langcare-chronic-disease-registries

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)