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.
Description | Structure Definition | Samples |
---|---|---|
Patient | Patient.StructureDefinition.json | patient_cht.fhir.json,patient_openSRP.fhir.json |
ServiceRequest | ServiceRequest.StructureDefinition.json | service_request.fhir.json |
Encounter | Encounter.StructureDefinition.json | encounter_cht.fhir.json,encounter_openSRP.fhir.json |
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The proof of concept uses the Instant OpenHIE architecture interacting with multiple CHIS (CommCare, OpenSRP, and CHT).
The current setup includes the following components.
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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.