Chronic Disease Management

The Chronic Disease Management Playbook guides medical practitioners through standard protocols for long-term conditions like Hypertension and Diabetes Mellitus. It details how to audit historical laboratory values, authorize repeat prescriptions, and schedule reviews, all coordinated by workflow rules to ensure patient safety.

Detailed Step-by-Step Walkthrough

Step 1: Auditing Historical Lab Results (EMR Charts)

To monitor chronic condition progression and review biomarker trends over time:

1. Inside the active patient file, click the Lab Results tab (/patients/[patientId]/records/lab-results using lab-results-list.vue).
2. Select target biomarkers (e.g., HbA1c, Systolic/Esophageal Blood Pressure, LDL Cholesterol, or Serum Creatinine).
3. Click Show Chart to render a graphical time-series of historical values (lab-result-chart-slideover.vue or record-chart.vue).
4. The system aggregates LOINC-coded laboratory results and overlays reference thresholds.
5. Hover over individual data nodes on the chart to inspect specific dates, absolute readings, and percentage changes.

Step 2: Running a One-Click Repeat Prescription

For patients with stable conditions, doctors can avoid re-typing multi-drug regimens:

1. Navigate to the EMR Prescriptions panel (prescriptions.vue).
2. Click the Repeat Prescription button at the top of the prescription block.
3. The EMR automatically loads the exact medication list from the patient's last signed consultation (e.g., Amlodipine, Metformin, and Atorvastatin).
4. Review the auto-populated list, adjust quantities or dosages if necessary, and click Confirm Prescription.

Step 3: Workflow-Gated Review Intervals & Scheduling

Ensure continuous care by booking the next review during checkout. The Workflow Definition enforces clinical compliance rules:

1. Scroll to the consultation footer and click Schedule Follow-up.
2. Select In-Person Consult or Telehealth, and set the recurrence interval to 3 Months (or 6 Months) using the follow-up appointment widget.
3. Select an open slot from the doctor's calendar grid (/calendar).
4. Click Apply & Send. The booking is confirmed, and the patient receives confirmation details automatically.
5. Workflow Gating & Review Rule:
   • The Workflow Definition for chronic care contains Case Conditions (caseConditionsAsString) and Task Conditions (taskConditionsAsString) that audit the duration since the patient's last face-to-face consultation.
   • If the duration exceeds 6 months, the workflow blocks the front desk or pharmacy from issuing further repeat medication refills asynchronously. The state machine automatically routes the Episode of Care to the Mandatory Review Consultation state, requiring the patient to be seen by a doctor before further prescriptions can be dispensed.