Is care-gap-identifier safe to install?

SaferSkills independently audited care-gap-identifier (Agent Skill) and scored it 100/100 (green). The audit ran 55 deterministic rules across Security, Supply Chain, Maintenance, Transparency, and Community; it found 0 high-severity and 0 lower-severity findings. The full rule-by-rule trace and per-finding evidence are below. Free, methodology-open.

CategoryWeightCategory scoreContribution

Securityprompt, exec, net, exfil, eval

35%

100

35.0 pts

Supply chainhash, typosquat, maintainer, lockfile

20%

100

20.0 pts

Maintenancestaleness, pinning, CI

15%

100

15.0 pts

TransparencySKILL.md, perms, README

15%

100

15.0 pts

Communityinstalls, verify, response

15%

100

15.0 pts

Findings & checks · 0 flagged

Securityscore 100 · 0 findings

✓—All security checks passedNo findings in this category for the latest scan.pass

Supply chainscore 100 · 0 findings

✓—All supply chain checks passedNo findings in this category for the latest scan.pass

Maintenancescore 100 · 0 findings

✓—All maintenance checks passedNo findings in this category for the latest scan.pass

Transparencyscore 100 · 0 findings

✓—All transparency checks passedNo findings in this category for the latest scan.pass

Communityscore 100 · 0 findings

✓—All community checks passedNo findings in this category for the latest scan.pass

The primary manifest — the file an agent reads to learn what this artifact does.

skills/core/care-coordination/care-gap-identifier/SKILL.md · 1 file

skills/core/care-coordination/care-gap-identifier/SKILL.md15.4 KB · Markdown

name: care-gap-identifier

description: |

Screens for preventive care gaps per USPSTF A and B recommendations by checking existing Procedures, Observations,

and Immunizations against age/sex-appropriate due dates.

Use when user asks to "check care gaps", "preventive care due", "screenings overdue", "what is this patient due for",

"wellness check", "annual physical prep", or mentions "quality measures" or "HEDIS gaps".

Do NOT use for disease-specific management, acute care assessment, or medication review.

metadata:

author: LangCare

version: 1.0.0

mcp-server: langcare-mcp-fhir

category: care-coordination

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:

fhir_read Patient/54321 -- returns James Miller, DOB 1969-06-14, Male, age 55
fhir_search Observation?patient=54321&code=72166-2 -- current smoker, 30 pack-years
fhir_search Condition?patient=54321&clinical-status=active -- hypertension, obesity (BMI 32)
fhir_search Procedure?patient=54321&code=73761001 -- colonoscopy 2018 (6 years ago)
fhir_search Observation?patient=54321&code=4548-4 -- HbA1c 5.9% (2023-03-01, 10 months ago)
fhir_search Observation?patient=54321&code=57698-3 -- lipid panel 2021 (3 years ago)
fhir_search DiagnosticReport?patient=54321&code=87278-0 -- no LDCT on file
fhir_search Immunization?patient=54321&status=completed -- flu 2023, Td 2019 (no Tdap)
fhir_search Observation?patient=54321&code=44249-1 -- PHQ-9 not on file
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:

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

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

care-gap-identifier— agent skill

Is care-gap-identifier safe to install?

Care Gap Identifier

Overview

FHIR Resources Used

Instructions

Step 1: Retrieve Patient Demographics

Step 2: Retrieve Active Conditions (Risk Factors)

Step 3: Retrieve Family History

Step 4: Check Cancer Screenings

Step 5: Check Metabolic and Cardiovascular Screenings

Step 6: Check Immunizations

Step 7: Check Depression and Mental Health Screening

Step 8: Check STI Screening

Step 9: Check Additional USPSTF Screenings

Step 10: Format Output

Examples

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

Example 2: Young Female Patient

Troubleshooting

Screening Dates Not Found in Expected Resources

Patient Gender Does Not Match Expected Screening Criteria

Immunization Records Are Incomplete

Audit the pieces. Scan the whole. Decide.

Is care-gap-identifier safe to install?

Care Gap Identifier

Overview

FHIR Resources Used

Instructions

Step 1: Retrieve Patient Demographics

Step 2: Retrieve Active Conditions (Risk Factors)

Step 3: Retrieve Family History

Step 4: Check Cancer Screenings

Step 5: Check Metabolic and Cardiovascular Screenings

Step 6: Check Immunizations

Step 7: Check Depression and Mental Health Screening

Step 8: Check STI Screening

Step 9: Check Additional USPSTF Screenings

Step 10: Format Output

Examples

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

Example 2: Young Female Patient

Troubleshooting

Screening Dates Not Found in Expected Resources

Patient Gender Does Not Match Expected Screening Criteria

Immunization Records Are Incomplete

Related Skills

Audit the pieces. Scan the whole. Decide.