CascadeDMT Readiness

Source records

3 documents

Cascade Imaging Center

MRI Brain w/wo Contrast

Imaging reportC-CDA
MRI BRAIN W/WO CONTRAST. CLINICAL HISTORY: Relapsing-remitting MS, surveillance. FINDINGS: Multiple T2/FLAIR hyperintense lesions in periventricular and juxtacortical white matter. Compared to the prior exam dated 14 months ago, there are two new T2 lesions in the right frontal white matter and one enlarging lesion in the left centrum semiovale. One lesion demonstrates gadolinium enhancement, compatible with active demyelination. No infratentorial lesion. IMPRESSION: Interval radiologic disease activity.

QuestLab

JC Virus Antibody Panel

Lab resultFHIR R4
{ "resourceType": "Bundle", "id": "0a5f1e00-0000-4000-8000-000000000000", "type": "collection", "timestamp": "2026-05-21T14:32:00Z", "entry": [ { "fullUrl": "urn:uuid:0a5f1e00-0000-4000-8000-000000000001", "resource": { "resourceType": "Patient", "id": "0a5f1e00-0000-4000-8000-000000000001", "identifier": [ { "system": "urn:oid:2.16.840.1.113883.19.5.99999.2", "value": "QL-PT-4471" } ], "name": [ { "use": "official", "family": "Rivera", "given": [ "Jordan" ] } ], "gender": "female", "birthDate": "1992-03-15" } }, { "fullUrl": "urn:uuid:0a5f1e00-0000-4000-8000-000000000002", "resource": { "resourceType": "Condition", "id": "0a5f1e00-0000-4000-8000-000000000002", "clinicalStatus": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/condition-clinical", "code": "active", "display": "Active" } ] }, "verificationStatus": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/condition-ver-status", "code": "confirmed", "display": "Confirmed" } ] }, "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/condition-category", "code": "problem-list-item", "display": "Problem List Item" } ] } ], "code": { "coding": [ { "system": "http://hl7.org/fhir/sid/icd-10-cm", "code": "G35.A", "display": "Relapsing-remitting multiple sclerosis" } ], "text": "Relapsing-remitting multiple sclerosis" }, "subject": { "reference": "urn:uuid:0a5f1e00-0000-4000-8000-000000000001", "display": "Jordan Rivera" }, "onsetDateTime": "2024-09-12", "recordedDate": "2024-09-12" } }, { "fullUrl": "urn:uuid:0a5f1e00-0000-4000-8000-000000000003", "resource": { "resourceType": "DiagnosticReport", "id": "0a5f1e00-0000-4000-8000-000000000003", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v2-0074", "code": "SR", "display": "Serology" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "70173-0", "display": "JC virus Ab [Presence] in Serum or Plasma by Immunoassay" } ], "text": "JC Virus Antibody with Index, Serum" }, "subject": { "reference": "urn:uuid:0a5f1e00-0000-4000-8000-000000000001", "display": "Jordan Rivera" }, "effectiveDateTime": "2026-05-21T08:15:00Z", "issued": "2026-05-22T16:40:00Z", "performer": [ { "display": "QuestLab" } ], "result": [ { "reference": "urn:uuid:0a5f1e00-0000-4000-8000-000000000004" }, { "reference": "urn:uuid:0a5f1e00-0000-4000-8000-000000000005" } ] } }, { "fullUrl": "urn:uuid:0a5f1e00-0000-4000-8000-000000000004", "resource": { "resourceType": "Observation", "id": "0a5f1e00-0000-4000-8000-000000000004", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "Laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "70173-0", "display": "JC virus Ab [Presence] in Serum or Plasma by Immunoassay" } ], "text": "JC Virus Antibody, Serum" }, "subject": { "reference": "urn:uuid:0a5f1e00-0000-4000-8000-000000000001", "display": "Jordan Rivera" }, "effectiveDateTime": "2026-05-21T08:15:00Z", "issued": "2026-05-22T16:40:00Z", "performer": [ { "display": "QuestLab" } ], "valueCodeableConcept": { "coding": [ { "system": "http://snomed.info/sct", "code": "10828004", "display": "Positive" } ], "text": "Positive" }, "interpretation": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation", "code": "POS", "display": "Positive" } ] } ] } }, { "fullUrl": "urn:uuid:0a5f1e00-0000-4000-8000-000000000005", "resource": { "resourceType": "Observation", "id": "0a5f1e00-0000-4000-8000-000000000005", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "Laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "100977-8", "display": "JC