Healthcare decision architecture

Coordinate benefit, clinical, claims, risk and intervention decisions while preserving accountable human judgement.

Leadership operating experience

Grounded in healthcare-administration systems

The architecture reflects Tshepo Mashilo’s operating experience in healthcare administration. It does not imply that the illustrative case on this page is a current Brillion client deployment.

The decision environment

Healthcare decisions sit between clinical need, benefit design, evidence, affordability, capacity and patient circumstances. Many require rapid automation, while consequential exceptions must retain an explicit route to qualified human review.

DecisionOne makes the basis of an eligibility, authorisation, routing or intervention decision visible without presenting a predictive score as the final clinical or administrative authority.

Representative decision services

Determine benefit eligibilityGoverned determination

Authorise a serviceContext + policy + authority

Trigger a care interventionAction + evidence + outcome

Benefit authorisation with accountable human review

A service request must be assessed against member eligibility, benefit design, clinical information, prior use and the applicable review authority. The administrative decision must be timely without presenting a model output as clinical judgement.

The decision service assembles benefit and policy context, identifies the applicable rule path and routes consequential exceptions to qualified review. The record distinguishes benefit administration, clinical recommendation and final authority.

This is an architecture example, not a named customer case study or a claim of achieved results.

Decision networkFrom operational signals to outcome evidence

Signals and systemsClaims administrationEMR and EHRProvider systemsCare management

Governed decisionsDetermine benefit eligibilityAuthorise a serviceTrigger a care intervention

Authorised actionsAuthorise under the applicable benefitRequest clinically relevant evidenceRoute to qualified human review

Outcome evidenceTurnaround timePolicy adherenceReview and overturn rateAppropriate utilisation

MeasureLearnImprove the approved decision design

From enterprise systems to measurable outcomes.

Connected systemsClaims administrationEMR and EHRProvider systemsCare management

Configured decision domainsPricingTariffs and benefitsAdjudicationAuthorisations and claimsAllocationCare capacityForecastingHealth-risk demand

Outcome measuresAppropriate utilisationTurnaround timePayment integrityPatient outcome

These are reference decision patterns, not a claim that every organisation uses the same policy, process or measure. Implementation begins by confirming the actual decision landscape, authority and evidence required.

ALL

Explore every industry

Experience and capacityCurrent Brillion focusHospitality

Coordinate rate, inventory, demand and intervention decisions across a hospitality portfolio.

Set the next best rate
Accept a group request
Allocate constrained inventory

View decision map ↗Regulated financial decisionsLeadership and product experienceFinancial services

Unify credit, risk, pricing, fraud and customer-treatment decisions with explicit authority.

Approve a facility
Set risk-adjusted terms
Trigger enhanced review

View decision map ↗Risk and adjudicationEDAF™ reference applicationInsurance

Govern underwriting, premium, claims, fraud and recovery decisions across the policy lifecycle.

Accept and price a risk
Adjudicate a claim
Refer suspected fraud

View decision map ↗Care and benefit decisionsLeadership operating experienceHealthcare

Coordinate benefit, clinical, claims, risk and intervention decisions while preserving accountable human judgement.

Determine benefit eligibility
Authorise a service
Trigger a care intervention

View decision map ↗Public value and accountabilityEDAF™ reference applicationGovernment

Make grants, cases, inspections and service allocation more consistent, traceable and contestable.

Determine eligibility
Prioritise a case
Allocate a public resource

View decision map ↗Asset and operational decisionsEDAF™ reference applicationMining

Connect production, maintenance, safety, capital and resource-allocation decisions across the mining value chain.

Sequence production
Allocate mobile equipment
Trigger predictive maintenance

View decision map ↗Network and customer decisionsLeadership operating experienceTelecommunications

Coordinate offer, credit, retention, fraud and network-resource decisions across channels and services.

Select the next best offer
Set a customer credit limit
Prioritise a network intervention

View decision map ↗Infrastructure and market decisionsEDAF™ reference applicationEnergy

Govern dispatch, pricing, maintenance, demand-response and investment decisions across energy systems.

Dispatch constrained capacity
Schedule critical maintenance
Trigger demand response

View decision map ↗Flow and capacity decisionsEDAF™ reference applicationLogistics

Orchestrate routing, scheduling, capacity, exception and fulfilment decisions across logistics networks.

Select a route and carrier
Allocate constrained capacity
Recover a disrupted shipment

View decision map ↗Customer and merchandise decisionsEDAF™ reference applicationRetail

Unify pricing, promotion, assortment, inventory and customer-treatment decisions across channels.

Set a price or promotion
Allocate inventory by channel
Recommend the next best action

View decision map ↗Attention and content decisionsEDAF™ reference applicationMedia

Coordinate content, recommendation, advertising, rights and audience decisions across media platforms.

Recommend content
Allocate campaign inventory
Apply editorial or suitability policy

View decision map ↗Access and learner decisionsEDAF™ reference applicationEducation

Govern admissions, progression, resource allocation and learner-intervention decisions across education systems.

Determine admission eligibility
Allocate learning support
Trigger a learner intervention

View decision map ↗Funding and workforce outcomesDecisionOne product patternSkills development / SETAs

Govern funding, provider, learner and intervention decisions across the skills ecosystem.

Approve a funding application
Assess delivery risk
Trigger corrective action

View decision map ↗

What configuration changes—and what remains stable.

Industry terminology, source systems, policies, authority structures, workflows, KPIs and jurisdictional controls change by implementation.

The governed decision object, lifecycle, evidence model, dependency relationships and DecisionOps controls remain consistent.