Contact Tracing (Malawi Core)

[roywanyaga]

Context

Contact Tracing: To follow up with a person over the phone or in the community with the intention of bringing the person into care or provide them with a service they need.

In Malawi Core, there will be two tracing registers

• Phone Tracing: This register will contain patients who have been marked for tracing and have a phone number record
• Home Tracing: This register contains patients who have been marked for tracing and:
  1. Do not have a phone number record
  2. Have been on the Phone Tracing register but (a) Have had three phone tracing attempts but are still on the tracing register,or (b) Have had one phone tracing attempt and the tracing outcome is 'number does not exist' or 'number is not the patient's'

A patient can be on the tracing register for various reasons:

• Linkage: Newly diagnosed clients who have not started treatment after 14 days of their diagnosis (Activated by not completing the TB History, Regimen and Next Appointment questionnaire on the day of registration)
• High Viral Load: ART clients with a high viral load result (entered through the Viral Load Results questionnaire)
• Detectable Viral Load: ART clients with a detectable viral load result (entered through the Viral Load Results questionnaire)
• Missing Viral Load: ART clients with a missing viral load result (entered through the Viral Load Results questionnaire)
• Invalid Viral Load: ART clients with an invalid viral load result (entered through the Viral Load Results questionnaire)
• Interrupted Treatment: ART clients who have missed their appointment (set in TB History, Regimen and Next Appointment questionnaire) by 28 days or more
• Missed Appointment: ART clients who have missed their appointment (set in TB History, Regimen and Next Appointment), by 7 – 27 days
• Dual Referral (DR): ART clients who have agreed to bring their partner to the clinic or asked the CHW to come to their home during the contacts registration process. They will appear at the top of the list when the day is due.( Set in the Child Contact Registration and Sexual Contact Registration questionnaires)
• Contract Referral (CR): ART clients who have agreed to bring their partner to the clinic during the contacts registration process. They will appear at the top of the list when the day is due. ( Set in the Child Contact Registration and Sexual Contact Registration questionnaires)
• Provider Referral (PR): Child and Sexual Contacts who were identified through the ART client. They must appear on the tracing list immediately after being registered if PR is the preferred referral choice. ( Set in the Child Contact Registration and Sexual Contact Registration questionnaires)
• Missed Clinic Appointment: Sexual contacts and persons Who is Reactive at community who missed the appointment date agreed on in the HIV test and Next Appointment questionnaire
• Family Referral Services (FRS): ART clients who have agreed to bring their children to the clinic or asked the CHW to come to their home during the contacts registration process. They will appear at the top of the list when the day is due. (Set in the Child Contact Registration and Sexual Contact Registration questionnaires): There are two FRS: FRS No STK and FRS STK
• Dry Blood Sample Positive Result: Exposed Infant with a positive DBS result (entered through the HIV test and Results questionnaire)
• Dry Blood Sample Result Missing: Exposed Infants with a missing DBS result (entered through the HIV Test and Results questionnaire)
• Dry Blood Sample Result Invalid: Exposed Infants with a missing DBS result (entered through the HIV Test and Results questionnaire)
• Missed Milestone Visit: Exposed Infants who have missed their milestone appointment (one with Milestone HIV test questionnaire), set in Medicine and Next Appointment questionnaire, by 1 or more days
• Missed Routine Appointment: Exposed Infants who have missed their appointment (one without Milestone HIV test questionnaire), set in Medicine and Next Appointment questionnaire

FHIR Resource to track patient enrollment for Tracing

The following aspects of contact tracing for Malawi Core will need to be represented in FHIR:

• Representing enrollment of patients for tracing
• Tracking of Phone tracing and Home tracing patients
• Representing the Tracing start date
• Representing the reason for contact tracing
• Representing when the patient is removed from the tracing register either by
  1. Positive outcome of the tracing encounter
  2. The patient is removed from tracing because (a) they have opted out of care provision (b) they have transferred to a different catchment area (c) they have died
  3. The health workers were not able to reach the patient
• Representing when patient agrees to an appointment from the tracing encounter.