virus Ab Index in Serum or Plasma by Immunoassay" } ], "text": "JC Virus Antibody Index, Serum" }, "subject": { "reference": "urn:uuid:0a5f1e00-0000-4000-8000-000000000001", "display": "Jordan Rivera" }, "effectiveDateTime": "2026-05-21T08:15:00Z", "issued": "2026-05-22T16:40:00Z", "performer": [ { "display": "QuestLab" } ], "valueQuantity": { "value": 0.42, "unit": "index", "system": "http://unitsofmeasure.org", "code": "{Index_val}" }, "interpretation": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation", "code": "POS", "display": "Positive" } ] } ], "referenceRange": [ { "text": "Index less than 0.20 negative; 0.20 to 0.40 indeterminate; greater than 0.40 positive" } ], "note": [ { "text": "Anti-JCV antibody positive. Per natalizumab REMS, index value is used for PML risk stratification." } ] } }, { "fullUrl": "urn:uuid:0a5f1e00-0000-4000-8000-000000000006", "resource": { "resourceType": "DiagnosticReport", "id": "0a5f1e00-0000-4000-8000-000000000006", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v2-0074", "code": "HM", "display": "Hematology" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "57021-8", "display": "CBC W Auto Differential panel - Blood" } ], "text": "CBC with Automated Differential" }, "subject": { "reference": "urn:uuid:0a5f1e00-0000-4000-8000-000000000001", "display": "Jordan Rivera" }, "effectiveDateTime": "2026-05-21T08:15:00Z", "issued": "2026-05-21T11:05:00Z", "performer": [ { "display": "QuestLab" } ], "result": [ { "reference": "urn:uuid:0a5f1e00-0000-4000-8000-000000000007" }, { "reference": "urn:uuid:0a5f1e00-0000-4000-8000-000000000008" } ] } }, { "fullUrl": "urn:uuid:0a5f1e00-0000-4000-8000-000000000007", "resource": { "resourceType": "Observation", "id": "0a5f1e00-0000-4000-8000-000000000007", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "Laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "6690-2", "display": "Leukocytes [#/volume] in Blood by Automated count" } ], "text": "WBC" }, "subject": { "reference": "urn:uuid:0a5f1e00-0000-4000-8000-000000000001", "display": "Jordan Rivera" }, "effectiveDateTime": "2026-05-21T08:15:00Z", "issued": "2026-05-21T11:05:00Z", "performer": [ { "display": "QuestLab" } ], "valueQuantity": { "value": 6.1, "unit": "10*9/L", "system": "http://unitsofmeasure.org", "code": "10*9/L" }, "interpretation": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation", "code": "N", "display": "Normal" } ] } ], "referenceRange": [ { "low": { "value": 4.5, "unit": "10*9/L", "system": "http://unitsofmeasure.org", "code": "10*9/L" }, "high": { "value": 11, "unit": "10*9/L", "system": "http://unitsofmeasure.org", "code": "10*9/L" } } ] } }, { "fullUrl": "urn:uuid:0a5f1e00-0000-4000-8000-000000000008", "resource": { "resourceType": "Observation", "id": "0a5f1e00-0000-4000-8000-000000000008", "status": "final", "category": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/observation-category", "code": "laboratory", "display": "Laboratory" } ] } ], "code": { "coding": [ { "system": "http://loinc.org", "code": "731-0", "display": "Lymphocytes [#/volume] in Blood by Automated count" } ], "text": "Lymphocytes (absolute)" }, "subject": { "reference": "urn:uuid:0a5f1e00-0000-4000-8000-000000000001", "display": "Jordan Rivera" }, "effectiveDateTime": "2026-05-21T08:15:00Z", "issued": "2026-05-21T11:05:00Z", "performer": [ { "display": "QuestLab" } ], "valueQuantity": { "value": 1.8, "unit": "10*9/L", "system": "http://unitsofmeasure.org", "code": "10*9/L" }, "interpretation": [ { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation", "code": "N", "display": "Normal" } ] } ], "referenceRange": [ { "low": { "value": 1, "unit": "10*9/L", "system": "http://unitsofmeasure.org", "code": "10*9/L" }, "high": { "value": 4, "unit": "10*9/L", "system": "http://unitsofmeasure.org", "code": "10*9/L" } } ] } } ] }

