Metaxu

μεταξύ (metaxu, pronounced meh-TAX-oo) — Greek for "between."

Metaxu is an AI assurance and provenance layer for healthcare — model-agnostic, agent-agnostic, EHR-agnostic. It's not another healthcare AI agent; it's the trust infrastructure that sits between AI systems and clinical users, the way HTTPS sits between browsers and servers, or OpenTelemetry sits between services and observability tooling.

Healthcare AI today lacks a standardized assurance layer providing provenance, transparency, auditability, and trust. Metaxu is an open framework for exactly that.

Instead of an AI system returning:

Answer

an instrumented system returns:

Answer + Assurance Artifact

The Assurance Artifact is a machine-readable record that lets any consumer — a clinician, a dashboard, a CI pipeline, an auditor — answer:

• Where did this answer come from?
• What evidence supports it?
• Which tools were called?
• Which clinical policies were verified?
• What information was missing?
• Can this result be reproduced?
• Should a clinician trust it?

Status

0.3.0 (release candidate, not yet published) — a working reference SDK with every core component from the founding vision implemented (provenance, policy, safety, trust, terminology, evidence graph, correlation/merge, governance, drift, replay), plus three adapters (MCP, OpenTelemetry, CDS Hooks). Validated end-to-end against docs/USE_CASES.md. APIs and the artifact schema may still change before 1.0. Feedback and design discussion are the point of publishing this early. See CHANGELOG.md for the release history and RELEASING.md for how releases are cut.

What's here

Quick start

pip install metaxu           # stdlib-only core, zero required dependencies
# or, from a clone, for development:
pip install -e ".[dev]" && pytest

# Run the demo: same question, two agents, two very different artifacts
python examples/anticoagulation/run_demo.py
metaxu inspect examples/anticoagulation/out/careless-artifact.json

The careless agent recommends warfarin without checking allergies, renal function, or pregnancy status, and asserts "renal function is normal" without ever retrieving it. Its artifact says so:

Policy checks (2):
  - before_anticoagulation: FAIL (missing: allergy_check, pregnancy_status, creatinine)
  - answer_must_cite_patient_record: PASS

Safety findings (1):
  - [critical] unsupported_claims: Claim has no linked evidence: Renal function is normal.

Trust dimensions:
  - policy_compliance: 0.50  1 of 2 triggered policies passed.
  - provenance_coverage: 0.50  1 of 2 claims are linked to retrieved evidence.
  - safety: 0.00  1 critical and 0 warning safety findings.
  ...

Instrumenting an agent

Adopting Metaxu should feel like adding logging — decorate the tools the agent already has, record claims and evidence, get an artifact:

from metaxu import AssuranceSession, PolicyEngine, ProvenanceRecord, assured_tool

@assured_tool(tags=["platelet_count"], version="fhir-tools/1.2.0")
def get_platelet_count(patient_id: str) -> dict:
    resource = fhir.read("Observation", ...)   # your existing code
    return resource

engine = PolicyEngine.from_file("policies.json")

with AssuranceSession(question=question, policy_engine=engine) as session:
    obs = get_platelet_count("pat-001")            # traced automatically
    prov = session.record_retrieval(
        ProvenanceRecord.for_resource(
            source_system=fhir.base_url,
            resource_type="Observation",
            resource_id=obs["id"],
            content=obs,
        )
    )
    claim = session.record_claim("Platelet count is adequate.")
    session.link_evidence(claim, [prov])
    session.set_answer(answer)

session.artifact.save("artifact.json")

Zero-code instrumentation: the MCP proxy

For MCP-based workflows you don't need to touch agent code at all. Wrap any MCP stdio server with the assurance proxy — a config change, not a code change:

// in your MCP client configuration, instead of running the server directly:
{
  "command": "metaxu",
  "args": ["mcp-proxy", "--out", "artifacts/",
           "--tags", "tags.json", "--policies", "policies.json",
           "--", "my-fhir-mcp-server", "--their", "args"]
}

The proxy forwards JSON-RPC byte-for-byte (recording can never drop or mutate a message) while capturing every tools/call — name, arguments, result summary, errors, timing — plus content hashes and snapshots of everything retrieved, and the client/server/protocol versions for reproducibility. A tags.json file ({"get_allergies": ["allergy_check"]}) maps tool names to policy tags so institutional policies evaluate against any server's tool vocabulary. An artifact is written when the session ends.