Task Resource

The proposed resource to track enrollment for contact tracing is the Task Resource
The table below outlines the adopted elements of the Task Resource:

Element	Description/Example
resourceType	Task
id	logical identifier for the resource (UUID)
meta	a tag entry identifying whether the Patient ihas been enrolled to the Phone Tracing or the Home Tracing register. value for Phone Tracing: {"tag": [{"system": "https://d-tree.org","code": "phone-tracing","display": "Phone Tracing"}]} value for Home Tracing: {"tag": [{"system": "https://d-tree.org","code": "home-tracing","display": "Home Tracing"}]}
identifier	official business identifier. denoted as the FHIR identifier data type including use (official) and value (UUID). example value: [{"use": "official","value": "e04d015e-3a67-4a37-8633-b3eabad41f47"}]
partOf	Reference to the parent Task. When a patient agrees to an appointment during the tracing encounter, the initial Task's status is update to 'in-progress' and a new Task due on the appointment date is created and linked to the initial Task through this field. example value: {"reference": "Task/01469d46-1cc0-4e82-a140-e27902b0df4d"}
status	one of the TaskStatus codes as outlined in the TaskStatus section below
intent	TaskIntent. The value for this will be plan
priority	RequestPriority. The value will be routine
code	CodeableConcept to identify the Task Type. We will utilize the SNOMED CT code for the contact tracing procedure. The value will be: {"coding": [{"system": "http://snomed.info/sct","code": "225368008","display": "Contact tracing (procedure)"}],"text" : "Contact Tracing"}
description	Description of task. For Home tracing the description will be HIV Contact Tracing via home visit and for Phone tracing, the description will be HIV Contact Tracing via phone
for	Reference to the Patient to be Traced. example value: {"reference": "Patient/01466d46-1cc0-4e82-a140-e27982b0df4d"}
executionPeriod	Period indicating the start and end time of execution of the task. The start dateTime will denote when the Tracing will be due. This could be a future date for some of the reasons and also for the Tasks created following a Tracing encounter. The end dateTime will denote when the patient is removed from the Tracing Register. example value: {"start": "2022-10-26T00:00:00.00Z","end": "2022-11-01T00:00:00.00Z"}. Patients with Tracing Tasks that are due in the future will not appear on the Tracing Register
authoredOn	Task Creation Date and Time
owner	Reference to the practitioner to whom the Patient is assigned. example value: {"reference": "Practitioner/01466d46-1cc0-4e82-a140-e27582b0df4d"}
reasonCode	Custom CodeableConcept to identify the Tracing Reason as outlined in the tracing reason section below. example value: {"coding": [{"system": "https://d-tree.org","code": "linkage","display": "Linkage"}],"text" : "Linkage"}
reasonReference	Reference to the Tracing Outcome Questionnaire. example value: {"reference": "Questionnaire/1bdf21ef-d31a-446e-aaa6-cec516eceab1"}

TaskStatus

The following are the TaskStatus codes that will be utilized to represent Tracing from the posible value set defined by the FHIR project.

Code	Definition
ready	The default code for any Tracing Task that is being created denoting that it is ready to be performed.
in-progress	During a Tracing encounter, if the patient agrees to visit the clinic and sets a date for the visit, the current Tracing Task is marked as in-progress and a new Task will be created. The new task is linked to the current Task through the partOfelement and its executionPeriod start date set as the date when the visit is due
completed	The Tracing Task is marked as completed when the Patient is to be removed from a patient register after a tracing encounter and a successful clinic visit based on the tracing reason
cancelled	The Tracing Task is marked as cancelled when the Patient is to be removed from the patient register for any reason other than a succefful clinic visit following a tracing encounter

Tracing Reason Codes

The following are the custom codes that will be utilized to reprent the different tracing reasons in the reasonCode element of the Tracing Task .

Tracing Reason	system	code	display	text
Linkage	https://d-tree.org	linkage	Linkage	Linkage
High Viral Load	https://d-tree.org	hvl	High Viral Load	HVL
Detectable Viral Load	https://d-tree.org	detectable-vl	Missing Viral Load	Detectable VL
Missing Viral Load	https://d-tree.org	missing-vl	Missing Viral Load	Missing VL
Invalid Viral Load	https://d-tree.org	invalid-vl	Invalid Viral Load	Invalid VL
Interrupted Treatment	https://d-tree.org	interrupt-treat	Interrupted Treatment	Interrupt Treat
Missed Appointment	https://d-tree.org	miss-appt	Missed Appointment	Miss Appt
Dual Referral	https://d-tree.org	dual-referral	Dual Referral	Dual Referral
Contract Referral	https://d-tree.org	contact-referral	Contact Referral	Contact Referral
Provider Referral	https://d-tree.org	provider-referral	Provider Referral	Provider Referral
Missed Clinic Appointment	https://d-tree.org	miss-clinic-appt	Missed Clinic Appointment	Miss Clinic Appt
Family Referral Services Self Test Kit	https://d-tree.org	frs-stk	Family Referral Services Self Test Kit	FRS STK
Family Referral Services No Self Test Kit	https://d-tree.org	frs-no-stk	Family Referral Services No Self Test Kit	FRS no STK
Dry Blood Sample Positive Result	https://d-tree.org	dbs-positive	Dry Blood Sample Positive Result	DBS Positive
Dry Blood Sample Result Missing	https://d-tree.org	dbs-missing	Dry Blood Sample Result Missing	DBS Missing
Dry Blood Sample Invalid	https://d-tree.org	dbs-invalid	Dry Blood Sample Invalid	DBS Invalid
Missed Milestone Visit	https://d-tree.org	miss-milestone	Missed Milestone Visit	Miss Milestone
Missed Routine Visit	https://d-tree.org	miss-routine	Missed Routine Visit	Miss Routine

