{
  "loop": "Identity -> Data -> Medication Response Profile -> Context -> DecisionObject -> Action -> Passport -> Clinician View -> Outcome -> Audit",
  "demo": {
    "profile": {
      "personId": "person_jordan_smith",
      "generatedAt": "2026-08-22T20:15:00.000Z",
      "activeCount": 3,
      "uncertainCount": 1,
      "historicalCount": 1,
      "conflictCount": 3,
      "pgxRelevantCount": 4,
      "active": [
        {
          "id": "episode_sertraline",
          "personId": "person_jordan_smith",
          "concept": {
            "id": "med_sertraline",
            "name": "Sertraline",
            "ingredient": "sertraline",
            "rxCui": "36437",
            "drugClass": "SSRI antidepressant"
          },
          "state": "active",
          "prescriptionState": "taken",
          "dose": "50 mg",
          "route": "oral",
          "frequency": "once daily",
          "indication": "Major depressive disorder, user confirmed",
          "startDate": "2025-03-14",
          "lastConfirmedAt": "2026-08-22",
          "verificationStatus": "authoritative-source-supported",
          "sourceIds": [
            "src_user_entry",
            "src_payer_api"
          ],
          "provenanceIds": [
            "prov_sertraline_user",
            "prov_sertraline_claim"
          ],
          "orders": [
            {
              "id": "order_sertraline",
              "medicationConceptId": "med_sertraline",
              "prescriber": "Dr. Patel",
              "orderedAt": "2025-03-14",
              "sig": "Take one tablet by mouth daily",
              "provenanceId": "prov_sertraline_user"
            }
          ],
          "dispenses": [
            {
              "id": "dispense_sertraline_aug",
              "medicationConceptId": "med_sertraline",
              "pharmacy": "Northstar retail pharmacy network",
              "dispensedAt": "2026-08-02",
              "daysSupply": 30,
              "provenanceId": "prov_sertraline_claim"
            }
          ],
          "experiences": [
            {
              "id": "exp_sertraline",
              "medicationConceptId": "med_sertraline",
              "effectiveness": "better",
              "sideEffects": [
                "mild nausea in first week"
              ],
              "adherence": "taking",
              "affordability": "ok",
              "provenanceId": "prov_sertraline_user"
            }
          ],
          "conflicts": [],
          "pgxRelevantGenes": [
            "CYP2D6",
            "CYP2C19"
          ],
          "policyTags": [
            "treatment-use",
            "payer-program-only",
            "advertising-prohibited"
          ]
        },
        {
          "id": "episode_clopidogrel",
          "personId": "person_jordan_smith",
          "concept": {
            "id": "med_clopidogrel",
            "name": "Clopidogrel",
            "ingredient": "clopidogrel",
            "rxCui": "32968",
            "drugClass": "Antiplatelet"
          },
          "state": "active",
          "prescriptionState": "dispensed",
          "dose": "75 mg",
          "route": "oral",
          "frequency": "once daily",
          "indication": "Post-stent antiplatelet therapy, source supported",
          "startDate": "2026-08-10",
          "lastConfirmedAt": "2026-08-22",
          "verificationStatus": "authoritative-source-supported",
          "sourceIds": [
            "src_payer_api"
          ],
          "provenanceIds": [
            "prov_clopidogrel_claim"
          ],
          "orders": [],
          "dispenses": [
            {
              "id": "dispense_clopidogrel_aug",
              "medicationConceptId": "med_clopidogrel",
              "pharmacy": "Northstar retail pharmacy network",
              "dispensedAt": "2026-08-10",
              "daysSupply": 30,
              "provenanceId": "prov_clopidogrel_claim"
            }
          ],
          "experiences": [],
          "conflicts": [
            "User has not confirmed current use after new fill"
          ],
          "pgxRelevantGenes": [
            "CYP2C19"
          ],
          "policyTags": [
            "payer-program-only",
            "treatment-use",
            "advertising-prohibited"
          ]
        },
        {
          "id": "episode_metformin",
          "personId": "person_jordan_smith",
          "concept": {
            "id": "med_metformin",
            "name": "Metformin",
            "ingredient": "metformin",
            "rxCui": "6809",
            "drugClass": "Biguanide"
          },
          "state": "active",
          "prescriptionState": "taken",
          "dose": "500 mg",
          "route": "oral",
          "frequency": "twice daily",
          "indication": "Prediabetes, user confirmed",
          "startDate": "2025-11-01",
          "lastConfirmedAt": "2026-08-22",
          "verificationStatus": "user-reported",
          "sourceIds": [
            "src_user_entry"
          ],
          "provenanceIds": [
            "prov_sertraline_user"
          ],
          "orders": [],
          "dispenses": [],
          "experiences": [
            {
              "id": "exp_metformin",
              "medicationConceptId": "med_metformin",
              "effectiveness": "unchanged",
              "sideEffects": [
                "GI upset"
              ],
              "adherence": "missed-doses",
              "affordability": "cost-barrier",
              "provenanceId": "prov_sertraline_user"
            }
          ],
          "conflicts": [
            "Missed doses reported due to GI upset and cost"
          ],
          "pgxRelevantGenes": [],
          "policyTags": [
            "treatment-use",
            "care-navigation-use",
            "advertising-prohibited"
          ]
        }
      ],
      "uncertain": [
        {
          "id": "episode_codeine",
          "personId": "person_jordan_smith",
          "concept": {
            "id": "med_codeine",
            "name": "Codeine",
            "ingredient": "codeine",
            "rxCui": "2670",
            "drugClass": "Opioid analgesic"
          },
          "state": "uncertain",
          "prescriptionState": "unknown",
          "dose": "unknown",
          "route": "oral",
          "frequency": "as needed, uncertain",
          "indication": "Old cough medication, not confirmed active",
          "startDate": "2026-02-02",
          "lastConfirmedAt": "2026-08-21",
          "verificationStatus": "unknown-conflicting",
          "sourceIds": [
            "src_user_entry"
          ],
          "provenanceIds": [
            "prov_codeine_user"
          ],
          "orders": [],
          "dispenses": [],
          "experiences": [],
          "conflicts": [
            "Medication may no longer be active"
