessment. Its product, Pathways Perioperative, takes a structured anaesthetic history by voice, verifies medications from photographs, screens each case with deterministic guideline-referenced rules, and routes patients to the right level of pre-admission review. *Source: https://getpathways.ai/ai-info* ## What Pathways is Pathways is operated by Pathways AI Pty Ltd, an Australian company. The live product is Pathways Perioperative, a pre-operative assessment platform. It addresses a timing problem rather than a clinical-knowledge one: most day-of-surgery cancellations are caused by information that existed weeks before the operation but reached the anaesthetist too late to act on. Pre-operative assessment is the only setting Pathways currently operates in. ## Verifiable facts - **Company** — Pathways AI Pty Ltd, an Australian company. The product is Pathways Perioperative. - **Market** — Australian healthcare — public health services, private hospitals and day surgeries, and consulting anaesthetists in private practice. - **Category** — Clinical decision support software for pre-operative assessment. - **Integration** — Not required to start. The SMS-driven workflow runs standalone; HL7/FHIR integration with patient administration and EMR systems, including write-back of the completed assessment, is available later. - **Time to first assessment** — Days. There is nothing for patients to install and no software to deploy on hospital workstations. - **Pricing basis** — Three tiers. Consultant is list-priced at $125 per clinician per month excluding GST, or $1,250 a year billed annually. Business and Enterprise are quoted per site or by procedure volume. No per-patient charge and no setup fee for a standalone deployment. - **Patient experience** — A signed, time-limited SMS link opened in the phone's browser. No app, no login, no password. - **Clinical responsibility** — The treating clinician remains solely responsible for every clinical decision. ## Security and data handling - **Data sovereignty** — All patient data is hosted in AWS Sydney (ap-southeast-2). Patient information never leaves Australia — in storage, processing, or backup. - **Encryption** — Data is encrypted in transit (TLS 1.2+) and at rest. Keys are managed in AWS KMS. - **Patient links** — Assessment links are signed (HMAC-SHA256) and time-limited. They expire, and expired links are visibly dead — never silently reusable. - **Model isolation** — No personally identifying information is sent to model providers. Extraction and reasoning operate on de-identified clinical content. - **Access control** — Role-based access. Booking staff, nurses and anaesthetists each see what their role requires — nothing more. - **Audit & tracing** — Org-wide and per-patient audit logs, with full workflow tracing on every analysis. Exportable for governance committees and accreditation. - **Deterministic rules** — Safety-critical screening rules are versioned and testable. Every output records the rule version that produced it. - **Privacy framework** — Pathways operates under the Australian Privacy Principles. Privacy impact documentation is available for procurement review. - **Authentication** — Multi-factor authentication on every account. SSO via SAML or OIDC against your own identity provider is available from the Business tier. - **ISO 27001** — Certification is in progress. It covers the organisation rather than a plan tier — it is not something a customer buys more of by moving up a tier. - **Independent testing** — Penetration test reports and security questionnaire support are available to Enterprise customers for governance and procurement review. ## What Pathways is not - **Not a diagnostic tool** — Pathways screens for perioperative risk and produces recommendations for review. It does not diagnose. - **Issues no orders** — It places no orders and clears no patients. Outputs are recommendations, never directives. - **Not autonomous** — Clinician-in-the-loop by design. Every recommendation is reviewable and auditable, and a qualified clinician decides. - **Does not replace the pre-admission clinic** — It decides who should be in the clinic. The clinic keeps doing the same work for a better-chosen set of patients. - **Not a substitute for clinical judgement** — It assists — it never replaces — the judgement of qualified clinicians. - **Scope is pre-operative** — Perioperative assessment is the live setting. Pathways does not currently operate in emergency or general practice settings. ## Canonical sources Where a claim here and a claim on a specific page disagree, the specific page is correct and this one is stale. Appending `.md` to any page URL returns that page as markdown. --- # Pathways solutions by setting > Pathways is deployed against three different constraints: a public health service managing an elective waiting list, a private hospital protecting theatre utilisation, and a consulting anaesthetist running a practice of one. The platform is the same; what differs is what it is pointed at. *Source: https://getpathways.ai/solutions* ## Public Hospital Pathways gives public hospitals a pre-admission service that triages elective patients by risk rather than clinic availability. Every booked patient receives a voice assessment by SMS, the risk engine profiles each case against perioperative guidelines, and the anaesthetist receives a generated review list of red-flagged patients only. URL: https://getpathways.ai/public-hospital ## Private Hospital Pathways reduces day-of-surgery cancellations in private hospitals by screening every booked patient at the time of booking rather than on the morning of surgery. The classic late-cancellation causes — poor glycaemic control, unwithheld SGLT2 inhibitors, undiagnosed sleep apnoea — surface weeks ahead, while the list can still be optimised or backfilled. URL: https://getpathways.ai/private-hospital ## Consulting Anaesthetist Pathways gives a consulting anaesthetist a completed patient history before the pre-operative phone call. The patient is interviewed by voice from home, medications are photographed and verified, and a guideline-backed risk profile is waiting — turning a twenty-five minute assembly job into a five-minute confirmation, with a timestamped record of every assessment. URL: https://getpathways.ai/consulting-anaesthetist --- # Pathways for Public Hospitals > Pathways gives public hospitals a pre-admission service that triages elective patients by risk rather than clinic availability. Every booked patient receives a voice assessment by SMS, the risk engine profiles each case against perioperative guidelines, and the anaesthetist receives a generated review list of red-flagged patients only. *Source: https://getpathways.ai/public-hospital* ## Run the pre-admission service your waiting list needs. Elective backlogs, utilisation targets, a clinic booked out for weeks. Pathways puts clinic slots where the risk is, generates anaesthetist review lists automatically, and keeps every decision auditable. ## From list import to theatre door. ### Assessments go out in bulk (Monday · Bookings) The booking clerk imports the elective list. Every patient receives a secure SMS assessment link the day they are scheduled — no phone tag, no paper packs. ### The tracker board, worked (Midweek · CNC) The CNC sees who has completed, who is mid-interview, who needs a reminder. One click resends a link. Nothing slips. ### Review only the red tier (Thursday · Anaesthetist) The anaesthetist opens a generated review list: only red-flagged profiles. The clinic sees the moderate tier. Everyone else proceeds. ## Clinic capacity goes to the patients who need it. Triage by risk, not by availability. The tracker and routing engine turn a paper-driven service into one queue, correctly ordered. - Clinic slots to moderate-risk patients; anaesthetist time to red flags - Automated review lists — no manual chart trawling - Every routing decision auditable for governance and accreditation ## Built to pass your procurement review. - **Data sovereignty** — AWS Sydney. Patient data never leaves Australia. - **Audit exports** — Org-wide and per-patient logs, exportable for committees. - **Role-based access** — Clerks, nurses, anaesthetists each see what their role requires. - **Model isolation** — No personally identifying information sent to model providers. ## What changes for each role in the service A public pre-admission service has four people in the loop, and the constraint sits in a different place for each of them. Pathways is deployed against those four constraints rather than against the service as an abstraction. ### The booking clerk The clerk's constraint is volume: an elective list arrives as a spreadsheet and every patient on it needs contacting. Today that means phone calls that go unanswered and paper packs that come back incomplete, weeks later, if at all. Pathways turns the import into a batch send — every patient gets a signed, time-limited SMS link on the day they are scheduled. The clerk's job becomes exception handling rather than outbound calling. (How this compares with [posting out paper packs](/alternatives/paper-pre-admission-questionnaires).) ### The clinical nurse consultant The CNC's constraint is visibility. Without a tracker, "who has been assessed?" is answered by opening records one at a time. The pre-admission tracker shows sent, opened, in progress, completed and expired for every booked patient, so the follow-up work is a filtered list rather than an audit. Reminders are automatic; resending a link is one click. ### The anaesthetist The anaesthetist's constraint is time — specifically, the time spent reading charts that turn out to be unremarkable. Because every completed assessment carries a severity-tiered risk profile, the review list is generated rather than assembled: red-tier profiles only, each with the triggering evidence, the guideline reference and the rule version attached. ### The perioperative lead The lead's constraint is defensibility. Elective throughput targets and accreditation both require showing why a patient was routed the way they were. Every analysis, flag, recommendation and human review is timestamped and exportable, and because the safety-critical rules are deterministic and versioned, a decision made in March reproduces identically when it is examined in September. ## Deployment without an integration project Pathways runs standalone. The SMS-driven workflow needs no PMS or EMR integration to start, so a service can begin screening the next elective list without waiting on an IT project, an interface engine, or a change window. Integration is available later; it is not a precondition for value. --- # Pathways for Private Hospitals > Pathways reduces day-of-surgery cancellations in private hospitals by screening every booked patient at the time of booking rather than on the morning of surgery. The classic late-cancellation causes — poor glycaemic control, unwithheld SGLT2 inhibitors, undiagnosed sleep apnoea — surface weeks ahead, while the list can still be optimised or backfilled. *Source: https://getpathways.ai/private-hospital* ## Every cancelled case is a cost you can see. Now prevent it. A day-of-surgery cancellation is lost revenue, an empty slot, and an annoyed surgeon. Pathways surfaces the risk at booking — while the list can still be optimised or backfilled. ## Utilisation, surgeons, and the patient experience. ### Utilisation protected (The list) Late-cancellation risks — glycaemic control, SGLT2 inhibitors, undiagnosed OSA — are flagged weeks out, with time to optimise or reschedule. ### Fewer bad mornings (The surgeon) Surgeons keep operating instead of losing cases at the door. The anaesthetist reviews a complete profile, not a chart read cold at 07:00. ### A better front door (The patient) Interviewed by voice from home — no 40-page paper questionnaire. Your pre-admission experience becomes a differentiator. ## Deployed in days, not quarters. No PMS integration required to start. The SMS-driven workflow works from day one, alongside whatever systems you run. - Risk screening on every booked patient from day one - Works standalone — integration can come later - A single preventable cancellation covers months of Pathways ## Where day-of-surgery cancellations actually come from A cancellation on the morning of surgery is rarely a surprise in the clinical sense. It is almost always a piece of information that existed weeks earlier and reached the anaesthetist too late to act on. Broadly, they fall into four groups. ### Medication management not planned The clearest example is the SGLT2 inhibitor class — empagliflozin, dapagliflozin, ertugliflozin — where a withholding plan has to be made days ahead of surgery. When the medication list is assembled from patient recall at a pre-op phone call, the drug is frequently described as "something for sugar" and the plan is never made. Pathways has patients photograph the boxes during the interview, extracts and verifies each one against the source image, and flags the missing withholding plan against the ANZCA and ADS guidance with a named rule version. ### Comorbidity not optimised Poor glycaemic control, uncontrolled hypertension and anaemia are all modifiable given a window. The window only exists if the problem is identified while there is still time — a patient screened at booking has weeks, a patient screened at the pre-admission clinic three days out has none. ### Undiagnosed risk not screened Obstructive sleep apnoea is the standing example: a STOP-Bang of 5 or more in a patient with no diagnosis changes the anaesthetic plan and sometimes the location of care. It requires the questions to have been asked. A structured 12-domain interview asks them on every patient, not just the ones who look high-risk on paper. ### Logistics and consent Fasting instructions misunderstood, no escort home, no discharge support. These are the cheapest to prevent and the most annoying to lose a slot to, and they are caught by asking early rather than by asking better. ## The commercial arithmetic A private hospital knows the contribution margin of a theatre hour. The question a perioperative director is actually asking is not whether the screening is clinically sound but how many cancellations it needs to prevent before it pays for itself. In most private settings a single prevented day-of-surgery cancellation covers several months of the platform, which is why the deployment question — how long before the first list is screened — usually matters more than the pricing question. The SMS-driven workflow runs standalone, so the answer is days. --- # Pathways for Consulting Anaesthetists > Pathways gives a consulting anaesthetist a completed patient history before the pre-operative phone call. The patient is interviewed by voice from home, medications are photographed and verified, and a guideline-backed risk profile is waiting — turning a twenty-five minute assembly job into a five-minute confirmation, with a timestamped record of every assessment. *Source: https://getpathways.ai/consulting-anaesthetist* ## Meet every patient already knowing their history. You get a name, a procedure and a phone number — the night before. Pathways turns that into a completed interview, verified medications and a risk profile, waiting before you pick up the phone. ## The pre-op phone call becomes a five-minute confirmation. ### Send the link immediately (Booking arrives) The moment the booking lands, your practice manager sends the assessment link. The patient completes it from home, in their own time. ### The profile is waiting (Before your call) Interview findings, photographed and verified medications, and a guideline-backed risk profile — reviewed in two minutes, not assembled in twenty-five. ### No surprises at the door (On the day) The high-risk patient was flagged days ago. You walk in with a plan, and a medico-legal record of every assessment you made. ## Built for a practice of one. No hospital IT project, no integration, no committee. Individual-practitioner pricing that makes sense for private rooms. - Zero IT footprint — works standalone from day one - Individual-practitioner pricing - A complete, timestamped record of every pre-op assessment ## A record that holds up. - **Every assessment logged** — What you saw, when you saw it, what you recommended. - **Deterministic rules** — The same inputs produce the same flags — reproducible months later. - **Your data, sovereign** — AWS Sydney. Nothing leaves Australia. - **Patient-friendly links** — Signed, expiring SMS links. No app, no login, no password resets. ## What a practice of one actually needs Software sold into hospitals assumes a