A transparent proxy can't see claims, evidence links, or the final answer — those never cross the MCP wire. The proxy is the zero-effort floor; SDK instrumentation is the ceiling.

OpenTelemetry export

Assurance doesn't have to live in its own silo. The OpenTelemetry exporter turns an artifact into a span tree, so an assurance session shows up wherever a team already sends traces (pip install metaxu[otel]):

from metaxu.adapters.otel import export_artifact
export_artifact(artifact, tracer=my_tracer)     # into your existing TracerProvider

metaxu otel artifact.json                        # print spans to the console
metaxu otel artifact.json --endpoint http://localhost:4318/v1/traces

One root span per interaction carries the model, trust dimensions, and policy/safety/terminology roll-ups; tool calls and retrievals become child spans (timed by their recorded durations); claims, policy checks, and findings become span events. The root span's status is ERROR when the interaction has a critical safety finding, a failed policy, or a broken integrity hash — so an assurance regression trips the same alerting a latency spike would. Attributes use OpenTelemetry's gen_ai.* conventions where they fit and a metaxu.* namespace otherwise.

PHI note: question, answer, and claim text are omitted by default — observability backends are a different trust boundary than the artifact store. Pass capture_content=True (or --capture-content) only when the destination is authorized for PHI.

The exporter is the first of the adapter roadmap in ADR 0002; the core stays stdlib-only, so OpenTelemetry is an optional extra imported lazily.

CDS Hooks: assurance at the EHR boundary

CDS Hooks is how an EHR calls a decision-support service at workflow moments (order-sign, patient-view) and renders the returned cards. The adapter wraps one hook invocation in an assurance session — stdlib-only, framework-agnostic (plain dicts, so it drops into Flask/FastAPI/Functions):

from metaxu.adapters.cdshooks import assured_cds_service

@assured_cds_service(policy_engine=engine, tag_map={"platelets": ["platelet_count"]},
                     artifact_dir="artifacts/", add_assurance_card=True)
def my_service(request, session):
    ...                       # your logic; record claims/evidence as usual
    return [{"summary": "No contraindication found", "indicator": "info"}]

prefetch resources become hashed provenance with their codings validated; draft orders in context get their codes checked (a hallucinated RxNorm code on a proposed order is exactly what terminology validation exists to catch); hookInstance becomes the correlation interaction_id; the cards become the recorded answer. The response carries a dev.metaxu extension (artifact id + assurance summary), and with add_assurance_card=True a visible warning card is appended when checks fail — so the assurance verdict reaches the clinician in the EHR, not just the audit log. The request's fhirAuthorization bearer token is never recorded. See examples/cdshooks/.

Composing observers: correlation and merge

No single interception point sees a whole interaction, so artifacts are designed to be assembled from multiple observers. Every observer of one interaction shares an interaction_id (set METAXU_INTERACTION_ID in the environment, or pass interaction_id=/--interaction-id), each produces a partial artifact, and:

metaxu merge sdk-artifact.json proxy-artifact.json -o merged.json --policies policies.json

produces one merged artifact. A merge is a re-evaluation, not a concatenation: events and provenance are unioned, then the policy, safety, and trust engines run again over the combined observations — so a policy that failed on every partial view (the proxy never saw the platelet check; the SDK session never saw the allergy tool) can rightly pass on the merged view. Conflicting observations are never silently resolved; they're preserved in metadata["dev.metaxu/merge_conflicts"].

MCP is one adapter, not the interface: the core is transport-neutral, and adapters (metaxu.adapters) attach it to specific boundaries — MCP today; OpenTelemetry, CDS Hooks, and LLM gateways are the planned next vantage points.

Policies are declarative data, shareable across institutions:

{
  "policies": [{
    "name": "before_anticoagulation",
    "trigger": {"answer_mentions": ["warfarin", "heparin", "apixaban"]},
    "requires": [
      "allergy_check",
      "pregnancy_status",
      "creatinine",
      {
        "check": "platelet_count",
        "where": {"path": "result_summary.valueQuantity.value", "gte": 50},
        "within_hours": 48
      }
    ]
  }]
}

A requirement is a plain string ("this check occurred") or an object with conditions: where evaluates a dotted path into the matching event's payload (eq/ne/gt/gte/lt/lte/in), and within_hours requires the check to be no older than N hours at the time the answer was given — "used the newest labs", not just "used some labs". Results distinguish four outcomes per requirement: satisfied, missing (never attempted), errored (attempted, every attempt failed), and unmet (performed, but the value or timing failed the condition) — a platelet check that came back too low is not a passed platelet check.

