Request Community Based Follow-Up

Overview

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) *	<del></del>	FHIR
Assumptions and Prerequisites	<del></del>	<del></del> 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	<del></del>	<del></del> 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 OpenMRS. 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 SHR: Shared Health Record is a centralized data repository for storing patient’s shared health record.

Interaction Description

#	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.	~~~~
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)	See Alerting / Sending Reminders or Information for a description of this workflow
12	Follow up in CHIS
13	Save patient data	See Save Patient-level Clinical Data Workflow
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