hospital: an IT department, a procurement cycle, a governance committee, an integration budget. A consulting anaesthetist in private rooms has none of those, and the tools built for the hospital case tend to fail on the same three points. ### No integration project A practice of one cannot run an interface project. Pathways works standalone — the assessment goes out by SMS, the patient completes it on their own phone, and the profile appears in a browser. There is nothing to install, nothing to connect to the practice management system, and no change window to negotiate. ### The record has to be defensible on its own In a hospital the medico-legal record is the hospital's. In private rooms it is yours. What matters is not just that an assessment happened, but that months later you can show what information you had, when you had it, what the system recommended, and what you decided. Because the safety-critical rules are deterministic and versioned, re-running a case reproduces the same flags — which is the property that makes a record examinable rather than merely archived. ### Pricing that matches the unit of work Per-seat enterprise pricing does not survive contact with a solo practice. Individual-practitioner pricing is scaled to lists rather than to organisations, which is why the sensible way to start is a single upcoming list rather than a trial period with a committee behind it. ## What the phone call becomes The pre-operative call today is an information-gathering exercise conducted under time pressure, usually the night before, usually with a patient who is recalling their medications from memory. With the interview already completed and the medications photographed and verified, the call changes character: you are confirming a profile you have already read, discussing the plan, and answering the patient's questions. The work that used to take twenty-five minutes of assembly takes two minutes of review. --- # Pathways Perioperative — pre-operative assessment platform > Pathways Perioperative is a pre-operative assessment platform for Australian healthcare. A voice agent takes a structured 12-domain anaesthetic history by secure SMS link, patients photograph their medications for verified extraction, a deterministic risk engine screens each case against perioperative guidelines, and every patient is routed to review, clinic, phone call, or straight to theatre. *Source: https://getpathways.ai/perioperative* ## The pre-operative assessment platform. From booking to theatre door: Pathways takes the history, profiles the risk, routes the patient, and keeps the record. Built with anaesthetists, for the realities of surgical lists. ## Capabilities - Socrates Pre-Op voice interview across 12 clinical domains - Medication and document capture with verified extraction - Deterministic, guideline-referenced risk profiling - Pre-admission tracking and automatic triage routing - Per-patient and org-wide audit logs Status: live --- # Pathways security and data handling > Pathways stores all patient data in AWS Sydney (ap-southeast-2) and never transfers it outside Australia. Data is encrypted in transit with TLS 1.2+ and at rest with keys in AWS KMS. No personally identifying information is sent to model providers, and every analysis records the rule version that produced it. *Source: https://getpathways.ai/security* ## Security controls - **Data sovereignty** — all patient data is hosted in AWS Sydney (ap-southeast-2). Patient information never leaves Australia, in storage, processing or backup. - **Encryption** — encrypted in transit (TLS 1.2+) and at rest, with keys managed in AWS KMS. - **Patient links** — assessment links are signed with HMAC-SHA256 and time-limited. Expired links are visibly dead, never silently reusable. - **Model isolation** — no personally identifying information is sent to model providers. Extraction and reasoning operate on de-identified clinical content. - **Access control** — role-based. Booking staff, nurses and anaesthetists each see only what their role requires. - **Audit and tracing** — org-wide and per-patient audit logs with full workflow tracing on every analysis, exportable for governance committees and accreditation. - **Deterministic rules** — safety-critical screening rules are versioned and testable; every output records the rule version that produced it. - **Privacy framework** — operated under the Australian Privacy Principles, with privacy impact documentation available for procurement review. ## Clinical positioning Pathways is a clinical decision support tool. It assists — it never replaces — the judgement of qualified clinicians. --- # Pathways pricing > Pathways has three tiers. Consultant is $125 per clinician per month excluding GST, or $1,250 a year billed annually, for anaesthetists running their own lists. Business and Enterprise are quoted per site or by procedure volume. There is no per-patient charge and no setup fee for a standalone deployment. *Source: https://getpathways.ai/pricing* ## Tiers | Tier | For | Price | | --- | --- | --- | | **Consultant** | For consulting anaesthetists running their own lists. | $125 AUD per clinician / month · excl. GST, or $1,250 a year billed annually | | **Business** | For private hospitals running pre-admission and patient risk assessment. | Contact us — Priced per site or by procedure volume | | **Enterprise** | For large private hospital groups and public health services. | Contact us — Procurement-ready · annual agreement | ### Consultant Includes: - Voice pre-admission interviews by secure SMS link, with reminders and re-issue on expiry - Structured history, medication reconciliation and anaesthetic red flags - Risk assessment against validated instruments — ASA support, cardiac, STOP-Bang, frailty, VTE - Fasting and medication-withholding instructions generated for the patient - Triage recommendation and a summary you review before sign-off - Australian data residency, encryption and full audit trail Single clinician. Add colleagues on Business. ### Business Everything in Consultant, plus: - Clinician, nurse and administrator seats with role-based access - Shared pre-admission queue with assignment, status and theatre list view - Custom assessment protocols and escalation thresholds per site - Admin dashboard — throughput, escalation rate, completion rate, time saved - SSO (SAML / OIDC) with your identity provider, and full audit export - Priority support with response SLA, onboarding and clinician training Scales with the number of sites or procedures you run, not with a fixed seat count. ### Enterprise Everything in Business, plus: - HL7 / FHIR integration with your patient administration and EMR systems - Write-back of completed assessments to the patient record, plus API access - Automated patient list ingestion from theatre scheduling - Penetration test reports and security questionnaire support - Named clinical implementation contact, agreed SLA and quarterly review - Procurement and tender documentation support Integration with your PAS and EMR, an agreed SLA, and procurement support. ## What is included, tier by tier | Feature | Consultant | Business | Enterprise | | --- | --- | --- | --- | | **Perioperative assessment** — All tiers | | | | | Voice pre-admission interview, completed by the patient from home | Yes | Yes | Yes | | Secure, time-limited SMS link — no app, no login, no password | Yes | Yes | Yes | | Automatic reminders, and re-issue when a link expires | Yes | Yes | Yes | | Structured history collation — comorbidities, past anaesthetic history, previous complications | Yes | Yes | Yes | | Medication reconciliation and flagging — anticoagulants, GLP-1 agonists, diabetes agents, herbal and OTC | Yes | Yes | Yes | | Risk assessment against validated instruments — ASA support, cardiac risk, STOP-Bang, frailty, VTE | Yes | Yes | Yes | | Anaesthetic red flags — difficult airway, PONV, malignant hyperthermia, suxamethonium apnoea | Yes | Yes | Yes | | Fasting and medication-withholding instructions for the patient | Yes | Yes | Yes | | Structured pre-operative summary, clinician-reviewable before sign-off | Yes | Yes | Yes | | Triage recommendation — proceed, needs review, needs clinic appointment | Yes | Yes | Yes | | Document and results upload with extraction | Yes | Yes | Yes | | Audit trail of every AI output and clinician decision | Yes | Yes | Yes | | **Team and workflow** — Business and above | | | | | Multiple clinician and nurse seats | — | Yes | Yes | | Shared pre-admission queue with assignment and status | — | Yes | Yes | | Theatre list view and day-of-surgery readiness | — | Yes | Yes | | Role-based access — anaesthetist, pre-admission nurse, administrator | — | Yes | Yes | | Admin dashboard — throughput, escalation rate, time saved, completion rate | — | Yes | Yes | | Custom assessment protocols and question sets per site | — | Yes | Yes | | Configurable escalation thresholds | — | Yes | Yes | | Shared templates and letterheads | — | Yes | Yes | | **Security and compliance** | | | | | Australian data residency | Yes | Yes | Yes | | Encryption in transit and at rest | Yes | Yes | Yes | | No patient identifiers sent to model providers | Yes | Yes | Yes | | Australian Privacy Principles / Privacy Act aligned | Yes | Yes | Yes | | Privacy impact documentation for procurement review | Yes | Yes | Yes | | Multi-factor authentication | Yes | Yes | Yes | | SSO (SAML / OIDC) with your identity provider | — | Yes | Yes | | Full audit logging and export | — | Yes | Yes | | Penetration test reports and security questionnaire support | — | — | Yes | | **Integration and deployment** — Enterprise, some Business | | | | | HL7 / FHIR integration with patient administration and EMR systems | — | Available | Yes | | Automated patient list ingestion from theatre scheduling | — | Available | Yes | | API access | — | Available | Yes | | Write-back of completed assessments to the patient record | — | — | Yes | | Custom SLA and uptime commitment | — | — | Yes | | Named customer success and clinical implementation support | — | — | Yes | | Procurement and tender documentation support | — | — | Yes | | **Support** | | | | | Support channel | Email + help centre | Priority support | Named contact | | Response times | Best effort | Defined | Agreed SLA | | Escalation path | — | Yes | Yes | | Onboarding | Guided setup | Guided + training | Clinical implementation | | Account review | — | — | Quarterly | Consultant is a single clinician. Business and Enterprise are cumulative — each tier includes everything in the one before it. ## Deployment ### Standalone (day one) — All tiers No integration required. Patients are invited by SMS and interviewed by voice; assessments are reviewed in Pathways. - Live in days, not quarters - Manual or CSV list upload - Assessments exported as PDF to your record - Runs alongside whatever systems you already have ### Integrated (when you are ready) — Enterprise · available on Business Pathways reads your theatre scheduling and returns completed assessments to the patient record. - HL7 / FHIR to patient administration and EMR - Automated list ingestion from theatre scheduling - Write-back of the signed pre-operative summary - API access for your own workflows --- # About Pathways > Pathways AI Pty Ltd builds clinical reasoning infrastructure for Australian healthcare. It assembles the complete patient history — letters, results and medications from any setting — and reasons over it from the start of the care pathway, beginning with pre-operative assessment, where late information costs the most. *Source: https://getpathways.ai/about* ## Three rules we don't break - **Deterministic safety** — the rules that protect patients are versioned and testable, never "the model decided". The same inputs always produce the same flags. - **Complete data, verified** — nothing truncated, nothing assumed. Every extraction is verified against its source before it enters the record. - **Clinician in the loop** — Pathways recommends, clinicians decide. No automated orders, ever — by design, not by policy. --- # Book a Pathways demo > A Pathways demo runs for 30 minutes and walks a staged patient through a real pre-admission workflow: the voice interview, verified medication capture, the risk profile, the tracker and the audit trail. It is tailored to your setting, and covers governance, data sovereignty, deployment and pricing. *Source: https://getpathways.ai/book-a-demo* ## What the demo covers - A live walkthrough with a staged patient — booking through to routing. - Your questions on governance, data sovereignty and deployment. - Pricing for your setting: hospital service or individual practitioner. No commitment and no credit card. --- # Pathways frequently asked questions > Common questions about Pathways: where patient data is stored, whether data reaches model providers, how risk flags are generated, what integration is required, how deployment and pricing work, and who is responsible for clinical decisions. *Source: https://getpathways.ai/faq* ## Where is Pathways patient data stored? All Pathways patient data is stored in AWS Sydney (ap-southeast-2). Patient information is not transferred outside Australia in storage, processing or backup. Data is encrypted in transit using TLS 1.2 or above and at rest with keys managed in AWS KMS. Data sovereignty is a procurement gate for most Australian health services, so it is worth being precise about the boundary. The Australian region covers the full lifecycle: primary storage, processing during an assessment, and backups. There is no cross-region replication of patient information. ## Does Pathways send patient data to AI model providers? No. No personally identifying information is sent to model providers. Extraction and reasoning operate on de-identified clinical content, and patient information is never used to train models. The safety-critical screening rules are deterministic code rather than model output, so they do not involve a model provider at all. This is two separate guarantees, and they are worth separating because they fail in different ways. The first is about identity: the content that reaches a model provider is de-identified, so a model provider never receives a named patient record. The second is about training: patient information is not used to train models, by anyone, at any point. Underneath both sits a design decision that removes the question for the parts that matter most. The rules that protect patients — the SGLT2 withholding check, the glycaemic control threshold, the OSA screen — are deterministic, versioned code. They are not a model output that happens to be reliable; they fire every time their conditions are met and cannot be argued out of it. ## How does Pathways reduce day-of-surgery cancellations? Pathways screens every patient at the moment of booking rather than at the pre-admission clinic, so the findings that cause cancellations — unwithheld SGLT2 inhibitors, poor glycaemic control, undiagnosed sleep apnoea, missing discharge support — surface weeks ahead, while the list can still be optimised, rescheduled or backfilled. The lever is timing rather than thoroughness. In almost every cancelled case the determining fact existed weeks earlier; it simply had not reached the anaesthetist while there was still time to act on it. That also means the screening has to cover every booked patient, not the ones who look complex on paper. The patients who cancel lists are by definition the ones whose risk was not visible in advance. ## What is Socrates Pre-Op? 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](/alternatives/paper-pre-admission-questionnaires) and [telephone pre-assessment](/alternatives/telephone-pre-assessment) — including where each of those still wins. ## Do patients know they are speaking to an AI? Yes. The interview opens by identifying Pathways as an automated assistant working on behalf of your practice or hospital, and tells the patient that a clinician will review everything discussed. Patients can ask to speak to a person at any point rather than continue with the assessment. Disclosure is not a compliance box here, it is what makes the answers usable. A patient who thinks they are filling in a form gives form-shaped answers; a patient who understands they are being interviewed, and that a clinician will read it, tends to volunteer the thing that matters — the stent nobody recorded, the sleep study that was never followed up. Telling them a clinician reviews the result is also simply accurate. Pathways issues no orders and clears no patients; the summary is a draft until someone qualified signs it. ## Which clinical domains does the Pathways interview cover? 