Architecture

Healthcare AI  (chatbot / agent / MCP workflow / RAG pipeline / rule engine)
      │
      ▼
AssuranceSession ──── events: tool calls, retrievals, claims, evidence links
      │
      ├── Provenance engine    every resource: source, version, time, hash
      ├── Policy engine        declarative "these checks must have occurred"
      ├── Safety engine        structural checks: unsupported claims,
      │                        hallucinated resources, ignored allergies, …
      ├── Terminology engine   SNOMED/LOINC/RxNorm/UCUM/ICD code validation
      └── Trust engine         multiple dimensions, never one score
      │
      ▼
Assurance Artifact  ──►  clinician / dashboard / CI pipeline / auditor
      │
      ▼
metaxu CLI: inspect · validate · verify (provenance re-hashing / drift)

Design commitments:

• The artifact is the interface. Everything downstream consumes the artifact, never the AI system.
• Instrumentation is never load-bearing. Decorated tools behave identically outside a session; adopting Metaxu cannot change clinical behavior.
• No single trust score. Trust is reported per-dimension with a rationale and the inputs it was computed from — auditable, not oracular.
• Symbolic verification of neural output. LLMs generate hypotheses; policies, terminologies, and hashes verify them. The novelty is assurance, not reasoning.
• Stdlib-only core. pip install metaxu drags in nothing; YAML policies and full JSON Schema validation are optional extras.

CLI

metaxu inspect  artifact.json                     # human-readable summary
metaxu validate artifact.json                     # JSON Schema validation
metaxu verify   artifact.json --snapshots dir/    # integrity + provenance re-hashing
metaxu mcp-proxy --out dir/ -- <server cmd>       # wrap an MCP server transparently
metaxu merge a.json b.json -o merged.json         # combine observers of one interaction
metaxu report artifacts/ [--json | --html dash.html]  # governance metrics over a store
metaxu drift baseline/ current/ [--fail-on-drift] # what changed between two cohorts
metaxu diff original.json replay.json             # compare two runs of one interaction
metaxu replay artifact.json --runner mod:fn       # re-run the workflow and diff it
metaxu graph artifact.json [--format mermaid]     # render the reasoning chain

verify recomputes content hashes of the resources the AI saw. A mismatch means the source data changed since the decision was made — exactly the drift a reviewing clinician needs to know about.

replay re-runs the workflow for an artifact's question — the --runner module:function entrypoint receives (question, session) and should wire its data access to the recorded snapshots rather than live sources — then diffs the result against the original. reproduced: YES requires the answer, tool-call sequence (names and arguments), claim set, policy outcomes, and evidence base (same resources, same content hashes) to all match; a replay that saw different data is not a reproduction even if the answer text came out the same. diff runs the same comparison on any two existing artifacts. Exit codes make both usable in CI.

Governance: from artifacts to oversight

Individual artifacts answer "should a clinician trust this answer?". metaxu report answers the institutional questions over a whole artifact store: per-dimension trust (never collapsed into one number), policy pass rates with the most-unsatisfied requirements, hallucination and unsupported-claim rates, tool reliability, most-missed data, and a triage list of artifacts needing human review (critical findings, failed policies, integrity failures).

metaxu report artifacts/                    # terminal summary
metaxu report artifacts/ --json             # machine-readable, for pipelines
metaxu report artifacts/ --html dash.html   # self-contained HTML dashboard
metaxu report artifacts/ --fail-on-review   # CI gate: exit 1 if anything needs review

The input is just a directory of artifacts — any producer's artifacts aggregate identically, because the artifact is the interoperability boundary. Reports may quote clinical questions, so handle the output under the same PHI controls as the artifacts themselves.

metaxu drift asks the longitudinal question — what changed between a baseline cohort and the current one? It detects environment drift (model/prompt/tool/MCP-server versions that appeared or disappeared), behavioral drift (regressions in trust dimensions, policy pass rates, tool error rates, hallucination rates — improvements are reported but never flagged), answer drift (the same question answered differently), and source drift (the same resource carrying a different content hash — the record itself changed). Keep artifacts in dated directories and compare month over month, or run a benchmark before and after a deploy with --fail-on-drift as the release gate.

