langcare-care-gaps - SKILL.md Agent Skill

name: langcare-care-gaps description: > Identifies care gaps for an individual patient by checking overdue preventive screenings, missing chronic disease monitoring, and unmet quality measure criteria from FHIR data. Use when asked about care gaps, overdue screenings, missing preventive care, what is this patient due for, or patient care compliance check.

Care Gap Identifier

When to Use This Skill

Use when a clinician needs to identify overdue preventive screenings, missing chronic disease monitoring labs, and unmet quality measure criteria for an individual patient.

Clinical Workflow

Use fhir_read to retrieve Patient demographics (age, gender for screening eligibility)
Use fhir_search to pull active Condition resources for chronic disease monitoring requirements
Use fhir_search to pull Observation resources (labs, screenings) to check completion dates
Use fhir_search to pull Procedure and DiagnosticReport resources for cancer screenings (mammogram, colonoscopy, Pap)
Use fhir_search to pull Immunization resources for vaccination status
Apply USPSTF/ACS/ACIP screening schedules based on age, gender, and risk factors (see references/uspstf-recommendations.md)
For each applicable screening/monitoring item: determine if it was completed within the required interval; flag as current, due soon, or overdue
Present prioritized list of care gaps with recommended actions

FHIR Resources

Patient -- Age, gender for screening eligibility
Condition -- Chronic diseases requiring monitoring (DM, HTN, CKD)
Observation -- Lab results, screening scores (PHQ-9, AUDIT-C)
Procedure -- Screening procedures (colonoscopy, mammogram)
DiagnosticReport -- Screening results
Immunization -- Vaccination history

FHIR Query Examples

Pull Recent Screenings

fhir_search(resourceType="Procedure", queryParams="patient=[patient-id]&date=ge[3-years-ago]&_sort=-date")

Check Mammogram Status

fhir_search(resourceType="DiagnosticReport", queryParams="patient=[patient-id]&code=24606-6&date=ge[27-months-ago]")

Clinical Guidelines

USPSTF A and B grade recommendations
ACS cancer screening guidelines
ACIP immunization schedule
ADA diabetes monitoring standards
ACC/AHA lipid and BP monitoring guidelines

Interpretation Guide

Categorize gaps as: Overdue (past recommended interval), Due Now (within recommended window), Upcoming (due within 3 months)
Prioritize by clinical impact: cancer screenings, chronic disease monitoring, immunizations, general wellness
For each gap: state the screening/test, when it was last performed (or never), the recommended interval, and specific ordering action
Include age-specific screening eligibility cutoffs (e.g., colonoscopy 45-75, mammogram 50-74, lung cancer screening 50-80 with 20+ pack-year history)

Safety

Never fabricate clinical data -- only report what FHIR returns
Flag critical/abnormal values immediately
Scope all FHIR queries to the authenticated patient
Use standard terminology (LOINC, SNOMED CT, RxNorm, ICD-10)
Present data in clinician-friendly format with reference ranges