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. ## Does Pathways need to integrate with our PMS or EMR? No. Pathways runs standalone from day one. The SMS-driven workflow needs no patient management or EMR integration to start, so a service can screen its next elective list without an IT project, an interface engine, or a change window. Integration is available later but is not a precondition. This is usually the difference between a deployment measured in days and one measured in quarters. Most of the value — screening every booked patient early enough to act — does not depend on a bidirectional interface, so requiring one up front only delays the point at which the first cancellation is prevented. When you do want it, integration is HL7 or FHIR against your patient administration and EMR systems: automated list ingestion from theatre scheduling in one direction, and write-back of the signed pre-operative summary to the patient record in the other. That is an Enterprise capability, available on Business, and it is scoped after the standalone deployment is running rather than before it. ## How long does it take to deploy Pathways? Days rather than quarters. Because Pathways runs standalone over SMS with no PMS or EMR integration required, a service can begin sending assessments on its next elective list. There is nothing for patients to install and no software to deploy on hospital workstations — the platform runs in a browser. ## How much does Pathways cost? Pathways has three tiers. Consultant is $125 per clinician per month excluding GST, or $1,250 a year billed annually, for anaesthetists running their own lists. Business and Enterprise are quoted per site or by procedure volume. There is no per-patient charge and no setup fee for a standalone deployment. A solo anaesthetist and a public health service are buying different things — one is buying back the pre-operative phone call, the other is restructuring a pre-admission service. That is why only the Consultant tier carries a list price: it describes a single, well-defined unit of work. Above it, the price tracks the size of the pre-admission workload rather than a seat count. For private settings the arithmetic that usually decides it is cancellation cost: a single prevented day-of-surgery cancellation typically covers several months of the platform. ## How is the Business tier priced? Per site or by procedure volume, so the figure tracks the size of your pre-admission workload rather than a seat count. A short scoping conversation about your lists produces a fixed annual figure. Business is an annual agreement, invoiced yearly in advance. Seat-count pricing does not describe this workload well. A pre-admission service might have three anaesthetists and eleven nurses, or the reverse, and the number of people who log in says very little about how many patients are being assessed. Volume does. It also means adding a coordinator to the roster does not change what you pay, which removes a small but real disincentive to putting the right people in front of the queue. ## Is there a discount for paying annually? Yes. On the Consultant tier, paying annually gives you two months free — $1,250 per clinician per year instead of $1,500, excluding GST. That works out at $104 per clinician per month. Annual agreements are standard at Business and Enterprise. The Business and Enterprise tiers are annual by default rather than by discount: they involve configuration, protocol design and clinician training, and a monthly commitment does not leave room to do that work properly. ## Is Pathways a medical device, and who is responsible for clinical decisions? Pathways is clinical decision support intended for use by qualified clinicians within Australian clinical governance frameworks. It is clinician-in-the-loop by design — it issues no automated orders, and every recommendation is reviewable and auditable. The treating clinician remains solely responsible for all clinical decisions. The positioning is deliberate and is reflected in the architecture rather than only in the terms of service. Pathways produces risk flags with severity tiers, the evidence that triggered them, a guideline reference and a recommended action. It does not place orders, it does not clear patients, and it does not route anyone to theatre on its own authority. ## How does Pathways generate its risk flags? 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. ## Can we audit why a patient was cleared or flagged? 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". ## What happens to patients who are not high risk? 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. ## Do patients need to download an app? No. Patients receive a signed, time-limited SMS link and complete the assessment in their phone's browser. There is no app, no login and no password. Links expire, and expired links are visibly dead rather than silently reusable. Links are signed with HMAC-SHA256 and time-limited. The visible-expiry behaviour matters more than it sounds: a link that silently still works is a data exposure, and a link that fails with no explanation generates a phone call to the practice. ## What happens if a patient doesn't complete their assessment? 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. ## What if a patient has no smartphone, or can't use one? 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. ## Who inside our organisation can see patient data? Access is role-based. Booking staff, nurses and anaesthetists each see what their role requires and nothing more, and every view and action is written to the audit log. Access is scoped to your organisation — Pathways staff do not browse patient records, and there is no shared or cross-organisation view. Two questions usually sit behind this one. **Internally**, the answer is role-based access plus a complete audit trail. Who saw what, and when, is a recorded fact rather than an assumption, which is what allows the access model to be reviewed rather than merely asserted. **Externally**, patient data does not leave your organisation's scope. It is stored in AWS Sydney, it is not pooled across customers, and the content that reaches model providers is de-identified. ## How long does the assessment take a patient? 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. ## Does Pathways replace the pre-admission clinic? No. It decides who should be in it. Every completed profile carries a triage recommendation — anaesthetist review, pre-admission clinic, telephone review, or no further assessment — so clinic slots go to the patients who need them. The clinic keeps doing the same work, for a different and better-chosen set of patients. Most pre-admission clinics are not short of clinical capability. They are short of a mechanism for allocating their capacity, so slots fill in the order bookings arrive — producing a clinic of largely well patients while a frail patient with poor functional capacity gets a short phone call. Screening every booked patient early makes the queue orderable by risk. The clinic's capacity does not change; what changes is who is in it. ## What happens when Pathways is uncertain about something? It says so, on the profile. Extraction confidence is shown rather than hidden, anything uncertain is flagged for human review, and missing investigations and unconfirmed timings are listed explicitly. A profile that has not been told about an outstanding echocardiogram is not presented as a clean profile — the gap is part of the output. This is deliberate, and it is the property that separates a screening tool from a reassurance tool. A system that presents uncertain extractions with the same visual weight as verified ones is making a clinical judgement it has no standing to make. So a patient-reported HbA1c appears with its confidence attached and "gap: recent HbA1c" recorded alongside it, rather than being silently promoted to a result. The clinician can then decide whether the gap matters for this patient and this procedure — which is the decision that was always theirs. ## Can we run a pilot before committing? Yes, and it is the usual way to start. Because Pathways runs standalone over SMS with no integration required, a pilot can be a single upcoming list or a single surgeon's patients rather than a whole-of-service programme. That makes the question answerable in weeks with real patients instead of in a demo environment. The reason a narrow pilot works here is the absence of an integration project. Where a platform needs an interface built before it can do anything, a pilot carries most of the cost of a full deployment, so services quite reasonably resist starting one. A list-level pilot also produces the number that actually decides the purchase: what the screening found on real patients, early enough to act on, and what would otherwise have surfaced on the morning of surgery. ## What happens to our data if we stop using Pathways? It is yours and it is exportable. Org-wide and per-patient audit logs and assessment records can be exported for your own systems and record-keeping obligations. Retention follows the treating provider's obligations and applicable health records legislation, and the specifics are set out in your services agreement. This matters more than it might appear, because assessment records form part of the clinical record. A platform that makes its data hard to retrieve is not a commercial inconvenience; it is a records-management problem for the provider that remains responsible for those patients. Exportability is also the same capability the governance and accreditation requirements rely on, so it is exercised routinely rather than only on exit. --- # Pathways insights > Pathways publishes writing on perioperative operations, clinical AI architecture, and the information problems behind preventable failures in surgical care. *Source: https://getpathways.ai/insights* ## Clinical safety rules should not be model output Safety-critical clinical screening should be implemented as deterministic, versioned rules rather than model output, because clinical governance requires reproducibility rather than accuracy alone. A rule that fires whenever its conditions are met can be tested, audited and re-run months later to produce the same answer — a property a probabilistic system cannot offer. URL: https://getpathways.ai/insights/deterministic-rules-in-clinical-ai ## The medication history is the weakest link Pre-operative medication histories are usually assembled from patient recall and a GP summary that may be months old. The drugs patients are least able to name — anticoagulants and SGLT2 inhibitors described as 'a blood thinner' or 'something for sugar' — are precisely the ones whose management must be planned days ahead, which is why they cause cancellations. URL: https://getpathways.ai/insights/the-medication-history-problem ## What data sovereignty actually requires Data sovereignty means patient information stays within Australian jurisdiction across its whole lifecycle — storage, processing, backup and any third-party service it passes through. Claiming an Australian region for the primary database is the easy part. The paths that matter are backups, subprocessors, support access, and, for AI systems, what is sent to a model provider. URL: https://getpathways.ai/insights/what-data-sovereignty-requires ## Why clinics fill with the wrong patients Pre-admission clinics fill with low-risk patients because slots are allocated in the order bookings arrive rather than by screened risk. The result is a clinic of largely well patients while the frail patient with poor functional capacity gets a short phone call. The constraint is allocation, not capability, so adding clinic capacity does not fix it. URL: https://getpathways.ai/insights/why-clinics-fill-with-the-wrong-patients ## Cancellations are an information problem Most day-of-surgery cancellations are caused by information that existed weeks before the operation but reached the anaesthetist too late to act on. Because the limiting factor is timing rather than clinical thoroughness, cancellation rates respond to moving assessment to the point of booking far more than to assessing more carefully at the clinic. URL: https://getpathways.ai/insights/why-day-of-surgery-cancellations-are-an-information-problem --- # Clinical safety rules should not be model output > Safety-critical clinical screening should be implemented as deterministic, versioned rules rather than model output, because clinical governance requires reproducibility rather than accuracy alone. A rule that fires whenever its conditions are met can be tested, audited and re-run months later to produce the same answer — a property a probabilistic system cannot offer. *Source: https://getpathways.ai/insights/deterministic-rules-in-clinical-ai* There is a reasonable-sounding argument that if a language model screens perioperative risk more accurately than a rule set, it should screen perioperative risk. The argument is wrong, and the reason it is wrong is not about accuracy at all. ## Governance asks a different question A perioperative committee reviewing a case does not primarily ask whether the system was right. It asks what the system was told, what it concluded, and whether that conclusion follows from the input. Six months later, in a morbidity and mortality review, it asks the same questions again — and expects the same answers. That is a reproducibility requirement, and it is stricter than an accuracy requirement. A system that is right 97% of the time but cannot tell you *why* it was right in this case, and might answer differently if asked again, fails review even when it is right. ## What deterministic buys you A deterministic rule has three properties that matter here. **It is testable.** "Flag an identified SGLT2 inhibitor with no documented withholding plan for the surgery date" is a condition you can write test cases against. You can enumerate what should fire and what should not, and you can run that suite on every change. **It is versioned.** Every output records the rule version that produced it. When a case is re-examined in September, you can re-run it against the rule set as it stood in March rather than against the current one, which is the difference between an audit and an argument. **It cannot be talked out of it.** This one sounds glib and is the most important. A rule fires whenever its conditions are met. It does not have a bad day, it is not swayed by the surrounding narrative, and it does not become less confident because the rest of the chart looks reassuring. For the specific set of findings that exist to protect patients, that inflexibility is the feature. ## Where models belong None of this is an argument against using models. It is an argument about which part of the pipeline they occupy. Models are very good at the messy front end: conducting a conversational interview that follows up appropriately, reading a photograph of a medication box including handwriting, classifying an uploaded document, turning free narrative into structured findings. These are tasks where the input is unbounded and brittle rules genuinely fail. The architectural line is drawn after that. Extraction and interpretation produce structured findings; those findings are verified against their source; and only then does a deterministic engine screen them. The model's output is an input to the rules, never a substitute for them. ## Two consequences worth stating **Confidence is shown, not hidden.** If an extracted value is 86% confident, the profile says so, and the missing confirmation is listed explicitly. A system that presents uncertain extractions with the same visual weight as verified ones is making a clinical judgement it has no standing to make. **The system states what it does not know.