Langcare Langcare MCP Fhir Care Gap Identifier

Care Gap Identifier

Overview

Screen a patient for preventive care gaps based on USPSTF grade A and B recommendations. Query FHIR resources for prior screenings, immunizations, and relevant observations. Compare against age, sex, and risk-factor-adjusted intervals. Generate a prioritized list of overdue and upcoming preventive care items with patient-friendly descriptions.

FHIR Resources Used

Instructions

Step 1: Retrieve Patient Demographics

Tool: fhir_read
resourceType: "Patient"
id: "[patient-id]"

Extract and calculate:

• Age from birthDate
• Sex from gender (administrative gender; biological sex may differ)
• Smoking status: check Observation with LOINC 72166-2

Tool: fhir_search
resourceType: "Observation"
queryParams: "patient=[patient-id]&code=72166-2&_sort=-date&_count=1"

Step 2: Retrieve Active Conditions (Risk Factors)

Tool: fhir_search
resourceType: "Condition"
queryParams: "patient=[patient-id]&clinical-status=active"

Identify risk-modifying conditions:

• Diabetes (SNOMED 44054006) -- affects statin, BP screening thresholds
• HIV (SNOMED 86406008) -- affects STI, cancer screening frequency
• Obesity (SNOMED 414916001) -- affects diabetes screening age
• Immunocompromised states -- affects immunization recommendations
• Family history of colorectal cancer -- earlier screening start
• BRCA carrier status -- different breast cancer screening

Step 3: Retrieve Family History

Tool: fhir_search
resourceType: "FamilyMemberHistory"
queryParams: "patient=[patient-id]"

Key family history items affecting screening:

• First-degree relative with colorectal cancer before age 60 -- start screening at 40 or 10 years before youngest case
• First-degree relative with breast cancer -- discuss earlier mammography
• Family history of abdominal aortic aneurysm -- lower threshold for AAA screening

Step 4: Check Cancer Screenings

Breast Cancer Screening (assigned female, age 50-74)

Tool: fhir_search
resourceType: "DiagnosticReport"
queryParams: "patient=[patient-id]&code=http://loinc.org|24606-6&_sort=-date&_count=1"

LOINC 24606-6 = Mammography screening. Interval: every 2 years. Also check Procedure for SNOMED 71651007 (mammography).

Cervical Cancer Screening (assigned female, age 21-65)

Tool: fhir_search
resourceType: "Observation"
queryParams: "patient=[patient-id]&code=10524-7&_sort=-date&_count=1"

LOINC 10524-7 = Cervical cytology (Pap smear). Interval: every 3 years (Pap alone, age 21-65) or every 5 years (Pap + HPV cotesting, age 30-65). Also check HPV test LOINC 21440-3.

Colorectal Cancer Screening (age 45-75)

Check multiple modalities:

Tool: fhir_search
resourceType: "Procedure"
queryParams: "patient=[patient-id]&code=http://snomed.info/sct|73761001&_sort=-date&_count=1"

SNOMED 73761001 = Colonoscopy. Interval: every 10 years.

Also check stool-based testing:

Tool: fhir_search
resourceType: "Observation"
queryParams: "patient=[patient-id]&code=57905-2&_sort=-date&_count=1"

LOINC 57905-2 = Fecal immunochemical test (FIT). Interval: annually.

Lung Cancer Screening (age 50-80, 20+ pack-year smoking history)

Tool: fhir_search
resourceType: "DiagnosticReport"
queryParams: "patient=[patient-id]&code=http://loinc.org|87278-0&_sort=-date&_count=1"

LOINC 87278-0 = Low-dose CT chest screening. Interval: annually. Only for current smokers or those who quit within 15 years with 20+ pack-year history.