Tracing Event

The tracing event and its outcome is recorded through the Tracing Outcome Questionnaire. Two FHIR Resources are proposed for extraction from the Questionnaire to represent this event.

1. Encounter Resource
2. Observation Resource

Encounter Resource

The table below outlines the adopted elements of the Encounter Resource:

Element	Description/Example
resourceType	Encounter
id	logical identifier for the resource (UUID)
status	The EncounterStatus. The value for this will be finished
class	A Coding representing the ActEncounterCode classification of the patient encounter. For Phone Tracing the value will be {"system": "http://terminology.hl7.org/CodeSystem/v3-ActCode","code": "VR"} and for Home Tracing, the value will be {"system": "http://terminology.hl7.org/CodeSystem/v3-ActCode","code": "HH"}
type	CodeableConcept to identify the Encounter Type. We will utilize the SNOMED CT code for the contact tracing procedure. The value will be: {"coding": [{"system": "http://snomed.info/sct","code": "225368008","display": "Contact tracing (procedure)"}],"text" : "Contact Tracing"}
priority	CodeableConcept to indicate the urgency of the encounter. ActPriority codes will be utilised. The value will be: {"coding": [{"system": "http://terminology.hl7.org/ValueSet/v3-ActPriority","code": "EL","display": "elective"}],"text" : "elective"}
subject	Reference to the Patient being Traced. example value: {"reference": "Patient/01466d46-1cc0-4e82-a140-e27982b0df4d"}
participant	BackboneElement containing Reference to the Practitioner performing the Tracing. example value: [{"individual":{"reference":"Practitioner/1bdf21ef-d30a-446e-aaa6-cec516eceab1"}}]
period	Period indicating the start and end time of execution of the task. example value: {"start": "2022-10-26T00:00:00.00Z","end": "2022-11-01T00:00:00.00Z"}
reasonCode	Custom CodeableConcept to identify the Tracing Reason as outlined in the tracing reason section above. example value: {"coding": [{"system": "https://d-tree.org","code": "linkage","display": "Linkage"}],"text" : "Linkage"}
serviceProvider	Reference to the Organization responsible for this encounter i.e. The organization that the practitioner belongs to

Observation Resource

The table below outlines the adopted elements of the Observation Resource:

Element	Description/Example
resourceType	Observation
id	logical identifier for the resource (UUID)
status	The EncounterStatus. The value for this will be finished
category	CodeableConcept to identify the Category of the type of Observation. We will utilize the SNOMED CT code for the contact tracing procedure. The value will be: {"coding": [{"system": "http://snomed.info/sct","code": "225368008","display": "Contact tracing (procedure)"}],"text" : "Contact Tracing"}
code	Custom CodeableConcept to identify the Type of Tracing outcome as outlined in the Tracing Outome Type section below. example value: {"coding": [{"system": "https://d-tree.org","code": "not-spoken","display": "Not Spoken To Client"}],"text" : "Not Spoken To Client"}
subject	Reference to the Patient being Traced. example value: {"reference": "Patient/01466d46-1cc0-4e82-a140-e27982b0df4d"}
encounter	Reference to the Encounter through which the observation is made
performer	BackboneElement containing Reference to the Practitioner performing the Tracing. example value: [{"individual":{"reference":"Practitioner/1bdf21ef-d30a-446e-aaa6-cec516eceab1"}}]
valueCodeableConcept	Custom CodeableConcept to identify the Tracing outcome as outlined in the Tracing Outome section below. example value: {"coding": [{"system": "https://d-tree.org","code": "not-spoken","display": "Not Spoken To Client"}],"text" : "Not Spoken To Client"}

Tracing Oucome Types

To be defined when tracing outcomes are provided

Tracing Oucomes

To be defined when tracing outcomes are provided