FHIR Clinical Workflows

Structured clinical workflows using LangCare MCP FHIR Server's 4 generic tools: fhir_search, fhir_read, fhir_create, fhir_update.

1. Patient Chart Review

Purpose: Comprehensive review of patient's clinical record.

Workflow

Step 1: Verify Patient Identity

Tool: fhir_search
resourceType: "Patient"
queryParams: "family=[lastname]&given=[firstname]&birthdate=[YYYY-MM-DD]"

• Confirm demographics match (name, DOB, MRN)
• If multiple matches, ask user to specify

Step 2: Retrieve Active Problems

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

• Group by category (problem, diagnosis, symptom)
• Note onset dates and verification status

Step 3: Get Current Medications

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

• Include medication name, dose, frequency, route
• Check for high-risk medications (anticoagulants, insulin, opioids)

Step 4: Review Recent Lab Results

Tool: fhir_search
resourceType: "Observation"
queryParams: "patient=[patient-id]&category=laboratory&date=ge[30-days-ago]"

• Present with reference ranges
• Flag abnormal values (High/Low indicators)

Step 5: Check Recent Encounters

Tool: fhir_search
resourceType: "Encounter"
queryParams: "patient=[patient-id]&date=ge[90-days-ago]"

• Include type, date, provider, location
• Note hospital admissions vs outpatient visits

Step 6: Review Allergies

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

• Include substance, reaction, severity
• Distinguish true allergies from intolerances

Summary Format

Present findings in clinical order:

1. Demographics - Name, DOB, MRN
2. Active Problems - Conditions with dates
3. Medications - Name, dose, frequency
4. Allergies - Substance and reaction
5. Recent Labs - Results with flags
6. Recent Visits - Date, type, provider

2. Medication Reconciliation

Purpose: Ensure accurate, complete medication list during care transitions.

Workflow

Step 1: Retrieve All Medication Sources

Tool: fhir_search (run in parallel)
1. resourceType: "MedicationStatement" (patient-reported)
2. resourceType: "MedicationRequest" (prescribed)
3. resourceType: "MedicationAdministration" (administered, if available)

Step 2: Identify Discrepancies

• Compare lists for duplicates (same ingredient, different name)
• Check for conflicting doses
• Note discontinued medications still listed as active

Step 3: Validate Each Medication

• Indication: Does it match active conditions?
• Dose: Within therapeutic range?
• Drug-Drug Interactions: Check high-risk combinations:
• Warfarin + NSAIDs (bleeding risk)
• ACE inhibitors + K+ supplements (hyperkalemia)
• MAOIs + SSRIs (serotonin syndrome)
• Contraindications: Check against allergies and conditions

Step 4: Check for Gaps

• Is there treatment for all active chronic conditions?
• Are guideline-recommended medications present (e.g., statin for diabetes)?

Step 5: Document Reconciled List

Tool: fhir_update (for each medication)
resourceType: "MedicationStatement"
id: "[medication-id]"
resource: { confirmed status, last_reviewed timestamp }

Safety Checks

• High-Alert Medications: Insulin, heparin, warfarin, opioids, chemotherapy
• Renal Dosing: Adjust for CrCl if available
• Geriatric Concerns: BEERS criteria for patients 65+
• Pregnancy: Category X medications in women of childbearing age

3. Lab Result Interpretation

Purpose: Review and interpret laboratory results in clinical context.

Workflow

Step 1: Retrieve Lab Results

Tool: fhir_search
resourceType: "Observation"
queryParams: "patient=[patient-id]&category=laboratory&date=ge[date]"

Step 2: Organize by Category

• CBC: WBC, Hemoglobin, Hematocrit, Platelets
• BMP/CMP: Sodium, Potassium, Creatinine, Glucose, Calcium
• Liver Panel: ALT, AST, Alkaline Phosphatase, Bilirubin
• Lipids: Total Cholesterol, LDL, HDL, Triglycerides
• Other: TSH, HbA1c, Vitamin D, etc.

