Request Community Based Follow-Up
Last updated
Last updated
This workflow allows a point-of-care system to make requests to a Community Health Information System (CHIS) for patient follow-up. A common implementation is for Lost to Follow-Up whereby a clinic generates a list of patients who have missed appointments for follow-up through CHIS. During the follow-up, Community Health Workers (CHW) encourage the identified patients to attend their appointments and seek to understand the reason for non-attendance. The follow-up process may involve a CHW physically going to find the patient or reaching out through other communication protocols such as phone call or SMS.
Workflow Maturity
Newly Defined
Workflow is defined and ARB approved
Initial implementations are being discussed
Standard(s) *
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FHIR
Assumptions and Prerequisites
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The Point-of-Service (PoS) system is a trusted application known by the HIE and it is registered with the interoperability layer to be able to send and receive data securely
The Community Health Information System (CHIS) is a trusted application known by the HIE and it is registered with the interoperability layer to be able to send and receive data securely
Actors
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CHIS: A Community Health Information System is an information system that supports the routine and emergency health care of a patient population within community contexts in defined geographic areas. This is often a mobile application.
IOL: Interoperability Layer to handle data governance and security issues, CSD Services Finder
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Interaction
Data
Transaction Options
1
Determine Patients Requiring Follow-up
Using an EMR or other Point-of-care system, the users will designate patients that require community-based follow-up. This may be due to a missed appointment or other action triggering a follow-up.
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2, 3
ServiceRequest
A service request is created with "Active" status and sent through the IOL to the SHR. The IOL may need to orchestrate use of the patient identity used in the HIE. These steps are not shown.
FHIR ServiceRequest
4,5
Query ServiceRequest
Query for "Active" ServiceRequest. If necessary, the IOL can translate the patient ID.
FHIR ServiceRequest query
6,7
Return results
The results of the query are returned. If necessary, the IOL can translate the patient ID.
Query response
8
Claim Service Requests
Through use of the CHIS, the end users may determine which ServiceRequests for follow-up or other community services that they are going to address,
9, 10
Update Service Request
Claimed service requests will be set to "On Hold" status.
FHIR ServiceRequest
11
Alert CHW (optional)
12
Follow up in CHIS
13
Save patient data
14
Update Service Request
Claimed ServiceRequest will be set to "Complete" status.
FHIR ServiceRequest
15, 16
Query ServiceRequest
Status "completed"
FHIR ServiceRequest query
17, 18
Return results
19
Update CHIS
Point-of-Care System: System that makes the request for a community health worker (CHW) to find and follow-up on a patient. The requesting system will often be an EMR like .
SHR: is a centralized data repository for storing patient’s shared health record.
See for a description of this workflow
See
