The Community Based Follow-up use case allows any system to make requests to a 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.
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From a very high level perspective, the workflow is designed around having the Requesting System determine which patients need to be followed-up with and a CHW trying to find the patient and recording the outcome of their attempt(s).
The flow is centered around the use of the FHIR "ServiceRequest" resource to initiate follow-ups in the community.
This video provides a demonstration of a CHIS fetching a service request in FHIR format (steps 3-9 outlined above).
This video goes through how to configure an application with FHIR resources (specifically for CommCare)
The diagram below illustrates the data flow between the SHR / FHIR Server and CHISs.
Based on the high level workflow mentioned above, the list of transactional indicators are below:
The ultimate goal of these follow-ups is that the patient returns to care. One of the most important indicators to track is % of patients that have returned to care.
The essential resources for this workflow were created and profiled with minimal fields/concepts and provide only a high level structure to get prototype the workflow. As the results of the Delphi Study become available, these can be profiled in more detail.
The proof of concept uses the Instant OpenHIE architecture interacting with multiple CHIS (CommCare, OpenSRP, and CHT).
The current setup includes the following components.
This proof of concept use case was explored to learn about a number of things among others:
Hence there are more explorations to be made.