Step 5: Check Metabolic and Cardiovascular Screenings

Diabetes Screening (age 35-70, overweight/obese)

Tool: fhir_search
resourceType: "Observation"
queryParams: "patient=[patient-id]&code=4548-4&_sort=-date&_count=1"

LOINC 4548-4 = HbA1c. Also check fasting glucose (1558-6). Interval: every 3 years if normal.

Lipid Screening (age 40-75)

Tool: fhir_search
resourceType: "Observation"
queryParams: "patient=[patient-id]&code=57698-3&_sort=-date&_count=1"

LOINC 57698-3 = Lipid panel. Interval: every 5 years (more frequently if borderline or on treatment).

Hypertension Screening (all adults)

Tool: fhir_search
resourceType: "Observation"
queryParams: "patient=[patient-id]&code=85354-9&_sort=-date&_count=1"

LOINC 85354-9 = Blood pressure panel. Interval: annually.

Step 6: Check Immunizations

Tool: fhir_search
resourceType: "Immunization"
queryParams: "patient=[patient-id]&status=completed"

Check against adult immunization schedule:

• Influenza: CVX 158 (IIV4), CVX 197 (adjuvanted), CVX 185 (recombinant). Annual.
• Tdap/Td: CVX 115 (Tdap). Every 10 years.
• Pneumococcal: CVX 215 (PCV20) or CVX 133 (PCV15) + CVX 33 (PPSV23). Age 65+ or high-risk.
• Shingles: CVX 187 (Shingrix). Age 50+, 2-dose series.
• Hepatitis B: CVX 43 (HepB). Universal adult recommendation if not previously vaccinated.
• COVID-19: CVX 213, 228, 229. Per current CDC schedule.
• HPV: CVX 165 (HPV9). Through age 26 (shared decision 27-45).

Step 7: Check Depression and Mental Health Screening

Tool: fhir_search
resourceType: "Observation"
queryParams: "patient=[patient-id]&code=44249-1&_sort=-date&_count=1"

LOINC 44249-1 = PHQ-9 total score. Interval: annually. Also check PHQ-2 (55758-7).

Step 8: Check STI Screening

HIV Screening (age 15-65)

Tool: fhir_search
resourceType: "Observation"
queryParams: "patient=[patient-id]&code=75622-1&_sort=-date&_count=1"

LOINC 75622-1 = HIV 1/2 Ag+Ab. At least once; annually if high-risk.

Hepatitis C Screening (all adults 18-79)

Tool: fhir_search
resourceType: "Observation"
queryParams: "patient=[patient-id]&code=16128-1&_sort=-date&_count=1"

LOINC 16128-1 = Hepatitis C antibody. One-time screening.

Hepatitis B Screening (all adults 18+)

Tool: fhir_search
resourceType: "Observation"
queryParams: "patient=[patient-id]&code=5195-3&_sort=-date&_count=1"

LOINC 5195-3 = Hepatitis B surface antigen. One-time screening.

Step 9: Check Additional USPSTF Screenings

Abdominal Aortic Aneurysm (males age 65-75, ever smoked)

Tool: fhir_search
resourceType: "DiagnosticReport"
queryParams: "patient=[patient-id]&code=http://loinc.org|24850-0&_sort=-date&_count=1"

LOINC 24850-0 = Abdominal ultrasound. One-time screening.

Osteoporosis (females age 65+, or postmenopausal with risk factors)

Tool: fhir_search
resourceType: "DiagnosticReport"
queryParams: "patient=[patient-id]&code=http://loinc.org|38269-7&_sort=-date&_count=1"

LOINC 38269-7 = DEXA scan. Interval: per risk assessment (typically every 2 years if abnormal).

