langcare-chronic-disease-registries

langcare-chronic-disease-registries is a skill for Claude Code, Codex from langcare/langcare-mcp-fhir. It costs 76 tokens per session (718 once invoked), scanned A, original, MIT.

A clinical report that finds patients with selected long-term diseases—such as diabetes, high blood pressure, heart failure, COPD, kidney disease, or asthma—and groups them by disease control and severity.

In plain words
What is it for?
Use it to produce disease registries, review measures such as A1c or blood pressure, assess current medicines, and identify patients needing follow-up.
Why use it?
It gives care teams a view of which patients are controlled, lack recent measurements, or may need changes in care.

Skill for Claude CodeCodex

Written for no agent in particular: nothing here depends on one.

Good fit Use it to produce disease registries, review measures such as A1c or blood pressure, assess current medicines, and identify patients needing follow-up.

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Install with agentmods
npx agentmods add skills/langcare/langcare-mcp-fhir/chronic-disease-registries
Install

Getting it into your agent

One page per mod, every tool's command on it. A separate URL per tool would split the same page into five that compete with each other.

Any agent
npx skills add langcare/langcare-mcp-fhir --skill chronic-disease-registries
Clone the repo
git clone --depth 1 https://github.com/langcare/langcare-mcp-fhir

Made for: Claude Code, Codex.

Wrote this? Show the measurements

A badge with what this costs and how it scanned, read live from this page, so it follows the numbers instead of freezing them. Markdown for a README, HTML for a documentation site or a project page.

agentmods badge for langcare-chronic-disease-registries

README.md
[![agentmods](https://agentmods.dev/badge/skills/langcare/langcare-mcp-fhir/chronic-disease-registries/github.svg)](https://agentmods.dev/skills/langcare/langcare-mcp-fhir/chronic-disease-registries)
Your own site
<a href="https://agentmods.dev/skills/langcare/langcare-mcp-fhir/chronic-disease-registries"><img src="https://agentmods.dev/badge/skills/langcare/langcare-mcp-fhir/chronic-disease-registries/github.svg" alt="Measured on agentmods" height="20"></a>

Or the 80×15 button, for a site that already has a row of RSS and ATOM ones. Only the verdict fits; the numbers stay here.

agentmods 80×15 button for langcare-chronic-disease-registries

Your own site · 80×15
<a href="https://agentmods.dev/skills/langcare/langcare-mcp-fhir/chronic-disease-registries"><img src="https://agentmods.dev/badge/skills/langcare/langcare-mcp-fhir/chronic-disease-registries.svg" alt="Reviewed on agentmods" width="80" height="20"></a>
Per session 76 Skills are progressive disclosure: only the name and description are preloaded; the body loads when the skill is used.
When invoked 718 The whole file, excluding the scripts and references it only reads on demand.
Security scan A 0 findings. A grade says what 26 rules found in the file — not that it is safe.
Origin original No closer match found in the catalogue.
Token cost

What it costs to keep this loaded

Counted locally with the o200k_base tokenizer, which is exact for GPT models; Claude uses its own tokenizer and its counts differ. Treat this as one consistent yardstick across the catalogue rather than a bill. Prices are per million input tokens.

ModelPer sessionOnce invoked
Fable 5.1 $0.00076 $0.00718
Opus 5 $0.00038 $0.00359
Sonnet 5 $0.00015 $0.00144
Haiku 4.5 $0.00008 $0.00072

Measured 12d ago against content hash 00124d74a9a3, method: parsed. Prices are Anthropic first-party input rates as of 2026-09-12, from the pricing page.

Security

Grade A, and why

langcare-chronic-disease-registries scanned grade A with 0 findings against 26 rules in 11 categories — prompt injection, anti-refusal, data exfiltration, privilege escalation, supply chain, agent snooping, system-prompt leakage, SSRF and excessive agency — measured 12d ago.

A static scan of the body, not an audit. Every finding is printed with the line that produced it so you can judge whether it matters here. A mod is markdown that instructs an agent; that is exactly why what it instructs is worth reading.

Nothing flagged

None of the 26 patterns this scan looks for appear in this file: no shell pipes, no recursive deletes, no credential paths, no hidden text, no instruction-override or anti-refusal phrasing, no agent-config snooping. That is not a guarantee, it is the absence of the things that are checkable.

cma/skills/population-health/chronic-disease-registries/SKILL.md · 58 lines

How it starts

The opening of the file, as written. The whole thing — 58 lines — stays where its author put it; the contents beside it link to each section on GitHub.

Chronic Disease Registry Query

When to Use This Skill

Use when a clinician or care manager needs a disease-specific population report with severity stratification, control metrics, and patients needing escalation.

Clinical Workflow

  1. Use fhir_search to pull all patients with the target Condition (e.g., diabetes, HTN, CHF) active
  2. For each patient, use fhir_search to pull key outcome Observations (A1c for diabetes, BP for HTN, EF for CHF, FEV1 for COPD, eGFR for CKD)
  3. Stratify by severity/control: well-controlled, moderately controlled, poorly controlled, unknown (no recent data)
  4. Use fhir_search to pull active MedicationRequest for each patient to assess therapy appropriateness
  5. Identify patients needing intervention: above target despite therapy, no recent monitoring, on suboptimal regimen
  6. Present registry report with population counts, severity distribution, and actionable patient lists

FHIR Resources

  • Condition -- Registry population identification
  • Patient -- Demographics for stratification
  • Observation -- Disease-specific outcome measures
  • MedicationRequest -- Current therapy assessment

FHIR Query Examples

Pull Diabetes Registry

fhir_search(resourceType="Condition", queryParams="code=http://snomed.info/sct|44054006&clinical-status=active&_count=500")

Pull A1c Values for Registry Patients

fhir_search(resourceType="Observation", queryParams="code=http://loinc.org|4548-4&date=ge[6-months-ago]&_sort=-date&_count=500")

Clinical Guidelines

  • PCMH population management standards
  • Disease-specific guidelines (ADA for diabetes, AHA/ACC for CHF, GOLD for COPD, KDIGO for CKD)
  • CMS Chronic Care Management requirements

Interpretation Guide

  • Registry dashboard format: total patients, severity tiers (by control metric), therapy distribution, patients needing action
  • For diabetes registry: stratify by A1c (<7, 7-8, 8-9, >9, no recent A1c); report statin and ACEi/ARB rates
  • For HTN registry: stratify by last BP (<130/80, 130-140/80-90, >140/90, no recent BP); report medication class distribution
  • For CHF registry: stratify by EF (HFrEF <40%, HFmrEF 40-49%, HFpEF >=50%); report GDMT utilization (ACEi/ARB/ARNI, beta-blocker, MRA, SGLT2i)

Read the full file on GitHub · 58 lines

Changes

What this file has done since we first saw it

Hashed on every crawl. A supply-chain change to an agent config is a question of when, not whether, so the history is kept rather than the latest state alone.

  1. 12d ago First seen · 58 lines · 76 tokens per session scan A 00124d74a9a3

Subscribe to this mod's changes

langcare-chronic-disease-registries is a skill published in the GitHub repository langcare/langcare-mcp-fhir (55 stars, last pushed 5mo ago), licensed MIT. It adds 76 tokens to every session and 718 once invoked, about $0.0004 per session on Opus 5. A static security scan graded it A with 0 findings. No closer match exists in the catalogue, so it is treated as the original; first seen 2026-08-30.

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