          ],
          "pgxRelevantGenes": [
            "CYP2D6"
          ],
          "policyTags": [
            "treatment-use",
            "care-navigation-use",
            "advertising-prohibited"
          ]
        }
      ],
      "historical": [
        {
          "id": "episode_simvastatin",
          "personId": "person_jordan_smith",
          "concept": {
            "id": "med_simvastatin",
            "name": "Simvastatin",
            "ingredient": "simvastatin",
            "rxCui": "36567",
            "drugClass": "Statin"
          },
          "state": "historical",
          "prescriptionState": "stopped",
          "dose": "20 mg",
          "route": "oral",
          "frequency": "nightly",
          "indication": "Hyperlipidemia",
          "startDate": "2024-01-03",
          "lastConfirmedAt": "2026-08-21",
          "verificationStatus": "user-reported",
          "sourceIds": [
            "src_user_entry"
          ],
          "provenanceIds": [
            "prov_sertraline_user"
          ],
          "orders": [],
          "dispenses": [],
          "experiences": [
            {
              "id": "exp_simvastatin",
              "medicationConceptId": "med_simvastatin",
              "effectiveness": "unknown",
              "sideEffects": [
                "muscle pain"
              ],
              "adherence": "stopped",
              "affordability": "ok",
              "reasonStopped": "muscle pain, patient report",
              "provenanceId": "prov_sertraline_user"
            }
          ],
          "conflicts": [],
          "pgxRelevantGenes": [
            "SLCO1B1"
          ],
          "policyTags": [
            "treatment-use",
            "care-navigation-use",
            "advertising-prohibited"
          ]
        }
      ],
      "conflicts": [
        {
          "episodeId": "episode_clopidogrel",
          "medication": "Clopidogrel",
          "conflict": "User has not confirmed current use after new fill"
        },
        {
          "episodeId": "episode_codeine",
          "medication": "Codeine",
          "conflict": "Medication may no longer be active"
        },
        {
          "episodeId": "episode_metformin",
          "medication": "Metformin",
          "conflict": "Missed doses reported due to GI upset and cost"
        }
      ],
      "pgxRelevant": [
        {
          "id": "episode_sertraline",
          "personId": "person_jordan_smith",
          "concept": {
            "id": "med_sertraline",
            "name": "Sertraline",
            "ingredient": "sertraline",
            "rxCui": "36437",
            "drugClass": "SSRI antidepressant"
          },
          "state": "active",
          "prescriptionState": "taken",
          "dose": "50 mg",
          "route": "oral",
          "frequency": "once daily",
          "indication": "Major depressive disorder, user confirmed",
          "startDate": "2025-03-14",
          "lastConfirmedAt": "2026-08-22",
          "verificationStatus": "authoritative-source-supported",
          "sourceIds": [
            "src_user_entry",
            "src_payer_api"
          ],
          "provenanceIds": [
            "prov_sertraline_user",
            "prov_sertraline_claim"
          ],
          "orders": [
            {
              "id": "order_sertraline",
              "medicationConceptId": "med_sertraline",
              "prescriber": "Dr. Patel",
              "orderedAt": "2025-03-14",
              "sig": "Take one tablet by mouth daily",
              "provenanceId": "prov_sertraline_user"
            }
          ],
          "dispenses": [
            {
              "id": "dispense_sertraline_aug",
              "medicationConceptId": "med_sertraline",
              "pharmacy": "Northstar retail pharmacy network",
              "dispensedAt": "2026-08-02",
              "daysSupply": 30,
              "provenanceId": "prov_sertraline_claim"
            }
          ],
          "experiences": [
            {
              "id": "exp_sertraline",
              "medicationConceptId": "med_sertraline",
              "effectiveness": "better",
              "sideEffects": [
                "mild nausea in first week"
              ],
              "adherence": "taking",
              "affordability": "ok",
              "provenanceId": "prov_sertraline_user"
            }
          ],
          "conflicts": [],
          "pgxRelevantGenes": [
            "CYP2D6",
            "CYP2C19"
          ],
          "policyTags": [
            "treatment-use",
            "payer-program-only",
            "advertising-prohibited"
          ]
        },
        {
          "id": "episode_clopidogrel",
          "personId": "person_jordan_smith",
          "concept": {
            "id": "med_clopidogrel",
            "name": "Clopidogrel",
            "ingredient": "clopidogrel",
            "rxCui": "32968",
            "drugClass": "Antiplatelet"
          },
          "state": "active",
          "prescriptionState": "dispensed",
          "dose": "75 mg",
          "route": "oral",
          "frequency": "once daily",
          "indication": "Post-stent antiplatelet therapy, source supported",
          "startDate": "2026-08-10",
          "lastConfirmedAt": "2026-08-22",
          "verificationStatus": "authoritative-source-supported",
          "sourceIds": [
            "src_payer_api"
          ],
          "provenanceIds": [
            "prov_clopidogrel_claim"
          ],
          "orders": [],
          "dispenses": [
            {
              "id": "dispense_clopidogrel_aug",
              "medicationConceptId": "med_clopidogrel",
              "pharmacy": "Northstar retail pharmacy network",
              "dispensedAt": "2026-08-10",
              "daysSupply": 30,
              "provenanceId": "prov_clopidogrel_claim"
            }
          ],
          "experiences": [],
          "conflicts": [
            "User has not confirmed current use after new fill"
          ],
          "pgxRelevantGenes": [
            "CYP2C19"
          ],
          "policyTags": [
            "payer-program-only",
            "treatment-use",
            "advertising-prohibited"
          ]
        },
        {
          "id": "episode_codeine",
          "personId": "person_jordan_smith",
          "concept": {
            "id": "med_codeine",
            "name": "Codeine",
            "ingredient": "codeine",
            "rxCui": "2670",
            "drugClass": "Opioid analgesic"
          },
          "state": "uncertain",
          "prescriptionState": "unknown",
          "dose": "unknown",
          "route": "oral",
          "frequency": "as needed, uncertain",
          "indication": "Old cough medication, not confirmed active",