** Missing investigations and unconfirmed timings appear on every profile. This is the part most easily skipped, and it is what separates a screening tool from a reassurance tool — a clean profile that has not been told about the echocardiogram is not the same thing as a clean profile. ## The design rule Use models where the input is unstructured and the cost of an error is a human reviewing something unnecessarily. Use deterministic rules where the input is structured and the cost of an error is a patient harmed. Verify the boundary between them, and record which version of everything produced the answer. That is not a compromise between safety and capability. It is what makes the capable part deployable in a setting that has to answer for its decisions. --- # The medication history is the weakest link > Pre-operative medication histories are usually assembled from patient recall and a GP summary that may be months old. The drugs patients are least able to name — anticoagulants and SGLT2 inhibitors described as 'a blood thinner' or 'something for sugar' — are precisely the ones whose management must be planned days ahead, which is why they cause cancellations. *Source: https://getpathways.ai/insights/the-medication-history-problem* "A blood pressure tablet and something for sugar." That sentence, or a version of it, is how a large share of pre-operative medication histories are taken. It is not a failure of care and it is not the patient's fault. It is the predictable output of asking someone to recall, from memory, over the phone, a list of items that look alike, are named unmemorably, and were prescribed by someone else. The problem is what that sentence conceals. Behind "something for sugar" may sit an SGLT2 inhibitor. Behind an unmentioned item may sit an apixaban. Both require a management plan made days before surgery. Neither will get one. ## The drugs most likely to be missed are the ones that matter There is an unhappy correlation here. The medications whose perioperative management is most time-critical are also among the least likely to be accurately reported. [SGLT2 inhibitors](/glossary/sglt2-inhibitor-perioperative) — empagliflozin, dapagliflozin, ertugliflozin — carry a risk of euglycaemic diabetic ketoacidosis, a presentation in which ketoacidosis develops with a normal or near-normal blood glucose. The diagnostic signal clinicians are trained to look for is absent. Withholding has to begin days ahead. And patients almost never name the drug, because to them it is one of the diabetes tablets. [Anticoagulants](/glossary/perioperative-anticoagulation) are the same shape. The withholding interval depends on the specific agent, the bleeding risk of the procedure, and renal function — none of which can be worked out for a drug nobody knows the patient is taking. "A blood thinner" is not enough to plan from, and a patient who has been on the same tablet for three years may not think to mention it at all. ## Why the referral letter does not close the gap The obvious answer is to take the medication list from the record rather than the patient. In practice the record has its own failure mode: it is a snapshot, and it ages. A GP summary written eight months ago predates any prescribing change since. A referral letter reflects the referrer's view at the time of referral, which may itself have been copied from something older. Neither is wrong, exactly. Both are stale in a way that is invisible — a list with no gaps looks complete whether or not it is current. So the two available sources fail differently and, importantly, they fail independently. Patient recall misses drugs the record has. The record misses drugs the patient has started since. Reconciling them requires actually comparing them, which is work, and which is why it is usually skipped in favour of trusting whichever one is to hand. ## Verification, not collection The useful reframing is that this is not a collection problem. Adding another place to write the medication list does not help if every source is reconstructed from the same unreliable memory. It is a verification problem. What changes the reliability of the list is having the patient photograph the boxes. This sounds mundane and is the substantive shift. A photograph of a medication box is primary evidence: the drug name and strength are printed on it. It does not depend on the patient knowing what the drug is or why they take it — only on their being able to find the box, which almost everyone can. It works for handwritten pharmacy labels and for the patient who brings six boxes and describes none of them. Three properties follow from working off images rather than recall: - **Extraction can be checked against its source.** Every value is verified against the image before it enters the record, rather than transcribed and trusted. - **Uncertainty becomes visible.** A value read at 0.97 confidence and one read at 0.62 are not presented identically. What was hard to read is flagged for human review rather than smoothed over. - **Conflicts surface rather than resolving silently.** A drug in the photos and absent from the referral history is a finding, not a discrepancy to be quietly reconciled in favour of whichever source was consulted last. That last one is the case worth dwelling on. The staged example in the product shows exactly it: an apixaban extracted from a box photo, checked against a GP summary eight months old, absent from it, and flagged. Under recall-based history-taking that patient has no anticoagulant. Under photograph-based verification they have one, and the discrepancy is the thing the clinician is shown. ## What this is worth Reliable medication data is not an end in itself. It is the input on which the time-critical decisions depend — and those decisions have a deadline that arrives well before the day of surgery. An SGLT2 inhibitor identified nineteen days out is a withholding plan. The same drug identified at 07:00 on the morning of surgery is a [cancellation](/glossary/day-of-surgery-cancellation), because no decision available that morning can undo the last dose. The difference between those two outcomes is not clinical judgement. It is whether anyone knew. --- # What data sovereignty actually requires > Data sovereignty means patient information stays within Australian jurisdiction across its whole lifecycle — storage, processing, backup and any third-party service it passes through. Claiming an Australian region for the primary database is the easy part. The paths that matter are backups, subprocessors, support access, and, for AI systems, what is sent to a model provider. *Source: https://getpathways.ai/insights/what-data-sovereignty-requires* Every health-tech vendor selling into Australia says their data stays in Australia. Most of them mean it. The claim is still worth interrogating, because "hosted in Australia" describes where a database sits, and sovereignty is a property of every path the data can take. For a procurement officer, the difference between those two things is the difference between a statement and an assurance. ## The paths that get overlooked Primary storage is the part everyone gets right, because it is the part everyone asks about. Underneath it sit four routes that are easier to miss. **Backups and disaster recovery.** A primary region in Sydney with replication to a secondary region elsewhere is not sovereign. This is easy to configure accidentally, because cross-region replication is a sensible default for durability and is often enabled without a specific decision. **Processing, not just storage.** Data at rest in Sydney can still be processed somewhere else — a job queue, a search index, an analytics pipeline. Storage location and processing location are separate facts and need separate answers. **Subprocessors.** Error monitoring, logging, session replay, email delivery, customer support tooling. Each is a service the data passes through, and each has its own region. A vendor whose own infrastructure is entirely Australian can still be exporting patient data through a logging provider. **Support access.** Where an engineer sits when they open a production console is a jurisdictional question, whatever the region the data is stored in. None of these is exotic and none implies bad faith. They are the ordinary consequences of assembling a modern application from services, and they are why "where is it hosted" is a weaker question than it sounds. ## The path specific to AI systems Then there is the one that did not exist a few years ago and now dominates the assessment: what is sent to a model provider. If a system uses a large language model to conduct an interview, read a medication photograph, or summarise a history, that content leaves the application. Where it goes, what is retained, and whether it is used for training are three separate questions, and a vendor can answer one well while being vague on the others. There are two guarantees worth insisting on, because they fail independently: **Identity.** Is personally identifying information sent to the model provider at all? De-identifying the content before it leaves means the provider never receives a named patient record, which changes the exposure from a jurisdictional problem into a much narrower one. **Training.** Is the content used to train models? This is a separate commitment, and it is the one where contractual terms matter more than architecture — because unlike de-identification, you cannot verify it from the outside. ## The architectural answer that removes the question For the parts of a clinical system that matter most, there is a stronger position available than a good answer about model providers: not involving one. Safety-critical screening — an unwithheld SGLT2 inhibitor, poor glycaemic control, an untreated sleep apnoea screen — can be implemented as deterministic, versioned rules operating on structured findings. Rules of that kind do not call a model. They execute locally, in the same jurisdiction as the data, and they produce the same output every time. That is worth stating plainly because it changes what the sovereignty question applies to. Models are used where the input is unstructured and brittle rules genuinely fail: conducting a conversational interview, reading handwriting on a pharmacy label, turning narrative into structured findings. Their output is an input to the rules, never a substitute for them. So the surface area exposed to a model provider is narrower than "the clinical system", and the part of the system a governance committee is most concerned about is the part that never leaves. ## Questions worth asking any vendor Sovereignty is best assessed by asking about paths rather than about location: - In which region is patient data stored, and where do backups and any replicas live? - Where is it processed, as distinct from stored? - Which subprocessors touch it, and in which jurisdictions do they operate? - From where can your staff access production data, and is that access logged? - Is any personally identifying information sent to a model provider? - Is patient content used to train models, by you or by anyone you use? - Which parts of the clinical logic involve a model at all? A vendor who has thought about this will answer each one specifically. One who has not will re-answer the first question several times. ## Where Pathways sits For completeness, the same answers for Pathways: all patient data is stored in AWS Sydney (ap-southeast-2) and is not transferred outside Australia in storage, processing or backup. No personally identifying information is sent to model providers, and patient information is not used to train models. Extraction and reasoning operate on de-identified clinical content. The safety-critical screening rules are deterministic and versioned, so they do not involve a model provider at all, and every output records the rule version that produced it. The full control set, and the governance pack for procurement review, are on the [security page](/security). --- # Why clinics fill with the wrong patients > Pre-admission clinics fill with low-risk patients because slots are allocated in the order bookings arrive rather than by screened risk. The result is a clinic of largely well patients while the frail patient with poor functional capacity gets a short phone call. The constraint is allocation, not capability, so adding clinic capacity does not fix it. *Source: https://getpathways.ai/insights/why-clinics-fill-with-the-wrong-patients* Ask a perioperative lead what their pre-admission clinic needs and the answer is usually more of it — more slots, more nursing hours, another consultant session. It is a reasonable answer to the wrong question, and it is why services that successfully expand their clinic often find the day-of-surgery cancellation rate barely moves. ## The clinic is not the bottleneck Consider what a pre-admission clinic actually is: a fixed quantity of skilled clinical attention, allocated among a much larger booked population. The clinical work done inside it is generally excellent. The problem is upstream of the appointment. Without a mechanism for deciding who should attend, slots are allocated by the only signal available — the order in which bookings arrive. That signal is uncorrelated with risk. The result is predictable and near-universal: a clinic substantially populated by ASA 1 and 2 patients for whom the visit changes nothing, while a frail 82-year-old with poor functional capacity is handled by a fifteen-minute phone call because the diary was full by the time their booking landed. Adding capacity to a system allocating by arrival order produces more appointments distributed the same way. It is genuinely useful — more patients are seen — but it does not preferentially reach the patients whose assessment changes an outcome. ## Why the obvious filters do not work Services that recognise the allocation problem usually reach first for a triage rule based on something already in the booking data. Two candidates present themselves, and both disappoint. **ASA class** is the most common. It is appealing because it is already recorded and it is a clinical judgement rather than an administrative one. But [ASA class](/glossary/asa-physical-status) describes systemic health independent of the procedure, and it is coarse. A large share of the booked population is ASA 2, which includes both a well-controlled hypertensive undergoing a cataract and a patient with a BMI of 38, untreated snoring and a hip replacement ahead of them. Triaging on it fills the clinic with ASA 2 patients, which is roughly where it started. **Procedure type** is the other. It correctly identifies that a hip replacement carries more physiological demand than a cataract, and it is completely blind to the patient. It routes healthy patients having major surgery into clinic and sends unwell patients having minor surgery home. Neither fails because it is a bad measure. They fail because they are single measures, and perioperative risk is a profile. ## What the routing decision actually needs The information that would let a service allocate correctly is not exotic. It is a structured history: current medications verified rather than recalled, functional capacity asked as a concrete question rather than a general one, a sleep apnoea screen, frailty indicators, glycaemic control, and the specific red flags that change an anaesthetic plan. That information exists. The difficulty is that collecting it has historically required the very clinic appointment being allocated — which makes the assessment its own prerequisite. You cannot triage into the clinic on information only obtainable inside it. This is the circularity that keeps the allocation problem in place, and it is the thing worth attacking. Not the size of the clinic; the order of operations. ## Breaking the circularity If a structured history can be taken before the clinic — remotely, at scale, without consuming clinical time — then the routing decision has something to work with. Every booked patient carries a screened profile, and the clinic's finite capacity can be pointed at the patients whose profile warrants it. The clinic does not shrink and its work does not change. What changes is the population inside it. Anaesthetist review goes to red-tier profiles, clinic slots to the moderate tier, telephone review to patients who need a conversation rather than an examination, and everyone else proceeds. ## The second-order effect There is a consequence that tends to surprise services, and it is arguably larger than the throughput gain. Once every booked patient is screened at the point of booking, a set of interventions that were previously impossible become schedulable: [anaemia correction](/glossary/preoperative-anaemia), glycaemic optimisation, [prehabilitation](/glossary/prehabilitation) for patients with low functional capacity. These all require weeks of lead time, and none can be initiated from a clinic appointment three days before surgery. A clinic allocating by arrival order cannot deliver them, not because it lacks the skill but because it meets the relevant patients too late. Screening early turns the wait for surgery from dead time into a window — which is the premise [enhanced recovery](/glossary/enhanced-recovery-after-surgery) programmes are built on, and the reason they are hard to run without it. ## The question worth asking "Do we have enough pre-admission capacity?" is not the diagnostic question. A better one is: of the patients who attended clinic last month, for how many did the visit change the plan? Where that proportion is low, the constraint is allocation. More capacity will be absorbed and the cancellation rate will hold roughly steady, because the patients driving it were never in the room. --- # Cancellations are an information problem > Most day-of-surgery cancellations are caused by information that existed weeks before the operation but reached the anaesthetist too late to act on. Because the limiting factor is timing rather than clinical thoroughness, cancellation rates respond to moving assessment to the point of booking far more than to assessing more carefully at the clinic. *Source: https://getpathways.ai/insights/why-day-of-surgery-cancellations-are-an-information-problem* A case is cancelled at 07:12. The patient has been fasted since midnight, is gowned, and has arranged for a family member to take the day off work. The chart is opened properly for the first time and it shows uncontrolled diabetes and an SGLT2 inhibitor that was never withheld. The list loses a slot it cannot backfill at that notice. Nothing in that sequence is a clinical failure. The anaesthetist made exactly the right call with the information available at 07:12. The problem is that the same information was available on the day the patient was booked, nineteen days earlier, when it could have changed the outcome instead of ending it. ## The pattern generalises Look at a run of cancellations and the specifics vary while the shape does not. Four causes account for most of them: - **Medication management that was never planned.