Step 10: Format Output

PREVENTIVE CARE GAP ANALYSIS
==============================
Patient: [name] | Age: [age] | Sex: [sex]
Smoking Status: [current/former/never] | BMI: [value]

OVERDUE SCREENINGS (action needed)
-----------------------------------
1. [Screening name] -- Last: [date or Never] -- Due: [when] -- [Patient-friendly description]
2. [Screening name] -- Last: [date or Never] -- Due: [when] -- [Patient-friendly description]

UPCOMING SCREENINGS (within 6 months)
--------------------------------------
1. [Screening name] -- Due: [date] -- [Patient-friendly description]

UP TO DATE
----------
1. [Screening name] -- Last: [date] -- Next due: [date]

NOT APPLICABLE
--------------
1. [Screening name] -- Reason: [age/sex/risk factor exclusion]

IMMUNIZATION GAPS
-----------------
1. [Vaccine] -- Status: [Overdue/Never received/Series incomplete]

PATIENT SUMMARY (plain language)
---------------------------------
[2-3 sentence summary suitable for sharing with the patient, describing
what screenings are overdue and why they are important]

Examples

Example 1: Annual Physical Prep for 55-Year-Old Male

User says: "What preventive care is patient 54321 due for?"

Actions:

1. fhir_read Patient/54321 -- returns James Miller, DOB 1969-06-14, Male, age 55
2. fhir_search Observation?patient=54321&code=72166-2 -- current smoker, 30 pack-years
3. fhir_search Condition?patient=54321&clinical-status=active -- hypertension, obesity (BMI 32)
4. fhir_search Procedure?patient=54321&code=73761001 -- colonoscopy 2018 (6 years ago)
5. fhir_search Observation?patient=54321&code=4548-4 -- HbA1c 5.9% (2023-03-01, 10 months ago)
6. fhir_search Observation?patient=54321&code=57698-3 -- lipid panel 2021 (3 years ago)
7. fhir_search DiagnosticReport?patient=54321&code=87278-0 -- no LDCT on file
8. fhir_search Immunization?patient=54321&status=completed -- flu 2023, Td 2019 (no Tdap)
9. fhir_search Observation?patient=54321&code=44249-1 -- PHQ-9 not on file
10. fhir_search Observation?patient=54321&code=75622-1 -- HIV never tested

Result:

PREVENTIVE CARE GAP ANALYSIS
==============================
Patient: James Miller | Age: 55 | Sex: Male
Smoking Status: Current (30 pack-years) | BMI: 32

OVERDUE SCREENINGS (action needed)
-----------------------------------
1. Lung cancer screening (LDCT) -- Last: Never -- Due: Now -- Annual low-dose CT chest recommended for current smokers age 50-80 with 20+ pack-year history
2. Depression screening (PHQ-9) -- Last: Never -- Due: Now -- Annual screening recommended for all adults
3. HIV screening -- Last: Never -- Due: Now -- One-time screening recommended for all adults 15-65
4. Hepatitis C screening -- Last: Never -- Due: Now -- One-time screening for all adults 18-79

UPCOMING SCREENINGS (within 6 months)
--------------------------------------
1. HbA1c / diabetes screening -- Last: 2023-03-01 (prediabetes 5.9%) -- Due: 2024-03-01 -- Annual recheck recommended given prediabetes + obesity

UP TO DATE
----------
1. Colonoscopy -- Last: 2018 -- Next due: 2028 (10-year interval)
2. Blood pressure -- Monitored via HTN management
3. Influenza vaccine -- Received 2023

IMMUNIZATION GAPS
-----------------
1. Tdap -- Never received (Td 2019, but Tdap preferred). Recommend Tdap at next opportunity
2. Shingrix -- Age 50+, 2-dose series not started
3. Pneumococcal (PCV20) -- Not yet indicated (age < 65, review risk factors)

PATIENT SUMMARY
---------------------------------
You are due for a lung cancer screening CT scan because of your smoking history. You should also have a depression screening questionnaire, an HIV test, and a hepatitis C test, which are recommended for all adults. Your prediabetes should be rechecked soon with a blood sugar test.