Step 3: Flag Abnormal Values

• Parse interpretation field (High, Low, Critical)
• Compare to referenceRange if present
• Calculate delta from previous results (trend analysis)

Step 4: Clinical Correlation

• Link to relevant conditions (e.g., HbA1c → Diabetes)
• Note medication effects (e.g., Creatinine elevation on ACE inhibitor)
• Identify critical values requiring immediate action

Step 5: Trend Analysis (if historical data available)

Tool: fhir_search
resourceType: "Observation"
queryParams: "patient=[patient-id]&code=[LOINC-code]&date=ge[6-months-ago]"

• Plot trend: improving, worsening, stable
• Note response to interventions

Common LOINC Codes

• Glucose: 2339-0 (mg/dL), 2345-7 (mmol/L)
• Creatinine: 2160-0 (mg/dL)
• HbA1c: 4548-4 (%)
• TSH: 3016-3 (mIU/L)
• Total Cholesterol: 2093-3 (mg/dL)
• LDL: 18262-6 (mg/dL)

Interpretation Guidelines

• Critical Values: WBC <1.5 or >30, Platelets <20, K+ <2.5 or >6.5, Glucose <40 or >600
• Reference Ranges: Use provided ranges; may vary by lab
• Clinical Context: Always interpret in context of symptoms and history

4. Preventive Care Screening

Purpose: Identify overdue preventive care based on guidelines (USPSTF, ADA, ACC/AHA).

Workflow

Step 1: Get Patient Demographics

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

Extract: age, sex, smoking status

Step 2: Check Active Conditions

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

Look for: Diabetes, Hypertension, Hyperlipidemia, CKD

Step 3: Review Previous Screenings

Tool: fhir_search (run for each screening type)
resourceType: "Observation" or "Procedure"
queryParams: "patient=[patient-id]&code=[screening-code]"

Screening Recommendations

Cancer Screening:

• Colorectal (50-75 years): Colonoscopy q10y, FIT stool test annually
• Breast (50-74 years, female): Mammography q2y
• Cervical (21-65 years, female): Pap smear q3y or HPV q5y
• Lung (55-80 years, 30 pack-year smoking): Low-dose CT annually
• Prostate (discuss 55-69 years, male): Shared decision-making on PSA

Cardiovascular:

• Blood Pressure: All adults annually
• Lipids: Age 40-75, calculate 10-year ASCVD risk
• Diabetes: Age 35-70 with overweight/obesity, q3y

Immunizations:

• Influenza: Annual, all adults
• Pneumococcal: Age 65+, or high-risk
• Shingles: Age 50+, Shingrix x2
• Tdap: Every 10 years
• COVID-19: Per current CDC guidance

Step 4: Identify Overdue Screenings

• Calculate time since last screening
• Compare to guideline intervals
• Prioritize by risk and time overdue

Step 5: Generate Recommendations Present as structured list:

Overdue Screenings:
1. Colorectal Cancer Screening - Last: 2015 (8 years ago) - Recommend: Colonoscopy or FIT test
2. Mammography - Last: 2021 (2 years ago) - Recommend: Schedule mammogram
3. Lipid Panel - Last: 2019 (4 years ago) - Recommend: Check cholesterol

5. Diabetes Management

Purpose: Monitor and optimize diabetes care using FHIR resources.

Workflow

Step 1: Confirm Diabetes Diagnosis

Tool: fhir_search
resourceType: "Condition"
queryParams: "patient=[patient-id]&code=http://snomed.info/sct|44054006"

SNOMED code 44054006 = Diabetes Mellitus Type 2

Step 2: Retrieve Glucose Control Metrics

Tool: fhir_search
resourceType: "Observation"
queryParams: "patient=[patient-id]&code=4548-4&date=ge[3-months-ago]"

LOINC 4548-4 = Hemoglobin A1c

Target: HbA1c <7% (individualize to <6.5% or <8% based on comorbidities)

Step 3: Get Current Diabetes Medications

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

Filter for:

• Metformin (first-line)
• SGLT2 inhibitors (cardiovascular/renal protection)
• GLP-1 agonists (weight loss, CV benefit)
• DPP-4 inhibitors
• Sulfonylureas (hypoglycemia risk)
• Insulin (basal, bolus, mixed)

Step 4: Check for Complications Screening

Tool: fhir_search (run in parallel)
1. Retinopathy: resourceType="Procedure", code=[eye-exam-code]
2. Nephropathy: resourceType="Observation", code=[urine-albumin-code]
3. Neuropathy: resourceType="Procedure", code=[foot-exam-code]

Screening Intervals:

• Retinal exam: Annually (can extend to q2y if no retinopathy)
• Urine albumin/creatinine ratio: Annually
• Foot exam: Annually, more often if neuropathy present