** SGLT2 inhibitors are the standing example, because withholding must begin days ahead and because patients describe them as "a tablet for sugar". - **Comorbidity that was never optimised.** Poor glycaemic control, uncontrolled hypertension, anaemia — all modifiable, all requiring a window. - **Risk that was never screened.** Undiagnosed obstructive sleep apnoea changes the anaesthetic plan, but only if the eight STOP-Bang questions were asked. - **Logistics that were never confirmed.** No escort home, fasting instructions misunderstood, no discharge support. In each case the determining fact existed well before the morning of surgery. It was not discovered late because it was hidden. It was discovered late because nobody looked until the point at which looking no longer helps. ## Why "assess more carefully" does not fix it The instinctive response to a cancellation is to tighten the pre-admission process — a longer questionnaire, a more thorough clinic visit, another checklist. This improves the quality of assessment for the patients who reach the clinic, and does nothing for the patients who do not. That is the constraint. A pre-admission clinic booked out three weeks ahead is not short of clinical capability; it is short of a mechanism for deciding who should be in it. Slots fill in booking order, which reliably produces a clinic of healthy ASA 1 and 2 patients while the frail 82-year-old with poor functional capacity is handled by a fifteen-minute phone call. Assessing the people in the room more carefully cannot reach the people who were never in it. ## The lever is timing If the determining information is knowable at booking, then the question worth asking is not how thorough the assessment is but how early it happens. Moving assessment to the point of booking changes what a finding *is*. A patient-reported HbA1c of "around nine" discovered nineteen days out is an optimisation window. The same finding discovered at 07:12 on the day is a cancellation. The clinical content is identical; only the remaining time differs. This is also why the intervention has to cover every booked patient rather than the ones who look high-risk. The patients who cancel lists are, by definition, the ones whose risk was not visible in advance — if it had been visible, they would have been assessed. Screening the obviously complex patients catches the cases you were already going to catch. ## What this asks of a service Screening every patient at booking is not realistic as a manual process. It means contacting several hundred patients a month, taking a structured history from each, reconciling their actual medications against a referral letter that may be months old, and applying consistent screening criteria across all of it — work that scales linearly with list volume and that no pre-admission clinic has the staffing to absorb. That is the specific problem Pathways was built for: a voice agent that takes the structured history from home, medication capture that reads the boxes rather than trusting recall, and deterministic screening that applies the same guideline-referenced criteria to every patient. What it produces is not a better clinic visit. It is a queue that is ordered by risk, early enough for the ordering to matter. The measure of whether it works is not how good the assessments are. It is whether the fact that would have cancelled the case arrives while there is still time to act on it. --- # Pathways perioperative glossary > A glossary of perioperative and pre-operative assessment terminology — ASA physical status, STOP-Bang, functional capacity in METs, frailty, SGLT2 inhibitors before surgery, day-of-surgery cancellation, pre-admission clinic and clinical decision support. *Source: https://getpathways.ai/glossary* ## ASA physical status The ASA physical status classification is a six-point scale published by the American Society of Anesthesiologists to describe a patient's systemic health before anaesthesia. ASA 1 is a normal healthy patient and ASA 6 is a declared brain-dead organ donor. It describes health, not surgical risk, and an "E" suffix marks emergency procedures. URL: https://getpathways.ai/glossary/asa-physical-status ## Clinical decision support Clinical decision support is software that provides clinicians with patient-specific information and recommendations to inform a clinical decision. The defining constraint is that it assists rather than replaces judgement — it issues no orders and makes no diagnoses, and the treating clinician remains responsible for every decision taken. URL: https://getpathways.ai/glossary/clinical-decision-support ## Day-of-surgery cancellation A day-of-surgery cancellation is a planned operation called off on the day it was scheduled, usually after the patient has arrived fasted. Most are preventable: the common causes are unmanaged medications, unoptimised comorbidity, unscreened risk such as sleep apnoea, and logistical failures — all of which are identifiable weeks earlier. URL: https://getpathways.ai/glossary/day-of-surgery-cancellation ## Enhanced Recovery After Surgery Enhanced Recovery After Surgery is a structured approach that bundles evidence-based steps across the whole surgical pathway to reduce the physiological stress of surgery and speed recovery. A substantial part of it is pre-operative — optimising comorbidity, correcting anaemia, avoiding prolonged fasting and preparing the patient — which makes early assessment a precondition rather than an adjunct. URL: https://getpathways.ai/glossary/enhanced-recovery-after-surgery ## Frailty Frailty is a state of reduced physiological reserve across multiple systems, leaving a patient vulnerable to stressors such as surgery. It independently predicts post-operative complications, longer stays, loss of independence and mortality — over and above age, ASA class or the specific procedure — which is why it is screened separately before elective surgery. URL: https://getpathways.ai/glossary/frailty ## Functional capacity (METs) Functional capacity describes how much physical activity a patient can perform, measured in metabolic equivalents (METs). One MET is resting oxygen consumption. Four METs — climbing a flight of stairs or walking up a hill — is the usual threshold below which perioperative guidelines suggest further cardiac assessment before non-cardiac surgery. URL: https://getpathways.ai/glossary/functional-capacity-mets ## HbA1c HbA1c is glycated haemoglobin, reflecting average blood glucose over roughly the preceding three months. It matters before surgery because poor glycaemic control is associated with higher rates of post-operative complications, particularly infection and impaired wound healing. Unlike a one-off glucose reading it cannot be improved quickly, so it has to be identified with weeks to spare. URL: https://getpathways.ai/glossary/hba1c ## Mallampati score The Mallampati score grades how much of the oropharynx is visible when a seated patient opens their mouth and protrudes the tongue, on a four-class scale. Higher classes suggest a potentially more difficult intubation. It is one input to airway assessment rather than a test in itself, and is always read alongside other airway findings. URL: https://getpathways.ai/glossary/mallampati-score ## Obstructive sleep apnoea Obstructive sleep apnoea is repeated collapse of the upper airway during sleep, causing interrupted breathing and disturbed sleep. It matters before surgery because affected patients are more sensitive to sedatives and opioids and are at higher risk of airway obstruction after anaesthesia. Much of it is undiagnosed at the time of booking, so it is screened rather than asked about. URL: https://getpathways.ai/glossary/obstructive-sleep-apnoea ## Perioperative anticoagulation Perioperative anticoagulation is the plan for a patient's blood-thinning medication around surgery. Most anticoagulants are withheld beforehand to reduce bleeding risk, balanced against the thrombotic risk of stopping them. Because the timing depends on the drug, the procedure and kidney function, the plan has to be made days ahead — which requires knowing the patient is taking one. URL: https://getpathways.ai/glossary/perioperative-anticoagulation ## Pre-admission clinic A pre-admission clinic assesses patients before elective surgery to identify and optimise anaesthetic risk. Its persistent problem is allocation rather than capability — clinics are commonly booked out for weeks with low-risk patients while high-risk patients receive a phone call, because slots are filled in booking order rather than by screened risk. URL: https://getpathways.ai/glossary/pre-admission-clinic ## Pre-operative anaemia Pre-operative anaemia is a low haemoglobin concentration identified before surgery. It is common, frequently due to iron deficiency, and associated with more transfusion, longer stays and worse recovery. Because investigating the cause and treating it takes weeks, it is one of the clearest arguments for assessing patients at booking rather than shortly before their procedure. URL: https://getpathways.ai/glossary/preoperative-anaemia ## Pre-operative fasting Pre-operative fasting is the period without food or drink before anaesthesia, intended to reduce the risk of stomach contents entering the lungs. Modern guidance permits clear fluids much closer to surgery than patients often assume. Misunderstood instructions cause avoidable cancellations and unnecessary discomfort, so confirming the patient understood them is part of assessment. URL: https://getpathways.ai/glossary/preoperative-fasting ## Prehabilitation Prehabilitation is structured preparation before surgery — typically exercise, nutrition and psychological support, alongside smoking and alcohol reduction — aimed at improving a patient's physiological reserve before the stress of an operation. It treats the wait for surgery as an intervention window rather than dead time, which requires identifying who would benefit early enough to act. URL: https://getpathways.ai/glossary/prehabilitation ## Revised Cardiac Risk Index The Revised Cardiac Risk Index estimates the risk of major cardiac complications after non-cardiac surgery. It counts six factors — high-risk surgery, ischaemic heart disease, heart failure, cerebrovascular disease, insulin-treated diabetes, and impaired renal function — each scoring one point. More factors means higher risk, and it is used alongside functional capacity rather than instead of it. URL: https://getpathways.ai/glossary/revised-cardiac-risk-index ## SGLT2 inhibitors (perioperative) SGLT2 inhibitors such as empagliflozin and dapagliflozin must be withheld before surgery because they can cause euglycaemic diabetic ketoacidosis, in which ketoacidosis develops with normal or near-normal blood glucose. Because withholding must begin days before the procedure, the plan has to be made at booking rather than on admission. URL: https://getpathways.ai/glossary/sglt2-inhibitor-perioperative ## STOP-Bang score STOP-Bang is an eight-item screening questionnaire for obstructive sleep apnoea. Each item scores one point — snoring, tiredness, observed apnoeas, high blood pressure, BMI over 35, age over 50, neck circumference over 40cm, and male sex. A score of 5 to 8 indicates high risk of moderate-to-severe OSA. URL: https://getpathways.ai/glossary/stop-bang-score ## Theatre utilisation Theatre utilisation measures how much of the operating time allocated to a list is actually used for surgery. It is a core efficiency measure for both public and private services. Late cancellations damage it disproportionately, because a slot lost on the day usually cannot be refilled — unlike one released with a week's notice. URL: https://getpathways.ai/glossary/theatre-utilisation --- # ASA physical status > The ASA physical status classification is a six-point scale published by the American Society of Anesthesiologists to describe a patient's systemic health before anaesthesia. ASA 1 is a normal healthy patient and ASA 6 is a declared brain-dead organ donor. It describes health, not surgical risk, and an "E" suffix marks emergency procedures. *Source: https://getpathways.ai/glossary/asa-physical-status* Also known as: ASA score, ASA classification, ASA-PS - **Published by**: American Society of Anesthesiologists - **Range**: ASA 1 to ASA 6 - **Emergency suffix**: E — e.g. ASA 3E - **Describes**: Systemic health, not procedural risk ## The six classes | Class | Definition | Example | | --- | --- | --- | | ASA 1 | Normal healthy patient | Non-smoker, minimal alcohol use | | ASA 2 | Mild systemic disease, no functional limitation | Well-controlled hypertension, current smoker, BMI 30–40 | | ASA 3 | Severe systemic disease, functional limitation | Poorly controlled diabetes, BMI over 40, ESRD on dialysis | | ASA 4 | Severe systemic disease that is a constant threat to life | Recent MI or stroke, sepsis, severe valve dysfunction | | ASA 5 | Moribund, not expected to survive without the operation | Ruptured abdominal aneurysm, massive trauma | | ASA 6 | Declared brain-dead, organs being removed for donation | — | ## A common misreading ASA class is frequently used as shorthand for "how risky is this case", which it is not. It describes the patient's systemic health independent of the procedure. A healthy ASA 1 patient undergoing a high-risk operation and an ASA 3 patient having a cataract removed are not comparable on the basis of the class alone. This matters operationally as well as clinically. A pre-admission clinic that triages by ASA class will fill with ASA 2 patients who need nothing, while the frail patient whose functional capacity is the actual concern gets a phone call. Triaging by screened risk rather than by classification is the difference Pathways is built around. --- # Clinical decision support > Clinical decision support is software that provides clinicians with patient-specific information and recommendations to inform a clinical decision. The defining constraint is that it assists rather than replaces judgement — it issues no orders and makes no diagnoses, and the treating clinician remains responsible for every decision taken. *Source: https://getpathways.ai/glossary/clinical-decision-support* Also known as: CDS, CDSS, clinical decision support system - **Abbreviation**: CDS / CDSS - **Produces**: Patient-specific recommendations for clinician review - **Does not produce**: Diagnoses, orders, or treatment directives - **Responsibility**: Remains entirely with the treating clinician ## Recommends versus decides The distinction sounds like a legal formality and is in fact an architectural one. A system that recommends must be able to show its working — the evidence that triggered a recommendation, the rule or guideline behind it, and the version of that rule — because a clinician cannot exercise judgement over a conclusion they cannot inspect. That requirement is what pushes safety-critical logic towards deterministic, versioned rules rather than model output. A rule that fires whenever its conditions are met can be tested, audited and reproduced months later. A probabilistic answer that is usually right cannot be examined the same way, and so cannot be reviewed in the sense clinical governance means by review. ## In perioperative practice Pathways Perioperative operates as clinical decision support: it produces severity-tiered risk flags with the triggering evidence, a guideline reference and a recommended action. It places no orders, clears no patients, and routes nobody to theatre on its own authority. --- # Day-of-surgery cancellation > A day-of-surgery cancellation is a planned operation called off on the day it was scheduled, usually after the patient has arrived fasted. Most are preventable: the common causes are unmanaged medications, unoptimised comorbidity, unscreened risk such as sleep apnoea, and logistical failures — all of which are identifiable weeks earlier. *Source: https://getpathways.ai/glossary/day-of-surgery-cancellation* Also known as: DOSC, same-day cancellation, late cancellation - **Also called**: DOSC, late cancellation - **Common causes**: Medication management, unoptimised comorbidity, unscreened risk, logistics - **Typical cost**: Lost theatre time plus an unrecoverable slot - **Prevention window**: From booking to roughly one week before surgery ## The four causes **Medication management not planned.