Name: Langcare Chronic Disease Registries
Author: langcare

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

Use fhir_search to pull all patients with the target Condition (e.g., diabetes, HTN, CHF) active
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)
Stratify by severity/control: well-controlled, moderately controlled, poorly controlled, unknown (no recent data)
Use fhir_search to pull active MedicationRequest for each patient to assess therapy appropriateness
Identify patients needing intervention: above target despite therapy, no recent monitoring, on suboptimal regimen
Present registry report with population counts, severity distribution, and actionable patient lists

FHIR Resources

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

Use fhir_search to pull all patients with the target Condition (e.g., diabetes, HTN, CHF) active
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)
Stratify by severity/control: well-controlled, moderately controlled, poorly controlled, unknown (no recent data)
Use fhir_search to pull active MedicationRequest for each patient to assess therapy appropriateness
Identify patients needing intervention: above target despite therapy, no recent monitoring, on suboptimal regimen
Present registry report with population counts, severity distribution, and actionable patient lists

Langcare Chronic Disease Registries

Chronic Disease Registry Query

When to Use This Skill

Clinical Workflow

FHIR Resources

Langcare Chronic Disease Registries

Chronic Disease Registry Query

When to Use This Skill

Clinical Workflow

FHIR Resources

FHIR Query Examples

Pull Diabetes Registry

Pull A1c Values for Registry Patients

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