Care Gap Dashboard
FHIR-native clinical decision support for primary care
The Problem
Family physicians in Canada manage panels averaging 1,500 patients. Between 20–40% of chronic disease patients miss recommended monitoring intervals — not from lack of care, but because no system is actively watching for gaps. The downstream cost: preventable hospitalizations at $10,000–$15,000 each. Diabetes alone costs Canadian healthcare $30 billion annually.
What It Does
Four chronic conditions: Type 2 Diabetes, Hypertension, CKD, Hyperlipidemia. Eight clinical rules: four monitoring rules for diagnosed patients + four screening rules that catch undiagnosed disease from abnormal lab values. CRITICAL / HIGH / MEDIUM / LOW triage. Patient Panel, Patient Detail, Population Dashboard views. AI Clinical Summary via GPT-4o. Works with any FHIR-compliant EHR.
Demo Patient
Margaret, 68, has diagnosed Type 2 Diabetes and Hypertension. Her labs show eGFR 48 for 18 consecutive months (Stage 3 CKD — undiagnosed) and LDL 4.2 (hyperlipidemia — undiagnosed). The dashboard surfaces both gaps to her physician, catching disease she doesn't yet know she has.
Technical Implementation
FHIR Resources Used
Clinical Guidelines
Diabetes Canada CPG 2023 · Hypertension Canada 2023 · CTFPHC
Built with awareness of the HL7 Da Vinci DEQM framework — the industry direction for standardized gaps-in-care reporting in production systems. Designed for the regulatory environment Bill S-5 (Connected Care for Canadians Act) is creating.
Mirth Connect HL7 v2 → FHIR Pipeline
In ProgressAn integration engine pipeline converting HL7 v2 ADT messages to FHIR Patient and Encounter resources. Demonstrates message transformation skills required for health authority integration roles.