Step 5: Cardiovascular Risk Assessment

Tool: fhir_search
resourceType: "Observation"
queryParams: "patient=[patient-id]&code=18262-6" (LDL)

• Statin: Indicated for all diabetics 40-75 years
• Blood pressure: Target <130/80 mmHg
• Aspirin: Consider if ASCVD risk ≥10%

Step 6: Generate Care Plan

Tool: fhir_create
resourceType: "CarePlan"
resource: {
  status: "active",
  intent: "plan",
  subject: { reference: "Patient/[id]" },
  category: [{ coding: [{ system: "http://snomed.info/sct", code: "698358001", display: "Diabetes self-management plan" }] }],
  activity: [
    { detail: { description: "Check HbA1c every 3 months until at goal" } },
    { detail: { description: "Annual dilated eye exam" } },
    { detail: { description: "Check urine albumin annually" } }
  ]
}

ADA Quality Measures

• HbA1c <7%: Glycemic control
• BP <140/90 mmHg: Hypertension control
• LDL <100 mg/dL: Lipid control
• On ACE/ARB: If hypertensive or albuminuric
• On statin: If age 40-75

6. Hypertension Management

Purpose: Monitor blood pressure and optimize antihypertensive therapy.

Workflow

Step 1: Retrieve Blood Pressure Readings

Tool: fhir_search
resourceType: "Observation"
queryParams: "patient=[patient-id]&code=85354-9&date=ge[6-months-ago]"

LOINC 85354-9 = Blood Pressure Panel

• Extract systolic (8480-6) and diastolic (8462-4) components
• Calculate average of most recent 3 readings

Step 2: Classify Hypertension Stage

• Normal: <120/80 mmHg
• Elevated: 120-129/<80 mmHg
• Stage 1: 130-139/80-89 mmHg
• Stage 2: ≥140/90 mmHg
• Hypertensive Crisis: ≥180/120 mmHg (urgent evaluation)

Step 3: Review Current Antihypertensives

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

Medication classes:

• ACE Inhibitors: -pril (lisinopril, enalapril)
• ARBs: -sartan (losartan, valsartan)
• CCBs: -dipine (amlodipine, nifedipine)
• Diuretics: HCTZ, chlorthalidone, furosemide
• Beta-blockers: -olol (metoprolol, atenolol)

Step 4: Assess for Target Organ Damage

Tool: fhir_search (parallel)
1. Creatinine/eGFR (renal)
2. Echocardiogram (LVH)
3. Retinal exam (hypertensive retinopathy)
4. Urine albumin (proteinuria)

Step 5: Optimize Therapy

• Lifestyle: Weight loss, DASH diet, sodium <2g/day, exercise
• First-line: ACE/ARB, CCB, or thiazide diuretic
• Combination therapy: If Stage 2, start 2 drugs
• Monitoring: BP recheck in 1 month after change

Special Populations

• CKD: Prefer ACE/ARB (nephroprotection)
• Heart Failure: ACE/ARB + beta-blocker + diuretic
• Post-MI: Beta-blocker + ACE/ARB
• Diabetes: Target <130/80, use ACE/ARB
• Elderly: Individualize target (may accept <150/90)

7. Clinical Documentation

Purpose: Create structured clinical notes using FHIR resources.

Workflow

Step 1: Gather Visit Information

Tool: fhir_read
resourceType: "Encounter"
id: "[encounter-id]"

Extract: date, type, location, provider

Step 2: Create Composition Resource

Tool: fhir_create
resourceType: "Composition"
resource: {
  status: "final",
  type: { coding: [{ system: "http://loinc.org", code: "11506-3", display: "Progress note" }] },
  subject: { reference: "Patient/[id]" },
  encounter: { reference: "Encounter/[id]" },
  date: "[timestamp]",
  author: [{ reference: "Practitioner/[id]" }],
  title: "Progress Note",
  section: [
    { title: "Chief Complaint", text: { status: "generated", div: "<div>...</div>" } },
    { title: "History of Present Illness", ... },
    { title: "Assessment", ... },
    { title: "Plan", ... }
  ]
}

Step 3: Link Supporting Resources

• Observations (labs, vitals)
• Conditions (diagnoses)
• Procedures performed
• MedicationRequests (prescriptions)

Step 4: Add Provenance

Tool: fhir_create
resourceType: "Provenance"
resource: {
  target: [{ reference: "Composition/[id]" }],
  recorded: "[timestamp]",
  agent: [{
    who: { reference: "Practitioner/[id]" },
    role: [{ coding: [{ code: "author" }] }]
  }],
  signature: [{ type: [{ code: "1.2.840.10065.1.12.1.1" }], when: "[timestamp]", who: { reference: "Practitioner/[id]" } }]
}

Common Note Types (LOINC)

• Progress Note: 11506-3
• History & Physical: 34117-2
• Discharge Summary: 18842-5
• Consultation Note: 11488-4
• Operative Note: 11504-8

8. Vital Signs Tracking

Purpose: Record and monitor vital signs over time.