Example 2: Young Female Patient

User says: "Check care gaps for patient xyz-100"

Actions:

1. fhir_read Patient/xyz-100 -- returns Emma Johnson, DOB 1996-09-22, Female, age 27
2. fhir_search Observation?patient=xyz-100&code=72166-2 -- never smoker
3. fhir_search Condition?patient=xyz-100&clinical-status=active -- no active conditions
4. fhir_search Observation?patient=xyz-100&code=10524-7 -- Pap smear 2021 (3 years ago)
5. fhir_search Observation?patient=xyz-100&code=85354-9 -- BP 118/72 (2023-06-01)
6. fhir_search Immunization?patient=xyz-100&status=completed -- HPV series complete, flu 2022, Tdap 2020
7. fhir_search Observation?patient=xyz-100&code=44249-1 -- PHQ-9 score 3 (2023-06-01)
8. fhir_search Observation?patient=xyz-100&code=75622-1 -- HIV negative (2022)
9. fhir_search Observation?patient=xyz-100&code=16128-1 -- HCV negative (2022)

Result:

PREVENTIVE CARE GAP ANALYSIS
==============================
Patient: Emma Johnson | Age: 27 | Sex: Female
Smoking Status: Never | BMI: 23.1

OVERDUE SCREENINGS (action needed)
-----------------------------------
1. Cervical cancer screening (Pap) -- Last: 2021 -- Due: 2024 -- Pap smear every 3 years for ages 21-29

UPCOMING SCREENINGS (within 6 months)
--------------------------------------
(none)

UP TO DATE
----------
1. Blood pressure -- Last: 2023-06-01 (118/72, normal)
2. Depression screening -- Last: 2023-06-01 (PHQ-9: 3, normal)
3. HIV screening -- Completed 2022
4. Hepatitis C screening -- Completed 2022
5. HPV vaccination -- Series complete
6. Tdap -- Current (2020, next due 2030)

NOT APPLICABLE
--------------
1. Mammography -- Not indicated until age 40 (or earlier if high-risk family history)
2. Colorectal cancer screening -- Not indicated until age 45
3. Lung cancer screening -- Never smoker
4. Diabetes screening -- Age < 35, not overweight
5. Lipid screening -- Age < 40 (unless risk factors)
6. AAA screening -- Female, not indicated
7. Osteoporosis screening -- Premenopausal, not indicated
8. Shingrix -- Age < 50

IMMUNIZATION GAPS
-----------------
1. Influenza -- Last: 2022. Overdue for annual flu vaccine

PATIENT SUMMARY
---------------------------------
You are due for your Pap smear, which screens for cervical cancer and is recommended every 3 years. You should also get your annual flu shot. Everything else is up to date.

Troubleshooting

Screening Dates Not Found in Expected Resources

• Mammography may be stored as Procedure (SNOMED 71651007), DiagnosticReport, or Observation. Search all three resource types.
• External screenings (done at another facility) may not be in the FHIR server. If critical screenings show as "never done" for a patient who reports otherwise, note that the record may be incomplete.

Patient Gender Does Not Match Expected Screening Criteria

• FHIR Patient.gender is administrative gender. Sex-specific screenings (cervical, breast, prostate) should be based on biological sex, which may be in an extension (http://hl7.org/fhir/us/core/StructureDefinition/us-core-birthsex). Check the extension before excluding screenings.
• If birth sex extension is unavailable, apply screenings based on administrative gender but note the limitation.

Immunization Records Are Incomplete

• Patients vaccinated before EHR adoption may not have historical records. If Immunization search returns zero results, note "No immunization records found -- may need patient-reported history or state immunization registry query."
• Check state IIS (Immunization Information System) if FHIR server supports it.

Related Skills

• clinical-summary-generator -- include care gap summary in clinical notes
• referral-generator -- generate referrals for identified screening needs (e.g., colonoscopy referral)
• follow-up-task-generator -- create tasks for overdue screenings

Converted and distributed by TomeVault — claim your Tome and manage your conversions.