          "startDate": "2026-02-02",
          "lastConfirmedAt": "2026-08-21",
          "verificationStatus": "unknown-conflicting",
          "sourceIds": [
            "src_user_entry"
          ],
          "provenanceIds": [
            "prov_codeine_user"
          ],
          "orders": [],
          "dispenses": [],
          "experiences": [],
          "conflicts": [
            "Medication may no longer be active"
          ],
          "pgxRelevantGenes": [
            "CYP2D6"
          ],
          "policyTags": [
            "treatment-use",
            "care-navigation-use",
            "advertising-prohibited"
          ]
        },
        {
          "id": "episode_simvastatin",
          "personId": "person_jordan_smith",
          "concept": {
            "id": "med_simvastatin",
            "name": "Simvastatin",
            "ingredient": "simvastatin",
            "rxCui": "36567",
            "drugClass": "Statin"
          },
          "state": "historical",
          "prescriptionState": "stopped",
          "dose": "20 mg",
          "route": "oral",
          "frequency": "nightly",
          "indication": "Hyperlipidemia",
          "startDate": "2024-01-03",
          "lastConfirmedAt": "2026-08-21",
          "verificationStatus": "user-reported",
          "sourceIds": [
            "src_user_entry"
          ],
          "provenanceIds": [
            "prov_sertraline_user"
          ],
          "orders": [],
          "dispenses": [],
          "experiences": [
            {
              "id": "exp_simvastatin",
              "medicationConceptId": "med_simvastatin",
              "effectiveness": "unknown",
              "sideEffects": [
                "muscle pain"
              ],
              "adherence": "stopped",
              "affordability": "ok",
              "reasonStopped": "muscle pain, patient report",
              "provenanceId": "prov_sertraline_user"
            }
          ],
          "conflicts": [],
          "pgxRelevantGenes": [
            "SLCO1B1"
          ],
          "policyTags": [
            "treatment-use",
            "care-navigation-use",
            "advertising-prohibited"
          ]
        }
      ]
    },
    "context": {
      "id": "context_compiled_runtime",
      "personId": "person_jordan_smith",
      "generatedAt": "2026-08-22T20:15:00.000Z",
      "signals": [
        {
          "id": "signal_new_clopidogrel",
          "personId": "person_jordan_smith",
          "type": "recent-medication-start",
          "description": "Clopidogrel was dispensed within the last 30 days.",
          "sourceIds": [
            "src_payer_api"
          ],
          "policyTags": [
            "payer-program-only",
            "advertising-prohibited"
          ],
          "observedAt": "2026-08-22T16:42:00.000Z"
        },
        {
          "id": "signal_unresolved_codeine",
          "personId": "person_jordan_smith",
          "type": "unresolved-pgx",
          "description": "Possible codeine exposure intersects with a clinical CYP2D6 poor metabolizer phenotype.",
          "sourceIds": [
            "src_user_entry",
            "src_genomic_upload"
          ],
          "policyTags": [
            "genomic",
            "sensitive",
            "advertising-prohibited"
          ],
          "observedAt": "2026-08-22T15:10:00.000Z"
        },
        {
          "id": "signal_cost_metformin",
          "personId": "person_jordan_smith",
          "type": "cost-barrier",
          "description": "User reported missed metformin doses and cost friction.",
          "sourceIds": [
            "src_user_entry"
          ],
          "policyTags": [
            "care-navigation-use",
            "advertising-prohibited"
          ],
          "observedAt": "2026-08-22T18:25:00.000Z"
        },
        {
          "id": "signal_goal_weight",
          "personId": "person_jordan_smith",
          "type": "user-goal-changed",
          "description": "User explicitly asked Twinome to help explore weight-management options.",
          "sourceIds": [
            "src_user_entry"
          ],
          "policyTags": [
            "care-navigation-use",
            "advertising-prohibited"
          ],
          "observedAt": "2026-08-22T18:40:00.000Z"
        },
        {
          "id": "context_recent_episode_clopidogrel",
          "personId": "person_jordan_smith",
          "type": "recent-medication-start",
          "description": "Clopidogrel started or was dispensed recently.",
          "sourceIds": [
            "src_payer_api"
          ],
          "policyTags": [
            "payer-program-only",
            "treatment-use",
            "advertising-prohibited"
          ],
          "observedAt": "2026-08-22T20:15:00.000Z"
        },
        {
          "id": "context_uncertain_episode_codeine",
          "personId": "person_jordan_smith",
          "type": "unresolved-pgx",
          "description": "Codeine has uncertain status and PGx relevance.",
          "sourceIds": [
            "src_user_entry"
          ],
          "policyTags": [
            "treatment-use",
            "care-navigation-use",
            "advertising-prohibited"
          ],
          "observedAt": "2026-08-22T20:15:00.000Z"
        },
        {
          "id": "context_cost_episode_metformin",
          "personId": "person_jordan_smith",
          "type": "cost-barrier",
          "description": "Metformin has a user-reported cost or coverage barrier.",
          "sourceIds": [
            "src_user_entry"
          ],
          "policyTags": [
            "treatment-use",
            "care-navigation-use",
            "advertising-prohibited"
          ],
          "observedAt": "2026-08-22T20:15:00.000Z"
        }
      ]
    },
    "flags": [
      {
        "id": "flag_live_clopidogrel_cyp2c19",
        "ruleId": "rule_cyp2c19_clopidogrel",
        "medicationEpisodeIds": [
          "episode_clopidogrel"
        ],
        "severity": "high",
        "title": "Reduced clopidogrel activation risk",
        "summary": "The active clopidogrel episode intersects with a clinical CYP2C19 reduced-function phenotype.",
        "missingInformation": [
          "Clinician confirmation of prescribing intent."
        ],
        "evidenceIds": [
          "evidence_fda_pgx",
          "evidence_cpic_clopidogrel"
        ]
      },
      {
        "id": "flag_live_codeine_cyp2d6",
        "ruleId": "rule_cyp2d6_codeine",
        "medicationEpisodeIds": [
          "episode_codeine"
        ],
        "severity": "medium",
        "title": "Possible codeine mismatch",
        "summary": "Possible codeine exposure intersects with a clinical CYP2D6 poor metabolizer phenotype.",
        "missingInformation": [
          "Confirm whether codeine is active."