Prior Neurology Note

Neurology Consultation Note

Clinical noteC-CDA
History: Started interferon beta-1a 18 months ago. Discontinued after 11 months due to breakthrough relapse (acute optic neuritis, treated with IV methylprednisolone) and patient-reported intolerance. Currently off DMT for 6 weeks.
CascadeResolving 3 sources into one structured record

Structured data

5 coded · 10 extracted

Diagnosis2

Diagnosis: Relapsing-remitting multiple sclerosis

Relapsing-remitting multiple sclerosis, status: active, ICD-10-CM G35.A

ICD-10-CM G35.A

Diagnosis: Relapsing-remitting MS

Relapsing-remitting MS

Narrative extracted, uncodedExtracted from narrativeAI extracted · 0.95

MRI disease activity5

Multiple T2/FLAIR lesions

Multiple T2/FLAIR hyperintense lesions in periventricular and juxtacortical white matter

Narrative extracted, uncodedExtracted from narrativeAI extracted · 0.95

New T2 lesions

two new T2 lesions in the right frontal white matter

Narrative extracted, uncodedExtracted from narrativeAI extracted · 0.95

Enlarging T2 lesion

one enlarging lesion in the left centrum semiovale

Narrative extracted, uncodedExtracted from narrativeAI extracted · 0.95

Gadolinium-enhancing lesion

One lesion demonstrates gadolinium enhancement

Narrative extracted, uncodedExtracted from narrativeAI extracted · 0.95

Interval radiologic disease activity

Interval radiologic disease activity

Narrative extracted, uncodedExtracted from narrativeAI extracted · 0.95

Relapse history1

Breakthrough relapse: acute optic neuritis

acute optic neuritis, treated with IV methylprednisolone

Narrative extracted, uncodedExtracted from narrativeAI extracted · 0.95

DMT history3

Prior DMT trial: interferon beta-1a

Started interferon beta-1a 18 months ago. Discontinued after 11 months

Narrative extracted, uncodedExtracted from narrativeAI extracted · 0.95

DMT intolerance reported

patient-reported intolerance

Narrative extracted, uncodedExtracted from narrativeAI extracted · 0.90

Currently off DMT

Currently off DMT for 6 weeks

Narrative extracted, uncodedExtracted from narrativeAI extracted · 0.95

Laboratory4

JC Virus Antibody, Serum

Positive

LOINC 70173-0

JC Virus Antibody Index, Serum

0.42 index

LOINC 100977-8

WBC

6.1 10*9/L

LOINC 6690-2

Lymphocytes (absolute)

1.8 10*9/L

LOINC 731-0

Prior-Authorization Readiness

natalizumab (Tysabri) · Relapsing-Remitting MS

5 of 6 criteria met. 1 needs clinician confirmation.

Every met criterion expands to the evidence it came from.

Diagnosis: relapsing form of MS

Member has a documented diagnosis of a relapsing form of multiple sclerosis, defined as relapsing-remitting MS, active secondary progressive MS, or clinically isolated syndrome, established by a qualified clinician using accepted diagnostic criteria.