Create Vital Sign Observation

Blood Pressure:

Tool: fhir_create
resourceType: "Observation"
resource: {
  status: "final",
  category: [{ coding: [{ system: "http://terminology.hl7.org/CodeSystem/observation-category", code: "vital-signs" }] }],
  code: { coding: [{ system: "http://loinc.org", code: "85354-9", display: "Blood pressure panel" }] },
  subject: { reference: "Patient/[id]" },
  effectiveDateTime: "[timestamp]",
  component: [
    { code: { coding: [{ system: "http://loinc.org", code: "8480-6", display: "Systolic blood pressure" }] }, valueQuantity: { value: 120, unit: "mmHg" } },
    { code: { coding: [{ system: "http://loinc.org", code: "8462-4", display: "Diastolic blood pressure" }] }, valueQuantity: { value: 80, unit: "mmHg" } }
  ]
}

Other Vital Signs:

• Heart Rate: LOINC 8867-4 (beats/min)
• Respiratory Rate: LOINC 9279-1 (breaths/min)
• Temperature: LOINC 8310-5 (°C or °F)
• Oxygen Saturation: LOINC 2708-6 (%)
• Weight: LOINC 29463-7 (kg or lb)
• Height: LOINC 8302-2 (cm or in)
• BMI: LOINC 39156-5 (kg/m²)

Trending

Tool: fhir_search
resourceType: "Observation"
queryParams: "patient=[patient-id]&code=8480-6&date=ge[6-months-ago]&_sort=date"

• Plot trend over time
• Identify patterns (e.g., morning vs evening BP)
• Assess treatment response

Safety Considerations

Patient Identity Verification

• Always confirm with at least 2 identifiers (name + DOB, name + MRN)
• Ask user to verify before any create/update operations
• Use partial matches cautiously (e.g., "John Smith" → multiple results)

Data Validation

• Check for required FHIR fields before creating resources
• Validate codes against proper code systems (LOINC, SNOMED, RxNorm)
• Ensure dates are in ISO 8601 format (YYYY-MM-DD)
• Verify references point to existing resources

Clinical Accuracy

• Always present reference ranges with lab values
• Note data source and recency (e.g., "Last measured 2 days ago")
• Distinguish between patient-reported and clinician-verified data
• Flag missing critical information (e.g., allergy status unknown)

Error Handling

• If search returns 0 results, suggest alternative searches
• If authentication fails, check OAuth scopes
• If resource not found, verify ID and resource type
• If create/update fails, check for validation errors in response

Documentation

• Log all PHI access in audit logs
• Note data source for clinical decisions
• Include timestamps for all retrievals
• Document reasoning for clinical recommendations

Appendix: Common Search Parameters

Patient

• name - Family and/or given name
• birthdate - Date of birth (YYYY-MM-DD)
• identifier - MRN or other identifier
• gender - male, female, other, unknown

Observation (Labs/Vitals)

• patient - Patient reference
• code - LOINC code
• category - laboratory, vital-signs, survey
• date - Date range (ge, le, eq)
• status - final, preliminary, amended

Condition (Diagnoses)

• patient - Patient reference
• code - SNOMED CT or ICD-10 code
• clinical-status - active, inactive, resolved
• onset-date - When condition began

MedicationStatement/MedicationRequest

• patient - Patient reference
• status - active, completed, stopped
• code - RxNorm code
• effective - Date range

Encounter

• patient - Patient reference
• date - Date range
• type - Visit type code
• status - planned, arrived, in-progress, finished

Date Modifiers

• ge - Greater than or equal (≥)
• le - Less than or equal (≤)
• gt - Greater than (>)
• lt - Less than (<)
• eq - Equal (=)

Example: date=ge2023-01-01&date=le2023-12-31 (year 2023)