Predicting Readmission Risk at the Point-of-Care: A Personalized AI-assisted Report Leveraging Multi-source Healthcare Data

Hospital readmission risk is typically assessed at or near discharge, limiting opportunities to address modifiable risk factors such as social determinants of health (SDOH). The Arrival Readmission Report (ARR), a proof-of-concept, AI-assisted, HIE-enabled tool was designed to facilitate readmission risk assessment at emergency department admission using an interpretable, structured format. The report incorporates 30-day readmission predictions from pre-admission variables, and SHapley Additive exPlanations (SHAP) to identify individual readmission risk drivers. Results are presented in structured modules, including a high-level risk snapshot, cohort comparisons, and patient-specific explanations. Preliminary formative evaluation highlighted strengths in interpretability and structure and opportunities for improving contextualization and decision support for earlier intervention.