        ],
        "evidenceIds": [
          "evidence_fda_pgx",
          "evidence_cpic_cyp2d6_opioids"
        ]
      },
      {
        "id": "flag_live_reconcile_episode_codeine",
        "ruleId": "rule_stale_list_uncertain_med",
        "medicationEpisodeIds": [
          "episode_codeine"
        ],
        "severity": "low",
        "title": "Codeine needs reconciliation",
        "summary": "This medication is not source-confirmed as active and should not silently become clinical truth.",
        "missingInformation": [
          "Current active use"
        ],
        "evidenceIds": [
          "evidence_twinome_staleness"
        ]
      },
      {
        "id": "flag_live_access_episode_simvastatin",
        "ruleId": "rule_cost_barrier_metformin",
        "medicationEpisodeIds": [
          "episode_simvastatin"
        ],
        "severity": "medium",
        "title": "Simvastatin access or adherence barrier",
        "summary": "Patient-reported experience suggests access, tolerability, or adherence may explain the outcome.",
        "missingInformation": [
          "Current benefit, price, and barrier reason"
        ],
        "evidenceIds": [
          "evidence_twinome_staleness"
        ]
      },
      {
        "id": "flag_live_access_episode_metformin",
        "ruleId": "rule_cost_barrier_metformin",
        "medicationEpisodeIds": [
          "episode_metformin"
        ],
        "severity": "medium",
        "title": "Metformin access or adherence barrier",
        "summary": "Patient-reported experience suggests access, tolerability, or adherence may explain the outcome.",
        "missingInformation": [
          "Current benefit, price, and barrier reason"
        ],
        "evidenceIds": [
          "evidence_twinome_staleness"
        ]
      }
    ],
    "decisions": [
      {
        "id": "decision_live_1_rule_cyp2c19_clopidogrel",
        "personId": "person_jordan_smith",
        "version": "decision-v1",
        "generatedAt": "2026-08-22T20:15:00.000Z",
        "clinicalFlagId": "flag_live_clopidogrel_cyp2c19",
        "patientContextUsed": [
          "active",
          "dispensed",
          "src_payer_api"
        ],
        "medicationEpisodeIds": [
          "episode_clopidogrel"
        ],
        "relevantPhenotypeIds": [
          "phenotype_cyp2c19"
        ],
        "relevantLabIds": [],
        "evidenceIds": [
          "evidence_fda_pgx",
          "evidence_cpic_clopidogrel"
        ],
        "ruleVersion": "rule_cyp2c19_clopidogrel@1.0.0",
        "sourceQuality": "authoritative-source-supported",
        "missingInformation": [
          "Clinician confirmation of prescribing intent."
        ],
        "confidence": 0.91,
        "severity": "high",
        "clinicianExplanation": "CYP2C19 intermediate metabolizer phenotype may reduce clopidogrel activation. Review antiplatelet strategy and source evidence.",
        "patientExplanation": "Your Passport found a medication-genetics flag that a clinician should review before relying on this medication plan.",
        "suggestedNextStep": "Clinician medication review",
        "clinicianInvolvementRequired": true,
        "overrideState": "not-reviewed",
        "outcomeWindowDays": 90
      },
      {
        "id": "decision_live_2_rule_cyp2d6_codeine",
        "personId": "person_jordan_smith",
        "version": "decision-v1",
        "generatedAt": "2026-08-22T20:15:00.000Z",
        "clinicalFlagId": "flag_live_codeine_cyp2d6",
        "patientContextUsed": [
          "uncertain",
          "unknown",
          "src_user_entry"
        ],
        "medicationEpisodeIds": [
          "episode_codeine"
        ],
        "relevantPhenotypeIds": [
          "phenotype_cyp2d6",
          "phenotype_consumer_cyp2d6"
        ],
        "relevantLabIds": [],
        "evidenceIds": [
          "evidence_fda_pgx",
          "evidence_cpic_cyp2d6_opioids"
        ],
        "ruleVersion": "rule_cyp2d6_codeine@1.0.0",
        "sourceQuality": "unknown-conflicting",
        "missingInformation": [
          "Confirm whether codeine is active."
        ],
        "confidence": 0.76,
        "severity": "medium",
        "clinicianExplanation": "CYP2D6 poor metabolizer phenotype with possible codeine exposure. Confirm active use before acting; codeine efficacy may be reduced.",
        "patientExplanation": "A medication listed as possible may be affected by your medication-genetics profile. Confirm whether you still use it.",
        "suggestedNextStep": "Medication reconciliation",
        "clinicianInvolvementRequired": false,
        "overrideState": "not-reviewed",
        "outcomeWindowDays": 30
      },
      {
        "id": "decision_live_3_rule_stale_list_uncertain_med",
        "personId": "person_jordan_smith",
        "version": "decision-v1",
        "generatedAt": "2026-08-22T20:15:00.000Z",
        "clinicalFlagId": "flag_live_reconcile_episode_codeine",
        "patientContextUsed": [
          "uncertain",
          "unknown",
          "src_user_entry"
        ],
        "medicationEpisodeIds": [
          "episode_codeine"
        ],
        "relevantPhenotypeIds": [
          "phenotype_cyp2d6",
          "phenotype_consumer_cyp2d6"
        ],
        "relevantLabIds": [],
        "evidenceIds": [
          "evidence_twinome_staleness"
        ],
        "ruleVersion": "rule_stale_list_uncertain_med@1.0.0",
        "sourceQuality": "unknown-conflicting",
        "missingInformation": [
          "Current active use"
        ],
        "confidence": 0.61,
        "severity": "low",
        "clinicianExplanation": "Medication source conflict: user-entered codeine may be historical. Reconcile before treating as active.",
        "patientExplanation": "One medication looks uncertain. Confirming whether you still take it keeps the Passport useful in urgent care.",
        "suggestedNextStep": "Patient confirmation",
        "clinicianInvolvementRequired": false,
        "overrideState": "not-reviewed",
        "outcomeWindowDays": 30
      },
      {
        "id": "decision_live_4_rule_cost_barrier_metformin",
        "personId": "person_jordan_smith",
        "version": "decision-v1",
        "generatedAt": "2026-08-22T20:15:00.000Z",
        "clinicalFlagId": "flag_live_access_episode_simvastatin",
        "patientContextUsed": [
          "historical",
          "stopped",
          "src_user_entry"
        ],
        "medicationEpisodeIds": [
          "episode_simvastatin"
        ],
        "relevantPhenotypeIds": [
          "phenotype_slco1b1"
        ],
        "relevantLabIds": [],
        "evidenceIds": [
          "evidence_twinome_staleness"