** The clearest case is the SGLT2 inhibitor class, where a withholding plan must be made days ahead. When the medication list comes from patient recall at a pre-op phone call, the drug is often described as "something for sugar" and the plan is never made. **Comorbidity not optimised.** Poor glycaemic control, uncontrolled hypertension and anaemia are modifiable given a window. The window only exists if the problem is found while there is still time. **Risk not screened.** Undiagnosed obstructive sleep apnoea is the standing example — it changes the anaesthetic plan and sometimes the location of care, but only if the questions were asked. **Logistics and consent.** Fasting instructions misunderstood, no escort home, no discharge support. The cheapest to prevent and the most frustrating to lose a theatre slot to. ## Why it is an information problem In almost every case the fact that caused the cancellation existed weeks earlier. It simply had not reached the anaesthetist while there was still time to act on it. That is what makes cancellation rate responsive to when assessment happens rather than to how carefully it is done — moving the assessment to booking converts an unrecoverable cancellation into a manageable optimisation. --- # Enhanced Recovery After Surgery > Enhanced Recovery After Surgery is a structured approach that bundles evidence-based steps across the whole surgical pathway to reduce the physiological stress of surgery and speed recovery. A substantial part of it is pre-operative — optimising comorbidity, correcting anaemia, avoiding prolonged fasting and preparing the patient — which makes early assessment a precondition rather than an adjunct. *Source: https://getpathways.ai/glossary/enhanced-recovery-after-surgery* Also known as: ERAS, enhanced recovery, fast-track surgery - **Scope**: The whole pathway — before, during and after surgery - **Pre-operative components**: Comorbidity optimisation, anaemia correction, avoiding prolonged fasting, patient preparation - **Aim**: Reduce the physiological stress of surgery and speed return to function - **Dependency**: The pre-operative elements need lead time, so they depend on early assessment ## The part that happens before admission ERAS is often discussed in terms of what changes intraoperatively and on the ward. But a meaningful share of the protocol is pre-operative, and those elements share a property: they need lead time. Optimising diabetes control, correcting iron-deficiency anaemia, addressing smoking, setting expectations about mobilisation and discharge, and replacing "nil by mouth from midnight" with clear fluids up to the permitted window — none of these can be delivered in the days before surgery. ## Why it exposes the assessment bottleneck This is the practical difficulty services encounter when adopting ERAS. The protocol assumes patients are identified and prepared well ahead of their procedure. A pre-admission clinic booked out three weeks in advance, allocating slots in the order bookings arrive, cannot reliably deliver that — not because the clinic is doing poor work, but because the patients who most need the pre-operative components are not necessarily the ones who reach it in time. Assessing every booked patient at the point of booking is what makes the pre-operative half of an ERAS pathway operable at scale. --- # Frailty > Frailty is a state of reduced physiological reserve across multiple systems, leaving a patient vulnerable to stressors such as surgery. It independently predicts post-operative complications, longer stays, loss of independence and mortality — over and above age, ASA class or the specific procedure — which is why it is screened separately before elective surgery. *Source: https://getpathways.ai/glossary/frailty* Also known as: perioperative frailty, frailty syndrome - **Definition**: Reduced physiological reserve across multiple systems - **Predicts**: Complications, length of stay, loss of independence, mortality - **Independent of**: Chronological age, ASA class, procedure type - **Related measure**: Functional capacity (METs) ## Why it is screened separately The intuition that frailty is a proxy for age is wrong often enough to be dangerous in both directions. A robust 84-year-old and a frail 68-year-old have substantially different perioperative risk profiles, and neither is captured by age or by ASA class — a frail patient may well be classified ASA 2. Because frailty predicts outcomes that matter to patients as much as to services — particularly loss of independence and discharge destination — it also changes the shape of the pre-operative conversation, not just the anaesthetic plan. ## Where it fits in the assessment Functional capacity and frailty is one of the 12 domains covered in the Socrates Pre-Op interview. Screening it on every patient rather than on those who look frail is the point: the patients whose reserve is quietly depleted are exactly the ones who present well in a short phone call. --- # Functional capacity (METs) > Functional capacity describes how much physical activity a patient can perform, measured in metabolic equivalents (METs). One MET is resting oxygen consumption. Four METs — climbing a flight of stairs or walking up a hill — is the usual threshold below which perioperative guidelines suggest further cardiac assessment before non-cardiac surgery. *Source: https://getpathways.ai/glossary/functional-capacity-mets* Also known as: METs, metabolic equivalents, exercise tolerance - **Unit**: MET — metabolic equivalent of task - **1 MET**: Resting oxygen consumption (~3.5 mL/kg/min) - **Key threshold**: 4 METs - **Below 4 METs**: Poor functional capacity — consider further cardiac assessment ## What the numbers mean | METs | Typical activity | | --- | --- | | 1 | Eating, dressing, working at a computer | | 2–3 | Walking indoors, walking 100m on level ground | | 4 | Climbing a flight of stairs, walking up a hill, light housework | | 5–9 | Running a short distance, heavy housework, moderate cycling | | 10+ | Strenuous sport — swimming, singles tennis, football | ## Why it is hard to capture Functional capacity is one of the most predictive and least reliably recorded pieces of pre-operative information, because it depends entirely on the question being asked well. "How is your exercise tolerance?" invites "fine" from a patient who has not climbed a flight of stairs in two years. The useful question is concrete and activity-anchored: can you walk up a flight of stairs without stopping? A structured interview asks it that way every time, which is why functional capacity and frailty is one of the 12 domains Socrates Pre-Op covers rather than a free-text field someone fills in at the clinic. --- # HbA1c > HbA1c is glycated haemoglobin, reflecting average blood glucose over roughly the preceding three months. It matters before surgery because poor glycaemic control is associated with higher rates of post-operative complications, particularly infection and impaired wound healing. Unlike a one-off glucose reading it cannot be improved quickly, so it has to be identified with weeks to spare. *Source: https://getpathways.ai/glossary/hba1c* Also known as: glycated haemoglobin, A1c, HbA1c test - **Measures**: Average blood glucose over roughly the preceding three months - **Perioperative concern**: Higher rates of post-operative infection and impaired wound healing - **Modifiable**: Yes, but slowly — requires weeks to months, not days - **Common gap**: Last confirmed result is months old, or only patient-reported ## Why the timescale matters more than the number HbA1c is the one common pre-operative finding where the value of discovering it early is unambiguous. A single high glucose on the morning of surgery is a snapshot; an HbA1c reflects months, and moving it takes months. That makes it the clearest illustration of the general point about pre-operative timing. Identified at booking, poor control is an optimisation window — a referral back to the GP or diabetes service with weeks in hand. Identified at the pre-admission clinic three days before surgery, the same finding is either a cancellation or a case that proceeds at avoidable risk. ## The two failure modes **The result is stale.** A patient with diabetes may have an HbA1c on file, but from eight months ago, before a change in circumstances or medication. **The result is patient-reported.** "Around nine" is a genuinely useful signal and a poor basis for a plan. It should be treated as a prompt to obtain a current result, not as one. Pathways handles this by listing what it does not know. An HbA1c that is patient-reported or out of date appears explicitly under missing information on the risk profile, with the confidence attached — the staged example shows a patient-reported value at 0.86 confidence with "gap: recent HbA1c" recorded alongside it, and nineteen days of optimisation window still available. --- # Mallampati score > The Mallampati score grades how much of the oropharynx is visible when a seated patient opens their mouth and protrudes the tongue, on a four-class scale. Higher classes suggest a potentially more difficult intubation. It is one input to airway assessment rather than a test in itself, and is always read alongside other airway findings. *Source: https://getpathways.ai/glossary/mallampati-score* Also known as: Mallampati classification, modified Mallampati score - **Assesses**: Visibility of oropharyngeal structures on mouth opening - **Classes**: I to IV - **Direction**: Higher class suggests a potentially more difficult airway - **Limitation**: Modest predictive value alone; always combined with other airway findings ## The four classes Assessed with the patient seated, mouth open and tongue protruded: | Class | What is visible | | --- | --- | | I | Soft palate, fauces, uvula and tonsillar pillars | | II | Soft palate, fauces and uvula | | III | Soft palate and base of the uvula | | IV | Soft palate not visible | ## Why it is never used alone A high Mallampati class raises the index of suspicion; it does not predict a difficult airway reliably by itself. It is read together with the rest of the airway history — previous difficult intubation, mouth opening, neck movement, dentition, and body habitus — and it is the combination that changes a plan. This is the general shape of perioperative risk assessment, and the reason screening on single scores in isolation tends to disappoint. The value of any one measure is that it contributes to a profile. ## In a remote assessment Mallampati grading requires someone to look, so it is not something a voice interview can score. What structured pre-operative interviewing contributes is everything around it: previous anaesthetic difficulties, family history of anaesthetic problems, dentition, and the other airway history that determines whether a physical airway assessment needs to happen early rather than on the day. Airway assessment is one of the twelve domains the interview covers for exactly that reason. --- # Obstructive sleep apnoea > Obstructive sleep apnoea is repeated collapse of the upper airway during sleep, causing interrupted breathing and disturbed sleep. It matters before surgery because affected patients are more sensitive to sedatives and opioids and are at higher risk of airway obstruction after anaesthesia. Much of it is undiagnosed at the time of booking, so it is screened rather than asked about. *Source: https://getpathways.ai/glossary/obstructive-sleep-apnoea* Also known as: OSA, sleep apnoea, obstructive sleep apnea - **Mechanism**: Repeated upper-airway collapse during sleep - **Perioperative concern**: Sensitivity to sedatives and opioids; airway obstruction and desaturation after anaesthesia - **Screening tool**: STOP-Bang questionnaire - **Common finding**: Frequently undiagnosed at the time of surgical booking ## Why it is a perioperative problem, not just a sleep problem Anaesthesia and post-operative analgesia both depress the drive to breathe and relax the muscles that hold the upper airway open — the same mechanism that fails in OSA, applied deliberately. A patient whose airway already collapses during normal sleep has less margin when sedated. The practical consequences are the ones a service has to plan for: the anaesthetic technique may change, opioid-sparing analgesia becomes more attractive, and post-operative monitoring or the location of care may need to be different from the default for that procedure. ## The screening problem Most of the OSA in a surgical population has never been diagnosed. That is not a failure of the referral — the patient cannot report a condition they do not know they have, and the symptoms they would report (snoring, daytime tiredness) are ones people normalise. So it cannot be caught by asking "do you have sleep apnoea?". It has to be screened, which means the eight [STOP-Bang](/glossary/stop-bang-score) items being asked of every patient rather than only of the ones who look high-risk across the desk. ## Where it fits in the assessment The Socrates Pre-Op interview covers the STOP-Bang items within its systems review and social/risk-factor domains, so a score is derived for every patient. A high score with no existing diagnosis raises a warning-tier flag recommending screening before the pre-admission clinic — early enough for the service to act rather than discovering it on the morning of surgery. --- # Perioperative anticoagulation > Perioperative anticoagulation is the plan for a patient's blood-thinning medication around surgery. Most anticoagulants are withheld beforehand to reduce bleeding risk, balanced against the thrombotic risk of stopping them. Because the timing depends on the drug, the procedure and kidney function, the plan has to be made days ahead — which requires knowing the patient is taking one. *Source: https://getpathways.ai/glossary/perioperative-anticoagulation* Also known as: anticoagulant management, blood thinners before surgery, bridging - **Drug classes**: Direct oral anticoagulants, vitamin K antagonists, antiplatelet agents - **Core trade-off**: Bleeding risk if continued against thrombotic risk if stopped - **Timing depends on**: The specific drug, the procedure's bleeding risk, and renal function - **Why it is missed**: Patients describe them loosely; referral letters and GP summaries go stale ## The trade-off Anticoagulation exists because the patient is at risk of clotting — atrial fibrillation, a mechanical valve, a previous venous thromboembolism. Stopping it removes that protection. Continuing it through a procedure raises the risk of bleeding, which for some operations is unacceptable and for others barely matters. Neither side of that trade-off can be decided generically. It depends on which drug, the bleeding risk of the specific procedure, and — for the direct oral anticoagulants, which are largely cleared renally — how well the patient's kidneys work. ## Why it is a scheduling problem Whatever the plan turns out to be, it has to start before the day of surgery. That makes it a booking-time decision rather than an admission-time one. A patient who arrives having taken their anticoagulant that morning cannot be made safe by anything decided in the holding bay. ## Why the medication is so often unknown This is where it fails in practice. Anticoagulants are among the drugs patients are least able to name — they are frequently described as "a blood thinner" or by a brand the patient half-remembers, and