# Langcare Langcare MCP Fhir Care Gap Identifier > Care Gap Identifier - Skill: `tomevault-io/langcare-langcare-mcp-fhir-care-gap-identifier` (Agent Skill, multi-file: 2 files) - Install (CLI): `npx skillmds@latest add tomevault-io/langcare-langcare-mcp-fhir-care-gap-identifier` - Raw SKILL.md: https://api.skillmd.com/api/skills/tomevault-io/langcare-langcare-mcp-fhir-care-gap-identifier/raw - Safety review: pending (external: skill-scanner PASS, skillspector PASS) - Works with: Claude Code, Claude.ai, OpenAI Codex - Category: AI & ML - Author: tomevault-io (https://skillmd.com/u/tomevault-io) - Updated: 2026-09-17 - Page: https://skillmd.com/skills/tomevault-io/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 | Resource | Purpose | Key Fields | |----------|---------|------------| | Patient | Demographics (age, sex, risk factors) | birthDate, gender, extension (race/ethnicity) | | Condition | Risk factors modifying screening criteria | code, clinicalStatus, onsetDateTime | | Observation | Screening results (labs, vital signs) | code, valueQuantity, effectiveDateTime, status | | Procedure | Completed screenings (colonoscopy, mammogram) | code, performedDateTime, status | | Immunization | Vaccination history | vaccineCode, occurrenceDateTime, status | | DiagnosticReport | Imaging results (mammogram, LDCT, DEXA) | code, effectiveDateTime, conclusion | | MedicationStatement | Medications affecting screening (e.g., statins) | medicationCodeableConcept, status | | FamilyMemberHistory | Family risk factors (cancer, CVD) | condition, relationship | ## 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](https://tomevault.io/claim/langcare) — claim your Tome and manage your conversions.