        ],
        "ruleVersion": "rule_cost_barrier_metformin@1.0.0",
        "sourceQuality": "user-reported",
        "missingInformation": [
          "Current benefit, price, and barrier reason"
        ],
        "confidence": 0.76,
        "severity": "medium",
        "clinicianExplanation": "Patient reports cost barrier and missed doses. Address adherence barrier before interpreting medication failure.",
        "patientExplanation": "You reported a cost or access barrier. Twinome can help compare options or route you to plan-supported help.",
        "suggestedNextStep": "Access support",
        "clinicianInvolvementRequired": false,
        "overrideState": "not-reviewed",
        "outcomeWindowDays": 30
      },
      {
        "id": "decision_live_5_rule_cost_barrier_metformin",
        "personId": "person_jordan_smith",
        "version": "decision-v1",
        "generatedAt": "2026-08-22T20:15:00.000Z",
        "clinicalFlagId": "flag_live_access_episode_metformin",
        "patientContextUsed": [
          "active",
          "taken",
          "src_user_entry"
        ],
        "medicationEpisodeIds": [
          "episode_metformin"
        ],
        "relevantPhenotypeIds": [],
        "relevantLabIds": [],
        "evidenceIds": [
          "evidence_twinome_staleness"
        ],
        "ruleVersion": "rule_cost_barrier_metformin@1.0.0",
        "sourceQuality": "user-reported",
        "missingInformation": [
          "Current benefit, price, and barrier reason"
        ],
        "confidence": 0.76,
        "severity": "medium",
        "clinicianExplanation": "Patient reports cost barrier and missed doses. Address adherence barrier before interpreting medication failure.",
        "patientExplanation": "You reported a cost or access barrier. Twinome can help compare options or route you to plan-supported help.",
        "suggestedNextStep": "Access support",
        "clinicianInvolvementRequired": false,
        "overrideState": "not-reviewed",
        "outcomeWindowDays": 30
      }
    ],
    "actions": [
      {
        "id": "candidate_reconcile_codeine",
        "definitionId": "action_reconcile",
        "personId": "person_jordan_smith",
        "decisionObjectId": "decision_codeine_reconcile",
        "relevanceReason": "Codeine is uncertain and intersects with a PGx flag.",
        "eligibility": "eligible",
        "policyTags": [
          "treatment-use",
          "care-navigation-use",
          "advertising-prohibited"
        ]
      },
      {
        "id": "candidate_confirm_pgx",
        "definitionId": "action_confirm_pgx",
        "personId": "person_jordan_smith",
        "decisionObjectId": "decision_codeine_reconcile",
        "relevanceReason": "Consumer genomic data has a CYP2D6 callability gap, so Twinome does not treat the available upload as complete.",
        "eligibility": "needs-review",
        "policyTags": [
          "genomic",
          "sensitive",
          "advertising-prohibited"
        ]
      },
      {
        "id": "candidate_refill_metformin",
        "definitionId": "action_refill_help",
        "personId": "person_jordan_smith",
        "decisionObjectId": "decision_metformin_access",
        "relevanceReason": "Missed doses and cost barrier were reported.",
        "eligibility": "eligible",
        "policyTags": [
          "care-navigation-use",
          "advertising-prohibited"
        ]
      },
      {
        "id": "candidate_savings_metformin",
        "definitionId": "action_savings",
        "personId": "person_jordan_smith",
        "decisionObjectId": "decision_metformin_access",
        "relevanceReason": "The user confirmed cost friction before Twinome considered a savings route.",
        "eligibility": "eligible",
        "policyTags": [
          "care-navigation-use",
          "advertising-prohibited"
        ]
      },
      {
        "id": "candidate_trial_post_stent",
        "definitionId": "action_trial_screen",
        "personId": "person_jordan_smith",
        "relevanceReason": "Potential research screening is separated from treatment consent.",
        "eligibility": "needs-review",
        "policyTags": [
          "sensitive",
          "redisclosure-prohibited",
          "advertising-prohibited"
        ]
      },
      {
        "id": "candidate_weight_care",
        "definitionId": "action_care_navigation",
        "personId": "person_jordan_smith",
        "relevanceReason": "User explicitly asked for weight-management options; routing waits for Explore.",
        "eligibility": "needs-review",
        "policyTags": [
          "care-navigation-use",
          "advertising-prohibited"
        ]
      },
      {
        "id": "candidate_runtime_decision_live_3_rule_stale_list_uncertain_med",
        "definitionId": "action_reconcile",
        "personId": "person_jordan_smith",
        "decisionObjectId": "decision_live_3_rule_stale_list_uncertain_med",
        "relevanceReason": "Patient confirmation",
        "eligibility": "eligible",
        "policyTags": [
          "treatment-use",
          "care-navigation-use",
          "advertising-prohibited"
        ]
      }
    ],
    "opportunities": [
      {
        "id": "opportunity_clopidogrel_review",
        "personId": "person_jordan_smith",
        "type": "clinician-review",
        "title": "Review clopidogrel with a clinician",
        "whyNow": "A current antiplatelet medication intersects with a verified clinical CYP2C19 result.",
        "basis": [
          "Medication-relevant markers from a consumer genomic upload",
          "Payer fill for clopidogrel",
          "Mercy EHR order assertion"
        ],
        "supportingSignalIds": [
          "signal_new_clopidogrel"
        ],
        "decisionObjectIds": [
          "decision_clopidogrel_cyp2c19"
        ],
        "confidence": "supported",
        "sensitiveInference": "none",
        "confirmationRequired": false,
        "actionDefinitionId": "action_care_navigation",
        "clinicalBoundary": "Twinome flags a review need; the clinician decides whether any therapy change is appropriate.",
        "dataRestrictions": [
          "genomic",
          "sensitive",
          "redisclosure-prohibited",
          "advertising-prohibited"
        ],
        "commercialEligibility": "not-evaluated",
        "suppressionState": "active",
        "expiresAt": "2026-11-20T00:00:00.000Z",
        "createdAt": "2026-08-22T20:15:00.000Z"
      },
      {
        "id": "opportunity_reconcile_codeine",
        "personId": "person_jordan_smith",
        "type": "medication-reconciliation",
        "title": "Confirm whether codeine is still active",
