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This, coupled with mass sequencing of individual cancers and pathogens, feels like the generalized way forward in medicine.

I wonder how they identify the targets in each genome. Is there an optimizing expert system? Generative AI?

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The short answer is, we sequence their genomes, identify mutations that change a protein sequence and are highly expressed, then run those all through suites of algorithms that predict how well they'll be presented to the immune system. (mostly neural networks trained on far-too-sparse experimental data). This prediction is the hard part right now - we still don't understand enough about how the immune system identifies and interacts with these altered peptides to do really accurate predictions of which ones will be most effective. Throw in that these tumors are actively suppressing the immune system in various ways, and it's complicated! There is lots of research going on, though, and lots of promising early results, like this one

How much of the end to end process requires artisanal human touch? In some future day, is there a chance of tailored mRNA is industrialized to the point that we go from biopsy to vaccine as a standard course of care?

Absolutely. We're not there yet, but it's not inconceivable.

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