The evidence graph

"Where did this answer come from?" has a structural answer, not just a log. Every artifact encodes a traversable reasoning graph — question → answer → claims (including claim-on-claim reasoning steps) → resources → codings — and metaxu graph renders it:

? Patient pat-001 has new-onset atrial fibrillation. Is it appropriate …
│
★ Anticoagulation (e.g. apixaban) appears appropriate…
├─ • No contraindication to anticoagulation identified. [based_on]
│  ├─ • Platelet count is 232 10*3/uL (adequate). [supports]
│  │  └─ ▤ Observation/obs-plt-9001 [supports]
│  │     ├─ # LOINC 777-3 [has_coding]
│  │     └─ # UCUM 10*3/uL [has_coding]
│  └─ …creatinine, allergies…
└─ • Guideline recommends oral anticoagulation for nonvalvular AF… [based_on]
   └─ ▤ PlanDefinition/guideline-af-anticoag [supports]
      └─ # SNOMED-CT 49436004 [has_coding]

Evidence not connected to the answer:
  ▤ Patient/pat-001

Record the linkage with the same session API: link_evidence accepts claims as well as resources (multi-hop chains), and set_answer(..., based_on=[claims]) names what the answer actually rests on — omit it and the graph connects the answer to every claim but marks those edges implicit, so recorded reasoning is never conflated with inferred. The graph is a derived view over the event stream (no schema change; any consumer can rebuild it), and it works in reverse too: metaxu graph artifact.json --dependents obs-plt-9001 answers "this lab was corrected — what rests on it?" Output formats: text tree, JSON, Mermaid, DOT.

Terminology validation

Clinical codes the AI cites — a LOINC code for a lab, a SNOMED CT concept, an RxNorm drug, a UCUM unit — are recorded as codings and validated at finalize. The built-in FormatResolver needs no data and no license: it checks shape and check digits (LOINC Luhn mod-10, SNOMED CT Verhoeff) to catch hallucinated or malformed codes. A malformed code becomes a critical safety finding and lowers the terminology_correctness trust dimension.

session.record_coding("http://loinc.org", "2160-0", "Creatinine")
session.record_codings_from(fhir_observation)   # or extract from a FHIR resource

Confirming a code is the right, active one for the claim needs the real code tables, which institutions supply through the TerminologyResolver interface (resolve(system, code) -> CodeValidation) — Metaxu ships the check logic, never the data. Every result carries the terminology_version it was checked against (format-check, or e.g. LOINC-2.78), because terminologies change: validating a historical artifact against "whatever's current" would make a since-retired code look like a hallucination and make re-validation non-deterministic. The full strategy — bundling constraints, why SNOMED CT is never redistributed, and the versioning discipline — is recorded in ADR 0001.

Roadmap

• MCP proxy that instruments any MCP server transparently
• Multi-observer correlation and artifact merging
• Adapter roadmap (priority order in ADR 0002):
  • OpenTelemetry exporter (artifact → spans, gen_ai.* conventions, PHI-safe by default)
  • CDS Hooks adapter (assured decision-support services; prefetch → provenance, cards → answer)
  • OpenTelemetry importer (spans → assurance events)
  • CDS Hooks transparent proxy variant (evaluate third-party services you don't control)
  • LLM API gateway adapter (closes the answer/claims blind spot without SDK adoption)
• Detached-signature envelope for artifact authentication
• Terminology validation — format/checksum (SNOMED / LOINC / RxNorm / UCUM / ICD) + pluggable resolver interface (ADR 0001)
• Evidence graph as a traversable structure (multi-hop chains, dependents tracing, Mermaid/DOT export)
• Terminology data backends: bundled LOINC/RxNorm, SNOMED local-build (see ADR 0001)
• Temporal-reasoning checks (newest labs, discontinued medications)
• Governance reporting and dashboard over artifact collections
• Drift detection between artifact cohorts (environment, behavior, answers, sources)
• Replay harness: re-run a recorded interaction and diff it against the original
• Benchmark scenario pack with reference artifacts
• Policy pack sharing/extension model across institutions

A note on the data

All patient data in this repository is synthetic. Real artifacts may contain PHI and must be handled under the same controls as the clinical record itself — see the PHI section of spec/ARTIFACT.md.

License

Apache License 2.0. Chosen to match how comparable open standards are licensed (OpenTelemetry, CycloneDX, the OpenAPI Specification): permissive enough for commercial EHR/AI vendors to embed the SDK and adapters, with an explicit patent grant and retaliation clause, and — per the NOTICE file — no grant of rights to the "Metaxu" name itself.