        "whyNow": "A historical medication entry is uncertain and would matter in an emergency medication review.",
        "basis": [
          "User-entered codeine record",
          "Medication episode is unresolved",
          "Clinical CYP2D6 result would matter only if exposure is real"
        ],
        "supportingSignalIds": [
          "signal_unresolved_codeine"
        ],
        "decisionObjectIds": [
          "decision_codeine_reconcile"
        ],
        "confidence": "needs-confirmation",
        "sensitiveInference": "none",
        "confirmationRequired": true,
        "actionDefinitionId": "action_reconcile",
        "clinicalBoundary": "This is a reconciliation task, not a medication recommendation.",
        "dataRestrictions": [
          "genomic",
          "sensitive",
          "advertising-prohibited"
        ],
        "commercialEligibility": "not-evaluated",
        "suppressionState": "active",
        "expiresAt": "2026-09-21T00:00:00.000Z",
        "createdAt": "2026-08-22T20:15:00.000Z"
      },
      {
        "id": "opportunity_pgx_confirmation",
        "personId": "person_jordan_smith",
        "type": "pgx-confirmation",
        "title": "Consumer genomic data confirmation may be useful for unresolved genes",
        "whyNow": "The consumer genotype upload has a CYP2D6 copy-number gap while medication history contains possible opioid exposure.",
        "basis": [
          "Consumer genotype callability requires copy-number information",
          "Consumer genomic data source is present for core demo genes",
          "Decision engine can abstain when genetic information is incomplete"
        ],
        "supportingSignalIds": [
          "signal_unresolved_codeine"
        ],
        "decisionObjectIds": [
          "decision_codeine_reconcile"
        ],
        "confidence": "provisional",
        "sensitiveInference": "confirmation-required",
        "confirmationRequired": true,
        "actionDefinitionId": "action_confirm_pgx",
        "clinicalBoundary": "Twinome can route to clinical testing when a real medication decision depends on missing PGx.",
        "dataRestrictions": [
          "genomic",
          "sensitive",
          "advertising-prohibited"
        ],
        "commercialEligibility": "not-evaluated",
        "suppressionState": "active",
        "expiresAt": "2026-10-21T00:00:00.000Z",
        "createdAt": "2026-08-22T20:15:00.000Z"
      },
      {
        "id": "opportunity_refill_savings",
        "personId": "person_jordan_smith",
        "type": "prescription-savings",
        "title": "Find a lower-cost way to fill metformin",
        "whyNow": "Jordan reported missed doses and cost friction, so the problem is confirmed rather than inferred from claims.",
        "basis": [
          "User-reported cost barrier",
          "Medication episode remains active",
          "Pharmacy feed has a possible gap but degraded observability"
        ],
        "supportingSignalIds": [
          "signal_cost_metformin"
        ],
        "decisionObjectIds": [
          "decision_metformin_access"
        ],
        "confidence": "supported",
        "sensitiveInference": "not-used",
        "confirmationRequired": false,
        "actionDefinitionId": "action_savings",
        "clinicalBoundary": "This is access support; Twinome does not interpret medication failure from refill data alone.",
        "dataRestrictions": [
          "care-navigation-use",
          "advertising-prohibited",
          "contract-restricted"
        ],
        "commercialEligibility": "eligible-after-explore",
        "suppressionState": "active",
        "expiresAt": "2026-09-06T00:00:00.000Z",
        "createdAt": "2026-08-22T20:15:00.000Z"
      },
      {
        "id": "opportunity_sleep_medication_review",
        "personId": "person_jordan_smith",
        "type": "care-navigation",
        "title": "Discuss sleep changes in medication context",
        "whyNow": "A recent medication change overlaps with user-reported sleep difficulty and permitted Oura readiness context, but Twinome does not infer causation.",
        "basis": [
          "User-reported sleep difficulty after a medication change",
          "Oura contributes limited context and receives no Passport data",
          "Temporal overlap is a question for review, not proof of cause"
        ],
        "supportingSignalIds": [
          "signal_sleep_change",
          "signal_new_clopidogrel"
        ],
        "decisionObjectIds": [],
        "confidence": "needs-confirmation",
        "sensitiveInference": "confirmation-required",
        "confirmationRequired": true,
        "actionDefinitionId": "action_care_navigation",
        "clinicalBoundary": "Twinome can suggest a medication-context discussion; it does not diagnose insomnia or attribute it to a drug.",
        "dataRestrictions": [
          "healthkit-derived",
          "care-navigation-use",
          "advertising-prohibited"
        ],
        "commercialEligibility": "not-evaluated",
        "suppressionState": "active",
        "expiresAt": "2026-09-21T00:00:00.000Z",
        "createdAt": "2026-08-22T20:15:00.000Z"
      },
      {
        "id": "opportunity_migraine_review",
        "personId": "person_jordan_smith",
        "type": "care-navigation",
        "title": "Review migraine-treatment pattern with a clinician",
        "whyNow": "Jordan has confirmed migraine context and reports increasing acute-medication use, making a clinician-led treatment review timely.",
        "basis": [
          "Migraine context is confirmed, not inferred from medication alone",
          "Patient-reported increase in acute-medication frequency",
          "Prior therapy history can travel into intake only after user Explore"
        ],
        "supportingSignalIds": [
          "signal_migraine_frequency"
        ],
        "decisionObjectIds": [],
        "confidence": "supported",
        "sensitiveInference": "none",
        "confirmationRequired": false,
        "actionDefinitionId": "action_care_navigation",
        "clinicalBoundary": "Twinome surfaces a care-navigation opportunity; the clinician decides diagnosis and treatment.",
        "dataRestrictions": [
          "care-navigation-use",
          "sensitive",
          "advertising-prohibited"
        ],
        "commercialEligibility": "not-evaluated",
        "suppressionState": "active",
        "expiresAt": "2026-09-28T00:00:00.000Z",
        "createdAt": "2026-08-22T20:15:00.000Z"
      },
      {
        "id": "opportunity_trial_prescreen",
        "personId": "person_jordan_smith",
        "type": "trial-prescreen",