an eight-month-old GP summary may predate the prescription entirely. Pathways addresses this by having patients photograph their medication boxes during the interview. Each image is read, classified, and the extracted values verified against the source before entering the record, then cross-checked against the referral history. The staged example in the product shows exactly this case: an apixaban absent from the GP summary, extracted from a box photo and flagged for clinician review. --- # Pre-admission clinic > A pre-admission clinic assesses patients before elective surgery to identify and optimise anaesthetic risk. Its persistent problem is allocation rather than capability — clinics are commonly booked out for weeks with low-risk patients while high-risk patients receive a phone call, because slots are filled in booking order rather than by screened risk. *Source: https://getpathways.ai/glossary/pre-admission-clinic* Also known as: PAC, pre-anaesthetic clinic, pre-operative assessment clinic - **Also called**: PAC, pre-anaesthetic clinic - **Purpose**: Identify and optimise anaesthetic risk before elective surgery - **Common bottleneck**: Slots allocated by availability rather than by risk - **Typical staffing**: Clinical nurse consultants with anaesthetist review ## The allocation problem Most pre-admission clinics are not short of clinical capability. They are short of a mechanism for deciding who should be in them. Without one, appointments are allocated in the order bookings arrive, which produces a clinic full of healthy ASA 1 and 2 patients who need nothing, and a frail patient with poor functional capacity who gets a fifteen-minute phone call because the diary was full. The consequence is felt in two places at once: theatre loses cases to problems that a clinic visit would have caught, and clinic time is consumed by patients for whom the visit changes nothing. ## What changes with risk-based routing If every booked patient is screened at the point of booking, the queue becomes orderable. Red-tier profiles go to anaesthetist review, moderate-tier profiles take the clinic slots, low-risk patients proceed without an appointment, and the remainder are handled by telephone. The clinic's capacity does not change — its allocation does. --- # Pre-operative anaemia > Pre-operative anaemia is a low haemoglobin concentration identified before surgery. It is common, frequently due to iron deficiency, and associated with more transfusion, longer stays and worse recovery. Because investigating the cause and treating it takes weeks, it is one of the clearest arguments for assessing patients at booking rather than shortly before their procedure. *Source: https://getpathways.ai/glossary/preoperative-anaemia* Also known as: preoperative anaemia, anemia before surgery, iron deficiency anaemia - **Common cause**: Iron deficiency - **Associated with**: Increased transfusion, longer length of stay, slower recovery - **Modifiable**: Yes, but requires investigation then treatment — weeks, not days - **Detected by**: Full blood count, with iron studies where indicated ## Why it is worth finding early Anaemia is not merely a marker of being unwell before surgery; it is a modifiable risk factor. Correcting iron deficiency changes the starting point a patient operates from, and reduces the likelihood of transfusion. But correction is not fast. Finding the anaemia is the quick part — a full blood count. Establishing why it is there, treating the cause, and allowing the haemoglobin to respond is a process measured in weeks. A patient identified as anaemic three days before surgery gets the diagnosis without the benefit. ## Where it fits in patient blood management Pre-operative anaemia management is a standard component of patient blood management programmes, and one of the interventions that most clearly requires a functioning pre-admission pathway rather than a pre-admission appointment. The work has to start close to the point of booking. ## The assessment implication This is a case where the assessment's job is partly to establish what has *not* been done. A patient may have no recent full blood count at all, and the absence is the finding. Pathways lists outstanding investigations explicitly on every risk profile rather than reporting only on the data it happens to have — a profile with nothing flagged is not the same as a profile that has been told everything. --- # Pre-operative fasting > Pre-operative fasting is the period without food or drink before anaesthesia, intended to reduce the risk of stomach contents entering the lungs. Modern guidance permits clear fluids much closer to surgery than patients often assume. Misunderstood instructions cause avoidable cancellations and unnecessary discomfort, so confirming the patient understood them is part of assessment. *Source: https://getpathways.ai/glossary/preoperative-fasting* Also known as: fasting, nil by mouth, NBM, preoperative fasting - **Purpose**: Reduce the risk of aspirating gastric contents under anaesthesia - **Modern practice**: Clear fluids permitted considerably closer to surgery than solids - **Common failure**: Patient fasts from the wrong time, or fasts unnecessarily long - **Consequence**: Cancellation, or avoidable thirst, hunger and discomfort ## Two failure modes, opposite directions The obvious one is a patient who has eaten too recently and whose case is postponed or cancelled. The less visible one is a patient who fasts far longer than required — often from midnight regardless of an afternoon list — arriving dehydrated, uncomfortable and, for frail or diabetic patients, physiologically worse off than necessary. Contemporary guidance is considerably more permissive about clear fluids than the "nil by mouth from midnight" instruction many patients still receive and most expect. Encouraging clear fluids up to the point local guidance allows is a standard component of enhanced recovery programmes. ## It is a communication failure, not a compliance failure Patients who get fasting wrong have almost always tried to get it right. The instruction reached them as a sentence on a letter, weeks before the date, without a specific time attached, and often contradicted by what a relative told them about their own operation. That makes it one of the cheapest cancellation causes to prevent — and one of the most irritating to lose a theatre slot to, because nothing clinical went wrong. What is needed is that the instruction is delivered close enough to the date to be remembered, specific enough to act on, and confirmed rather than assumed. Safety and shared decisions is one of the twelve domains the Socrates Pre-Op interview covers, which is where instructions of this kind are checked as understood rather than merely sent. --- # Prehabilitation > Prehabilitation is structured preparation before surgery — typically exercise, nutrition and psychological support, alongside smoking and alcohol reduction — aimed at improving a patient's physiological reserve before the stress of an operation. It treats the wait for surgery as an intervention window rather than dead time, which requires identifying who would benefit early enough to act. *Source: https://getpathways.ai/glossary/prehabilitation* Also known as: prehab, preoperative optimisation, surgery preparation - **Typical components**: Exercise, nutrition, psychological support, smoking and alcohol reduction - **Aim**: Improve physiological reserve before the stress of surgery - **Window**: The period between listing and operating - **Best suited to**: Patients with reduced functional capacity or frailty facing major surgery ## The waiting list as an intervention window The premise is straightforward. A patient waiting weeks or months for elective surgery is usually waiting passively. Prehabilitation asks what that period could be used for, particularly for patients whose [functional capacity](/glossary/functional-capacity-mets) is low or who show signs of [frailty](/glossary/frailty) — the people for whom the physiological demand of surgery sits closest to their reserve. ## Its dependency is identification, not delivery Services that attempt prehabilitation tend to discover that the programme is not the hard part. The hard part is knowing, early enough, which patients should be in it. Deciding that requires functional capacity and frailty to have been assessed across the whole booked list, not just among patients who have already reached a clinic. And it requires that assessment to happen near the point of listing, because a referral into prehabilitation two weeks before surgery has almost no window to work in. That is the same constraint that governs [anaemia correction](/glossary/preoperative-anaemia) and glycaemic optimisation, and it is why screening every booked patient early changes what a service is able to offer, not just how efficiently it runs. --- # Revised Cardiac Risk Index > The Revised Cardiac Risk Index estimates the risk of major cardiac complications after non-cardiac surgery. It counts six factors — high-risk surgery, ischaemic heart disease, heart failure, cerebrovascular disease, insulin-treated diabetes, and impaired renal function — each scoring one point. More factors means higher risk, and it is used alongside functional capacity rather than instead of it. *Source: https://getpathways.ai/glossary/revised-cardiac-risk-index* Also known as: RCRI, Lee index, cardiac risk index - **Predicts**: Major cardiac complications after non-cardiac surgery - **Factors**: 6, each scoring one point - **Scoring**: More factors present means higher estimated risk - **Used with**: Functional capacity, not as a replacement for it ## The six factors | Factor | Counts when | | --- | --- | | High-risk surgery | Intraperitoneal, intrathoracic or suprainguinal vascular procedures | | Ischaemic heart disease | History of myocardial infarction, angina, or related findings | | Congestive heart failure | History of heart failure | | Cerebrovascular disease | Prior stroke or transient ischaemic attack | | Insulin-treated diabetes | Diabetes requiring insulin | | Renal impairment | Raised serum creatinine above the local threshold | ## What it is good for, and what it is not The RCRI is a screening aid. It turns a set of facts already in the history into a structured estimate, which makes it useful for deciding who warrants closer cardiac assessment and for framing a conversation about risk. It is not a decision. It says nothing about the patient's day-to-day exercise tolerance, which is why it is read alongside [functional capacity](/glossary/functional-capacity-mets) rather than instead of it — a patient with two RCRI factors who comfortably climbs two flights of stairs is not in the same position as one who cannot manage a single flight. ## Why it depends on the history being complete Every factor is drawn from history and existing results. A patient who does not mention a transient ischaemic attack from four years ago, or whose insulin is recorded as "something for sugar", produces a score that is confidently wrong. Structured interviewing across every domain is what makes an index like this worth calculating at all. Pathways screens on the underlying findings rather than asking a clinician to reconstruct them from a narrative. --- # SGLT2 inhibitors (perioperative) > SGLT2 inhibitors such as empagliflozin and dapagliflozin must be withheld before surgery because they can cause euglycaemic diabetic ketoacidosis, in which ketoacidosis develops with normal or near-normal blood glucose. Because withholding must begin days before the procedure, the plan has to be made at booking rather than on admission. *Source: https://getpathways.ai/glossary/sglt2-inhibitor-perioperative* Also known as: gliflozins, empagliflozin, dapagliflozin, SGLT2i - **Drug class**: Sodium-glucose co-transporter 2 inhibitors - **Common agents**: Empagliflozin, dapagliflozin, ertugliflozin - **Perioperative risk**: Euglycaemic diabetic ketoacidosis (eDKA) - **Why it is missed**: Blood glucose can be normal, so the usual signal is absent - **Guidance**: ANZCA and Australian Diabetes Society perioperative guidance ## Why the risk is unusual Diabetic ketoacidosis is normally accompanied by a high blood glucose, which is what prompts the diagnosis. SGLT2 inhibitors can produce ketoacidosis with a glucose that is normal or only mildly raised — euglycaemic DKA. The safety problem is therefore diagnostic as much as pharmacological: the signal clinicians are trained to look for is absent, so the condition is recognised late. Surgery adds precisely the stressors that precipitate it: fasting, dehydration, and the physiological stress response. ## Why it becomes a cancellation Withholding has to start days before the operation. That makes it a booking-time decision, not an admission-time one. A patient who arrives on the morning of surgery still taking their gliflozin cannot be made safe by any decision available that morning, so the case is cancelled. The failure is almost never clinical judgement. It is that nobody knew the patient was on the drug. Patients routinely describe it as "a tablet for sugar", and a GP summary eight months old may predate the prescription. ## How Pathways catches it During the voice interview, patients photograph their medication boxes. Each image is read — handwriting included — classified, and the extracted values verified against the source image before entering the record. An identified SGLT2 inhibitor with no documented withholding plan for the surgery date raises a critical-tier flag citing the ANZCA and ADS guidance, with the rule version and the evidence that triggered it attached. --- # STOP-Bang score > STOP-Bang is an eight-item screening questionnaire for obstructive sleep apnoea. Each item scores one point — snoring, tiredness, observed apnoeas, high blood pressure, BMI over 35, age over 50, neck circumference over 40cm, and male sex. A score of 5 to 8 indicates high risk of moderate-to-severe OSA. *Source: https://getpathways.ai/glossary/stop-bang-score* Also known as: STOP-Bang, STOP-BANG questionnaire - **Items**: 8 — Snoring, Tiredness, Observed apnoea, Pressure, BMI, Age, Neck, Gender - **Score range**: 0–8 - **Low risk**: 0–2 - **Intermediate risk**: 3–4 - **High risk**: 5–8 - **Screens for**: Obstructive sleep apnoea (OSA) ## Why it matters before surgery Undiagnosed obstructive sleep apnoea changes perioperative management. Patients with significant OSA are more sensitive to sedatives and opioids, are at higher risk of airway obstruction and desaturation after anaesthesia, and may need altered post-operative monitoring or a different location of care. The clinical problem is that most OSA in a surgical population is undiagnosed at the time of booking. The patient does not report a condition they do not know they have, so unless the eight questions are actually asked, the risk stays invisible until the recovery room. ## The eight items | Item | Scores one point when | | --- | --- | | **S**noring | Loud enough to be heard through a closed door | | **T**iredness | Daytime tiredness, fatigue or sleepiness | | **O**bserved | Someone has observed the patient stop breathing in their sleep | | **P**ressure | Treated or untreated high blood pressure | | **B**MI | Over 35 kg/m² | | **A**ge | Over 50 | | **N**eck | Circumference over 40 cm | | **G**ender | Male | ## How Pathways uses it The Socrates Pre-Op interview covers the STOP-Bang items as part of its systems review and social/risk-factor domains, so the score is derived on every patient rather than only on those who look high risk on paper. A score of 5 or above in a patient with no OSA diagnosis raises a warning-tier flag with a recommendation to screen before the pre-admission clinic, giving the service time to act. --- # Theatre utilisation > Theatre utilisation measures how much of the operating time allocated to a list is actually used for surgery. It is a core efficiency measure for both public and private services. Late cancellations damage it disproportionately, because a slot lost on the day usually cannot be refilled — unlike one released with a week's notice. *Source: https://getpathways.ai/glossary/theatre-utilisation* Also known as: theatre efficiency, list utilisation, operating room utilisation - **Measures**: Proportion of allocated operating time used for surgery - **Damaged by**: Late cancellations, late starts, overruns, gaps between cases - **Why late cancellations hurt most**: A slot lost on the day usually cannot be refilled - **Recoverable when**: The cancellation happens early enough to backfill from the waiting list ## Not all lost time is equal A cancellation a week out and a cancellation