The same gate that decides PA
also decides clinical care.
Four flagship clinical-decision policies across four image modalities — chest X-ray, fundus, dermatology, histopathology — powered by Verum · Vision (our clinical vision-language model; MedGemma 4B foundation). Same deterministic gate as Verum · Decide; same audit ledger; same FHIR R4 export. Different rule libraries, different domain prompts, one platform.
No scans required. The text-only path produces actionable trinary verdicts on every case. The image path adds Verum · Vision verification — and feeds the BRIDGEworkflow inside Verum · Decide's /review, where AI findings get promoted into the deterministic policy gate by an attesting reviewer.
Four policies. Four output shapes.
One trinary verdict.
Every flagship produces the same canonical trinary (CLEAR / REVIEW / ESCALATE), but the shape of the underlying verdict differs by clinical-decision pattern. Flag-set for critical findings, severity-tier for graded scales, urgent-referral for weighted-score pathways, scoring-staging for derived grade groups. The deterministic gate is one piece of code; the four shapes are the canonical clinical-reasoning patterns it composes against.
FlagSetVerdict { flags: Array<{ ruleId, present, escalation, trinaryContribution }> }SeverityTierVerdict { tier, tierOrder, managementRoute, trinaryForTier, rationale[] }UrgentReferralVerdict { totalScore, threshold, urgent, pathway, contributingRules[] }ScoringStagingVerdict { componentScores, totalScore, matchedTrinary, matchedRuleId }Extract probabilistically.
Decide deterministically.
Every case flows through six stages. Stages 1 and 6 are LLM calls (extraction + synthesis); stages 2, 4, 5 are pure code (annotation, fact fusion, gate evaluation); stage 3 (multimodal image extraction) is Verum · Vision reading the attached image when present — best-effort and skippable when no image is attached. The load-bearing verdict comes out of stage 5 — pure code, instantly, deterministically — regardless of which model produced the extraction in stage 1.
LLM pulls structured clinical facts from the narrative (typed note · voice · dictation · pasted report). Per-flagship Zod schema constrains vocabulary.
Rule annotator scores rules primary / secondary / tertiary by fact-confidence + context hints. Pure code. Feeds attention for stages 3 + 6.
OPTIONAL. MedGemma adapter facade (Phase H). When no image submitted: skipped. When image present: stubbed in Phase G; lands in Phase H.
Merges text + image facts with provenance tags (text-only / image-only / both-agree / disputed). Pure code. Disputed flagged for operator.
Deterministic evaluator collapses fused facts → trinary verdict (CLEAR / REVIEW / ESCALATE). Per-flagship shape: flag-set, severity-tier, urgent-referral, scoring-staging.
LLM writes the per-flagship advisor read in specialty register (thoracic radiologist · vitreoretinal · GP dermatology · uropathologist). Six structured sections; streamed.
N modalities. One verdict.
When a patient bundle activates multiple flagships at once — say a septic ICU patient with concurrent fundus screening and a pending prostate biopsy — every applicable gate fires in parallel. The trinary precedence collapse (ESCALATE > REVIEW > CLEAR) yields one overall verdict; the per-lane verdicts remain visible for specialist routing. Curated bundles live on /insight/extended.
Triple-finding ICU patient — STAT collapse across 3 modalities
68M with longstanding T1DM (22 years, last HbA1c 9.4%), admitted to the MICU for septic shock with multi-organ dysfunction. Day-1 status post right-internal-jugular CVC placement and intubation. Pathology was already finalising a prostate biopsy obtained outpatient one week earlier following an isolated elevated screening PSA (38 ng/mL). Workup running in parallel: portable AP CXR after CVC, fundus screening per diabetic-eye protocol, and the pending pathology read. This bundle demonstrates the trinary precedence collapse — three independent modalities all flagging ESCALATE for different clinical reasons (mechanical, microvascular, oncologic) on the same patient.
Every flagship: FLAGSHIP REAL.
Each rule's criterion field quotes a real authoritative source verbatim. Wilkinson 2003 for ICDR's 4-2-1 rule. NICE NG12 §1.13 for Glasgow 7-point. ISUP 2019 + 2014 Consensus for Gleason. ACR-SCBT-MR + BTS + SCCM for CXR. The matrix below shows which sources back each flagship — primary anchors, encoded citations, cross-validation references. Full per-source provenance lives at /insight/coverage.
Same case. Different policy version.
Sometimes a different verdict.
Policy versions are first-class data in the registry. Pick a Gleason primary + secondary pattern below — the page evaluates against both ISUP 2014 and ISUP 2019 in pure code, side-by-side. The 3+4=GG2 vs 4+3=GG3 distinction is the load-bearing accuracy point; the ISUP-version comparison surfaces management-band drift across guideline revisions. Full what-if simulator at /insight/simulator.
Append-only ledger.
PDF + FHIR R4 export.
Every fact provenance, verdict event, confidence snapshot, and artifact append happens at the moment its producing stage fires — no retroactive audit assembly. Operator attestation seals the record (medical-records model: addenda, never edits). Sealed records export to react-pdf (operator-facing) and to FHIR R4 Bundle (Provenance + DocumentReference + AuditEvent[]; ATNA / EHR interop).
supersedes.Four policies. Four modalities. Lumbar-quality provenance per flagship.
Six cross-cutting surfaces.
Workspace tools spanning multiple flagships. Same operator ergonomics as Verum · Decide; different rule data.
Two products. One bridge.
Verum · Decide handles prior authorization — payer policy, member context, denial letters. Verum · Insight handles clinical decision support — imaging triage, screening protocols, grading. The same Verum · Visionthat powers Insight's standalone flagships also feeds BRIDGE inside Decide's /review: AI image findings get attested + promoted into the deterministic policy gate by the UM reviewer, flipping PEND → APPROVE on cases where the dictated report hedged on documentation. Two surfaces, one engine, one BRIDGE.