        "title": "Optional trial prescreen requires separate permission",
        "whyNow": "A confirmed post-stent context and active medication history could make research screening worth asking about.",
        "basis": [
          "Confirmed condition from source-supported record",
          "Medication history",
          "User has not granted trial-screening permission"
        ],
        "supportingSignalIds": [
          "signal_new_clopidogrel"
        ],
        "decisionObjectIds": [],
        "confidence": "provisional",
        "sensitiveInference": "confirmation-required",
        "confirmationRequired": true,
        "actionDefinitionId": "action_trial_screen",
        "clinicalBoundary": "A prescreen is not eligibility and is never sent without a separate user approval.",
        "dataRestrictions": [
          "sensitive",
          "redisclosure-prohibited",
          "advertising-prohibited"
        ],
        "commercialEligibility": "not-evaluated",
        "suppressionState": "active",
        "expiresAt": "2026-09-21T00:00:00.000Z",
        "createdAt": "2026-08-22T20:15:00.000Z"
      },
      {
        "id": "opportunity_weight_care",
        "personId": "person_jordan_smith",
        "type": "care-navigation",
        "title": "Explore clinician-led weight-management care",
        "whyNow": "Jordan explicitly stated a weight-management goal; Twinome does not infer it from metformin alone.",
        "basis": [
          "User goal explicitly reported",
          "Medication list is available for intake",
          "Partner routing waits until Explore"
        ],
        "supportingSignalIds": [
          "signal_goal_weight"
        ],
        "decisionObjectIds": [],
        "confidence": "needs-confirmation",
        "sensitiveInference": "none",
        "confirmationRequired": true,
        "actionDefinitionId": "action_care_navigation",
        "clinicalBoundary": "Twinome may surface a care option, but the partner clinician performs assessment and treatment decisions.",
        "dataRestrictions": [
          "care-navigation-use",
          "advertising-prohibited"
        ],
        "commercialEligibility": "not-evaluated",
        "suppressionState": "active",
        "expiresAt": "2026-09-21T00:00:00.000Z",
        "createdAt": "2026-08-22T20:15:00.000Z"
      }
    ],
    "recommendations": [
      {
        "id": "rec_clopidogrel_review",
        "personId": "person_jordan_smith",
        "kind": "decision",
        "objectId": "decision_clopidogrel_cyp2c19",
        "title": "A current medication may need clinician review",
        "explanation": "A verified PGx result may matter for clopidogrel. Twinome explains the evidence but does not change medication.",
        "whySeeingThis": "You have a source-supported clopidogrel episode and a clinical CYP2C19 result in your Passport.",
        "urgency": "high",
        "surface": "clinician",
        "status": "shown",
        "shownAt": "2026-08-22T20:03:00.000Z"
      },
      {
        "id": "rec_reconcile_codeine",
        "personId": "person_jordan_smith",
        "kind": "opportunity",
        "objectId": "opportunity_reconcile_codeine",
        "title": "Confirm an old medication",
        "explanation": "A possible codeine entry should be confirmed before it appears in urgent care as active.",
        "whySeeingThis": "You entered codeine as an old medication and Twinome cannot verify active use from other sources.",
        "urgency": "medium",
        "surface": "consumer-web",
        "status": "ready"
      },
      {
        "id": "rec_refill_savings",
        "personId": "person_jordan_smith",
        "kind": "opportunity",
        "objectId": "opportunity_refill_savings",
        "title": "Prescription cost help may be useful",
        "explanation": "You told Twinome cost is affecting metformin adherence, so savings support is relevant.",
        "whySeeingThis": "This is based on your explicit report of cost friction, not a commercial audience query.",
        "urgency": "medium",
        "surface": "consumer-web",
        "status": "explored",
        "shownAt": "2026-08-22T20:04:00.000Z"
      },
      {
        "id": "rec_weight_care",
        "personId": "person_jordan_smith",
        "kind": "opportunity",
        "objectId": "opportunity_weight_care",
        "title": "Clinician-led weight-management care may be worth exploring",
        "explanation": "Twinome can prepare a scoped intake only if you choose to explore a care option.",
        "whySeeingThis": "You explicitly asked for weight-management help; Twinome is not inferring a diagnosis from a medication.",
        "urgency": "low",
        "surface": "consumer-web",
        "status": "ready",
        "cooldownUntil": "2026-08-29T00:00:00.000Z"
      }
    ],
    "fulfillmentRoutes": [
      {
        "id": "fulfillment_metformin_savings",
        "opportunityObjectId": "opportunity_refill_savings",
        "actionCandidateId": "candidate_savings_metformin",
        "selectedAfterUserExplore": true,
        "partnerName": "Northstar covered pharmacy support",
        "eligibility": "eligible",
        "routeReason": "Chosen only after the user explored a confirmed affordability opportunity.",
        "dataDisclosureScopes": [
          "medications.read",
          "claims.read"
        ],
        "compensationModel": "pmpm",
        "disclosure": "Northstar sponsors this member support route. Compensation does not create the relevance signal.",
        "routedAt": "2026-08-22T20:06:00.000Z"
      },
      {
        "id": "fulfillment_weight_care_pending",
        "opportunityObjectId": "opportunity_weight_care",
        "actionCandidateId": "candidate_weight_care",
        "selectedAfterUserExplore": false,
        "partnerName": "No partner selected",
        "eligibility": "not-available",
        "routeReason": "The care opportunity can be relevant even before a monetizable route exists.",
        "dataDisclosureScopes": [],
        "compensationModel": "none",
        "disclosure": "No partner disclosure is shown until the user chooses Explore.",
        "routedAt": "2026-08-22T20:08:00.000Z"
      }
    ],
    "walletPass": {
      "id": "passport_jsmith_2026",
      "personId": "person_jordan_smith",
      "serialNumber": "TW-JSMITH-2026-0001",
      "passTypeIdentifier": "pass.ai.twinome.medication",
      "teamIdentifier": "WVAHYUW6U4",
      "version": 4,
      "revoked": false,
      "lastUpdatedAt": "2026-08-22T20:15:00.000Z",
      "barcodeUrl": "https://twinome.local/p/8F2K-QX41",
      "authenticationToken": "tw_demo_wallet_auth_TW-JSMITH-2026-0001",