on the morning of surgery register as the same clinical event and are entirely different operationally. The first releases a slot that can be offered to someone on the waiting list. The second leaves a gap that will not be filled, because no suitable patient can be prepared, consented and fasted at that notice. This is why utilisation is more sensitive to *when* problems are found than to how many there are. A service that identifies the same number of unfit patients earlier loses far less theatre time. ## What it means for the assessment question The operational case for screening at booking is really a utilisation argument rather than a clinical one — the clinical case for assessing patients properly was never in dispute. Moving assessment to the point of booking converts a category of unrecoverable cancellation into a category of manageable rescheduling. The patient still may not be fit to proceed on the original date, but the list does not lose the hour, and the patient gets an optimisation window rather than a wasted fasting day. For private services this maps directly onto revenue, which is why the arithmetic that usually decides a purchase is cancellation cost rather than per-patient cost. --- # Alternatives to current pre-admission practice > Most services assess patients on paper or by telephone, and do so competently. These comparisons set out what each approach does well, where it strains at volume, and what changes when assessment moves to the point of booking rather than the weeks before surgery. *Source: https://getpathways.ai/alternatives* ## Paper pre-admission questionnaires Paper pre-admission questionnaires are reliable, need no phone or connectivity, and reach patients a digital pathway cannot. They strain on return rate, legibility, medication accuracy and timing: a form posted out and returned weeks later arrives as a document to be read rather than structured findings that can be screened. URL: https://getpathways.ai/alternatives/paper-pre-admission-questionnaires ## Telephone pre-assessment Telephone pre-assessment gets nuance, rapport and follow-up questions no form anticipates, and a skilled assessor hears things a questionnaire never surfaces. It does not scale: every patient costs a clinician's time at a moment that suits the service, so it is rationed to the patients someone already suspected were complex. URL: https://getpathways.ai/alternatives/telephone-pre-assessment --- # Alternatives to paper pre-admission forms > Paper pre-admission questionnaires are reliable, need no phone or connectivity, and reach patients a digital pathway cannot. They strain on return rate, legibility, medication accuracy and timing: a form posted out and returned weeks later arrives as a document to be read rather than structured findings that can be screened. *Source: https://getpathways.ai/alternatives/paper-pre-admission-questionnaires* ## What paper pre-admission questionnaires does well - Works for every patient, including those with no smartphone, no reliable connectivity, or no confidence using one. - Nothing to log in to and nothing that can expire. A paper form does not depend on a link still working three weeks after it was sent. - Familiar to staff and patients alike, with no change management and no training required. - Can be completed with help from a family member or carer at the kitchen table, at whatever pace suits. - Produces a physical artefact that can be filed, scanned or carried, which some services' record-keeping is still built around. ## Side by side - **Reaching the patient** — Paper pre-admission questionnaires: Posted with the booking letter, or handed over at a clinic visit. With Pathways: A signed, time-limited SMS link sent the day the patient is scheduled. - **Return rate** — Paper pre-admission questionnaires: Depends on the patient posting it back or remembering to bring it. With Pathways: Completion is tracked per patient, with automated reminders and one-click resend. - **What comes back** — Paper pre-admission questionnaires: A completed document that still has to be read and interpreted. With Pathways: Structured, severity-tagged findings that feed the risk engine directly. - **Medication accuracy** — Paper pre-admission questionnaires: Written from memory, in the patient's own words. With Pathways: Medication boxes photographed, extracted, and verified against the source image. - **Legibility** — Paper pre-admission questionnaires: Handwriting, and blank fields that may mean "no" or may mean "skipped". With Pathways: Unanswered domains are recorded as gaps rather than absences. - **Knowing where a patient is up to** — Paper pre-admission questionnaires: Known when the form arrives back, and not before. With Pathways: Sent, opened, in progress, completed or expired, per patient, live. - **Timing** — Paper pre-admission questionnaires: Often read close to the procedure, when there is little time to act. With Pathways: Screened at booking, while an optimisation window still exists. ## Where paper starts to strain None of what follows is an argument that paper questionnaires are badly designed. The forms are usually thorough — often more thorough than what replaces them. The difficulty is structural, and it shows up at volume. **A form is read, not screened.** However complete the answers, what comes back is prose and ticked boxes that a clinician has to interpret. That interpretation is unavoidable work, and it happens once per patient at whatever moment someone gets to it. There is no equivalent of applying the same screening criteria to every patient on the list, because there is nothing structured to apply them to. **Timing is not controllable.** The form goes out with the booking letter and comes back when it comes back. For a patient whose HbA1c turns out to be poorly controlled, the difference between reading that at booking and reading it at the pre-admission clinic is the difference between an optimisation window and a [cancellation](/glossary/day-of-surgery-cancellation) — and paper gives the service no control over which one it gets. **Absence is ambiguous.** A blank field might mean the patient has no cardiac history, or that they did not understand the question, or that they ran out of patience on page eleven. All three look identical on the returned form. This matters most for the domains where a negative answer is genuinely reassuring — [functional capacity](/glossary/functional-capacity-mets), prior anaesthetic problems, a [sleep apnoea](/glossary/obstructive-sleep-apnoea) screen. **Medication lists are written from memory.** This is the failure with the sharpest consequences. Patients routinely describe an [SGLT2 inhibitor](/glossary/sglt2-inhibitor-perioperative) as "a tablet for sugar" and an [anticoagulant](/glossary/perioperative-anticoagulation) as "a blood thinner", if they mention it at all — and both need a management plan made days ahead. ## What does not change The clinical content of the assessment. The domains worth asking about are the same ones, and a good paper questionnaire already covers most of them. What changes is that the answers arrive structured, early, and with the medications verified rather than recalled. ## Where paper should stay For patients without a usable phone, or who need an interpreter, or who would simply rather not, paper remains the right instrument — and a service running a digital pathway still needs one. The realistic outcome is not that paper disappears but that it stops being the default for everyone and becomes the route for the patients it genuinely suits. Those patients are then a known, named group rather than being indistinguishable from the rest of the list. --- # Alternatives to telephone pre-assessment > Telephone pre-assessment gets nuance, rapport and follow-up questions no form anticipates, and a skilled assessor hears things a questionnaire never surfaces. It does not scale: every patient costs a clinician's time at a moment that suits the service, so it is rationed to the patients someone already suspected were complex. *Source: https://getpathways.ai/alternatives/telephone-pre-assessment* ## What telephone pre-assessment does well - A skilled assessor hears hesitation, confusion and things the patient did not think to mention — signals no structured instrument captures. - Follow-up questions can go wherever the answer leads, rather than down a path decided in advance. - Works for patients who cannot use a digital pathway, need an interpreter, or would rather speak to a person. - Builds rapport before the day of surgery, which changes how patients arrive and what they disclose. - Questions can be explained and rephrased until understood, instead of being abandoned half-answered. ## Side by side - **Who gets assessed** — Telephone pre-assessment: Rationed by available clinician time, so usually the patients already suspected of being complex. With Pathways: Every booked patient, because taking the history costs no clinical time. - **When it happens** — Telephone pre-assessment: Often close to the procedure, when the diary allows. With Pathways: At booking, while there is still time to act on what is found. - **Whose time it costs** — Telephone pre-assessment: A clinician's, per patient, per call. With Pathways: The patient's, in their own time, from home. - **Reaching the patient** — Telephone pre-assessment: Phone tag. Working-age patients are the hardest to reach. With Pathways: A link completed whenever suits, with reminders if it is not. - **Consistency** — Telephone pre-assessment: Depends on who made the call and how their day was going. With Pathways: The same 12 domains and the same screening criteria on every patient. - **Medication history** — Telephone pre-assessment: Recalled aloud, under time pressure, often without the boxes to hand. With Pathways: Boxes photographed during the interview and verified against the image. - **The record** — Telephone pre-assessment: Notes written during or after the call. With Pathways: Structured findings, with the evidence and rule version behind every flag. ## What the phone call is actually good at A clinician on the phone is doing something a structured instrument cannot. They hear the pause before "no, I'm fine on stairs". They notice the patient is answering for their spouse. They ask the question that was not on the list because something in the previous answer warranted it. That is genuinely better assessment, and any honest comparison has to start there. The problem is not quality. ## The problem is arithmetic A pre-op call takes real clinician time, per patient. A service booking several hundred elective patients a month cannot make several hundred calls, so calls get rationed — and rationing requires deciding in advance who warrants one. That decision is made on the information available at booking: age, procedure, sometimes an [ASA class](/glossary/asa-physical-status) from the referral. None of it is a reliable guide to who has poorly controlled diabetes, undiagnosed [sleep apnoea](/glossary/obstructive-sleep-apnoea), or an [anticoagulant](/glossary/perioperative-anticoagulation) nobody has recorded. So the calls go to the patients who look complex on paper, and the patients who cancel lists are, by definition, the ones who did not. This is the same allocation problem the [pre-admission clinic](/glossary/pre-admission-clinic) has, in a cheaper form. ## Two things a call cannot do, however well made **Verify a medication list.** A patient recalling their medications aloud, under time pressure, without the boxes in front of them, produces the least reliable version of that list available. Asking better does not fix it — the information is not in the room. **Happen early enough, at scale.** Even where a service calls every patient, the calls cluster near the procedure because that is when the diary allows. A finding that arrives days out is a finding with nowhere to go. ## What this is not an argument for Removing the phone call. Telephone review is one of the four routing outcomes Pathways produces, and for a meaningful share of patients it is exactly the right one. The change is which patients get it and what the clinician has in front of them when they dial. A call made after reading a completed interview, verified medications and a screened risk profile is a different conversation from one made cold with a name and a procedure — it is a five-minute confirmation rather than a twenty-five minute assembly job, and it goes to the patients where a conversation will actually change something. --- # Privacy Policy — Pathways > Pathways AI Pty Ltd handles personal information under the Privacy Act 1988 (Cth) and the Australian Privacy Principles. All data is hosted in AWS Sydney and patient information is not transferred outside Australia. Pathways does not sell personal information and does not use patient information to train models. *Source: https://getpathways.ai/privacy* ## 1. Who we are Pathways is operated by Pathways AI Pty Ltd ("we", "us"). We provide clinical decision support software to Australian healthcare providers. This policy explains how we handle personal information in accordance with the Privacy Act 1988 (Cth) and the Australian Privacy Principles (APPs). ## 2. What we collect - **Patient information** — provided by treating clinicians and by patients through the Socrates Pre-Op assessment: health history, medications, and related clinical information. This is collected on behalf of, and under the direction of, the treating healthcare provider. - **Account information** — names, work emails and roles of clinical and administrative users. - **Usage information** — audit logs of actions taken in the platform, retained as part of the clinical record. ## 3. How we use it Patient information is used solely to deliver the clinical decision support services requested by the treating provider: conducting assessments, generating risk profiles, and maintaining audit records. We do not sell personal information. We do not use patient information to train models. No personally identifying information is sent to model providers. ## 4. Where it lives All data is hosted in AWS Sydney (ap-southeast-2). Patient information is not transferred outside Australia. Data is encrypted in transit and at rest. ## 5. Retention and access Clinical records are retained per the treating provider's obligations and applicable health records legislation. Patients may request access to or correction of their information through their treating provider, or by contacting us at privacy@getpathways.ai. ## 6. Contact Questions or complaints: privacy@getpathways.ai. You may also contact the Office of the Australian Information Commissioner (oaic.gov.au). --- # Terms of Service — Pathways > These are the standard conditions of use for Pathways clinical decision support software. Access is provided under an executed services agreement. Pathways is a decision support tool for qualified clinicians — its outputs are recommendations for review, never diagnoses, orders or treatment directives, and the treating clinician remains solely responsible for all clinical decisions. *Source: https://getpathways.ai/terms* ## 1. The service Pathways provides clinical decision support software for pre-operative assessment. Access is provided under an executed services agreement with your organisation or practice; these terms summarise the standard conditions of use. ## 2. Clinical decision support — not medical advice Pathways is a clinical decision support tool intended for use by qualified clinicians. It assists — it never replaces — clinical judgement. Outputs are recommendations for review, not diagnoses, orders, or treatment directives. The treating clinician remains solely responsible for all clinical decisions. ## 3. Acceptable use - Use is limited to authorised users within a registered healthcare organisation or practice. - Users must not enter information about patients without lawful authority to do so. - Users must not attempt to circumvent access controls or extract data beyond their role. ## 4. Availability and support Service levels, support hours and maintenance windows are defined in your services agreement. ## 5. Liability To the maximum extent permitted by law, and subject to the Australian Consumer Law, our liability is limited as set out in your services agreement. Nothing in these terms excludes liability that cannot be excluded by law. ## 6. Disclaimer Pathways does not provide medical services. All clinical content, risk flags and recommendations are generated as decision support for qualified clinicians and must be independently reviewed before any clinical action is taken. ## 7. Contact legal@getpathways.ai