Prescribed by a neurologist

The requested therapy is prescribed by, or in documented consultation with, a neurologist or a physician who specializes in the management of multiple sclerosis.

Needs clinician confirmation. Prescriber specialty is not part of the patient record. The prescribing neurologist confirms this step locally when the request is signed.

Clinical relapse in the last year

Extracted from narrative

Member has experienced at least one clinically documented relapse, defined as an acute neurologic episode lasting 24 hours or longer in the absence of fever or infection, within the 12 months preceding this request.

New or enlarging MRI lesion in the last year

Extracted from narrative

Brain or spinal cord MRI within the preceding 12 months demonstrates ongoing disease activity, defined as one or more new or unequivocally enlarging T2/FLAIR lesions, or one or more gadolinium-enhancing lesions.

Multiple T2/FLAIR lesions

Multiple T2/FLAIR hyperintense lesions in periventricular and juxtacortical white matter

UncodedExtracted from narrative

“Multiple T2/FLAIR hyperintense lesions in periventricular and juxtacortical white matter”

Cascade Imaging Center · Findings section

Extraction: gemini-3-flash-preview · confidence 0.95

New T2 lesions

two new T2 lesions in the right frontal white matter

UncodedExtracted from narrative

“two new T2 lesions in the right frontal white matter”

Cascade Imaging Center · Findings section

Extraction: gemini-3-flash-preview · confidence 0.95

Enlarging T2 lesion

one enlarging lesion in the left centrum semiovale

UncodedExtracted from narrative

“one enlarging lesion in the left centrum semiovale”

Cascade Imaging Center · Findings section

Extraction: gemini-3-flash-preview · confidence 0.95

Gadolinium-enhancing lesion

One lesion demonstrates gadolinium enhancement

UncodedExtracted from narrative

“One lesion demonstrates gadolinium enhancement”

Cascade Imaging Center · Findings section

Extraction: gemini-3-flash-preview · confidence 0.95

Interval radiologic disease activity

Interval radiologic disease activity

UncodedExtracted from narrative

“Interval radiologic disease activity”

Cascade Imaging Center · Findings section

Extraction: gemini-3-flash-preview · confidence 0.95

Step therapy: prior DMT trial

Extracted from narrative

Member has demonstrated an inadequate response to, intolerance of, or a documented contraindication to at least one preferred disease-modifying therapy, such as an interferon beta product, glatiramer acetate, or an oral agent.

JC virus antibody status documented

Safety flag

Anti-JC virus (JCV) antibody serostatus has been tested and documented prior to initiation, consistent with the natalizumab Risk Evaluation and Mitigation Strategy (the TOUCH Prescribing Program) for progressive multifocal leukoencephalopathy risk stratification. A positive result is a safety consideration that informs monitoring and is not an absolute contraindication.

JCV antibody positive. A safety consideration for natalizumab (PML risk monitoring per the REMS program), not a blocker for readiness.

How this works

This demo renders from a fixture produced by one real local Cascade run, captured at build time. Every structured fact on the page is tool output from that run, not hand-authored content. All patient data is synthetic. Three things are configured or added around Cascade, disclosed below.

What is configured or added

  1. Narrative extraction in this demo runs on gemini-3-flash-preview, a cloud model, configured in place of the shipped Cascade default (the local Qwen3.5-2B extractor). Cascade's extractor is model-pluggable, so this is a configuration choice; production targets improved local models.
  2. Character offsets for source highlighting are computed demo-side by locating the extraction model's verbatim span in the source text. Cascade persists provenance at the document and section level today; persisted character offsets are a proposed protocol addition.
  3. Prior-authorization criteria evaluation runs demo-side as a pure function over Cascade's structured output. Cascade has no criteria evaluation engine yet; it is the highest-value proposed protocol addition.

Run details

Extraction model
gemini-3-flash-preview
cascade-cli
v0.5.9
Fixture generated
2026-06-11 by scripts/build-fixture.ts