      "installToken": "tw_demo_install_passport_jsmith_2026",
      "updateTag": "wallet-passport-jsmith-v4-20260822T201500Z",
      "activeFlagCount": 3,
      "medicationCount": 3,
      "genesTypedCount": 5,
      "pgxSummaryStatus": "Consumer genomic data available",
      "emergencyNote": "Reduced clopidogrel activation flag. Avoid treating old codeine entry as active until reconciled.",
      "supportContact": "support@twinome.ai"
    },
    "outcomeLinks": [
      {
        "id": "outcome_link_clopidogrel_shown",
        "outcomeEventId": "outcome_shown_clopidogrel",
        "decisionObjectId": "decision_clopidogrel_cyp2c19",
        "opportunityObjectId": "opportunity_clopidogrel_review",
        "contextStateId": "context_jordan_20260822",
        "evidenceVersion": "evidence_fda_pgx@2026-08",
        "observedAt": "2026-08-22T20:03:00.000Z"
      },
      {
        "id": "outcome_link_refill_explored",
        "outcomeEventId": "outcome_explored_refill",
        "decisionObjectId": "decision_metformin_access",
        "opportunityObjectId": "opportunity_refill_savings",
        "actionCandidateId": "candidate_refill_metformin",
        "fulfillmentRouteId": "fulfillment_metformin_savings",
        "contextStateId": "context_jordan_20260822",
        "evidenceVersion": "evidence_twinome_staleness@rulebook-0.1",
        "observedAt": "2026-08-22T20:05:00.000Z"
      }
    ],
    "auditEvents": [
      {
        "id": "audit_identity",
        "actor": "J. Smith",
        "personId": "person_jordan_smith",
        "type": "ConsentGranted",
        "purpose": "treatment",
        "summary": "Created Twinome identity and granted core treatment consent.",
        "createdAt": "2026-08-21T14:31:00.000Z"
      },
      {
        "id": "audit_med_added",
        "actor": "J. Smith",
        "personId": "person_jordan_smith",
        "type": "MedicationAdded",
        "purpose": "care-navigation",
        "summary": "Added sertraline, metformin, and historical codeine entry.",
        "createdAt": "2026-08-21T14:38:00.000Z"
      },
      {
        "id": "audit_pgx",
        "actor": "Twinome ingestion",
        "personId": "person_jordan_smith",
        "type": "PGxResultAdded",
        "purpose": "treatment",
        "summary": "Imported consumer genomic data and kept unresolved genes clearly marked for confirmation.",
        "createdAt": "2026-08-22T15:04:00.000Z"
      },
      {
        "id": "audit_connection_oura",
        "actor": "Twinome Passport Connect",
        "personId": "person_jordan_smith",
        "type": "PassportConnectionCreated",
        "purpose": "care-navigation",
        "summary": "Connected Oura as inbound-only; Oura can contribute observations but cannot read Passport data.",
        "createdAt": "2026-08-22T19:35:00.000Z"
      },
      {
        "id": "audit_assertion_healthkit",
        "actor": "HealthKit mock connector",
        "personId": "person_jordan_smith",
        "type": "PartnerAssertionReceived",
        "purpose": "treatment",
        "summary": "Received medication dose observation and preserved HealthKit observability limitations.",
        "createdAt": "2026-08-22T19:52:00.000Z"
      },
      {
        "id": "audit_access_mercy",
        "actor": "Mercy Urgent Care",
        "personId": "person_jordan_smith",
        "type": "PassportAccessRequested",
        "purpose": "emergency",
        "summary": "Requested scoped Passport resources from patient-presented QR share.",
        "createdAt": "2026-08-22T19:57:00.000Z"
      },
      {
        "id": "audit_decisions",
        "actor": "Twinome rules engine",
        "personId": "person_jordan_smith",
        "type": "DecisionGenerated",
        "purpose": "treatment",
        "summary": "Generated three DecisionObjects with evidence, source quality, and outcome windows.",
        "createdAt": "2026-08-22T20:15:00.000Z"
      },
      {
        "id": "audit_opportunities",
        "actor": "Twinome opportunity engine",
        "personId": "person_jordan_smith",
        "type": "OpportunityGenerated",
        "purpose": "care-navigation",
        "summary": "Generated six OpportunityObjects after context and policy checks, before partner routing.",
        "createdAt": "2026-08-22T20:15:00.000Z"
      },
      {
        "id": "audit_recommendation",
        "actor": "Twinome recommendation layer",
        "personId": "person_jordan_smith",
        "type": "RecommendationShown",
        "purpose": "care-navigation",
        "summary": "Showed prescription-cost opportunity because the user explicitly reported cost friction.",
        "createdAt": "2026-08-22T20:04:00.000Z"
      },
      {
        "id": "audit_pass",
        "actor": "Twinome Passport service",
        "personId": "person_jordan_smith",
        "type": "PassGenerated",
        "purpose": "emergency",
        "summary": "Generated Apple Wallet-compatible Medication Passport package.",
        "createdAt": "2026-08-22T20:15:00.000Z"
      },
      {
        "id": "audit_wallet_device",
        "actor": "Apple Wallet",
        "personId": "person_jordan_smith",
        "type": "WalletDeviceRegistered",
        "purpose": "emergency",
        "summary": "Registered Wallet device library identifier for future pass updates.",
        "createdAt": "2026-08-22T20:02:00.000Z"
      },
      {
        "id": "audit_scan",
        "actor": "Mercy Urgent Care",
        "personId": "person_jordan_smith",
        "type": "ClinicianSnapshotViewed",
        "purpose": "emergency",
        "summary": "Patient-presented scan opened limited clinician snapshot.",
        "createdAt": "2026-08-22T20:03:00.000Z"
      },
      {
        "id": "audit_action",
        "actor": "J. Smith",
        "personId": "person_jordan_smith",
        "type": "ActionExplored",
        "purpose": "care-navigation",
        "summary": "Explored refill and access help for metformin.",
        "createdAt": "2026-08-22T20:05:00.000Z"
      },
      {
        "id": "audit_route",
        "actor": "Twinome marketplace router",
        "personId": "person_jordan_smith",
        "type": "FulfillmentRouted",
        "purpose": "care-navigation",
        "summary": "Routed metformin savings after user explored the confirmed affordability opportunity.",
        "createdAt": "2026-08-22T20:06:00.000Z"
      },
      {
        "id": "audit_outcome",
        "actor": "Twinome outcomes service",
        "personId": "person_jordan_smith",
        "type": "OutcomeObserved",
        "purpose": "care-navigation",
        "summary": "Linked action exploration back to DecisionObject decision_metformin_access.",
        "createdAt": "2026-08-22T20:07:00.000Z"
      }
    ]
  }
}