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The Community Based Follow-up use case allows any system to make request requests to a CHIS to for patient follow-up for any reason.  A common implementation might be is for Lost to Follow-Up whereby a clinic generates a list of patients that who have missed appointments and wants community based systems to help find the patient and encourage them to attend their appointment or to understand why they cannot or will not. This might be achieved either by having a health worker physically go find the patient or by other communication protocols (SMS, for example)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

Useful Links

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  1. Requesting System: Any system that wants a community based health worker CHW to find and follow-up with a patient. The requesting system will often be an EMR like OpenMRS
  2. 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.
  3. CHW: Community Health Workers are the central users of CHIS. CHWs conduct household visits and are responsible for the health of their community.
  4. SHR: Shared Health Record is a centralized data repository for storing patient’s shared health record.

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  1. Requesting System → Determine patients needing follow-up
  2. Requesting SystemSend Sends list of patients
  3. CHIS → NotifyGives notification for patients requiring follow-up
  4. CHW→ Find Finds patient and record records the follow-up outcome
  5. CHW→ Sync Syncs results captured on CHIS
  6. CHIS→  Update Updated with outcome of follow-up outcome




Data Flow (High Level)

The flow is centered around the use of the FHIR "ServiceRequest" resource to initiate follow-ups in the community.

  1. Requesting system determines which patients need follow-up
  2. Requesting system creates a ServiceRequest for each patient and sends the ServiceRequest to HIE
  3. CHIS queries the HIE to determine if there are any patients to followbe followed-up with
  4. Requesting system returns results of CHIS' query
  5. CHIS determines where whether or not to claim the service request
  6. CHIS "claims" the ServiceRequest to confirm that they will be following up with the a patient
  7. CHIS tasks alerts the appropriate CHW with finding and advising the patient through a task
    1. This step is detailed below - Data Flow (CHIS / CHW Process)
  8. CHIS records the results of the CHW's efforts
  9. CHIS updates the ServiceRequest
  10. Requesting system receives update
  11. Requesting system updates itself accordingly

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The diagram below illustrates the dataflow data flow between the SHR / FHIR Server and CHISs.

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The ultimate goal of these follow-ups is that the patient returns to care, so . One of the most important indicator indicators to track is probably "% of patients that have returned to care".

Key FHIR Resources

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. 

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This proof of concept use case was explored to learn about a number of things among others:

  1. OpenHIE tooling

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  1. What modifications are required for CHIS' sharing data
  2. Gain experience with FHIR

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  1. Gain experience with Instant OpenHIE

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Hence there are more explorations to be made.