HEARTLAND Protocol FHIR Implementation Guide - Compilação de desenvolvimento local (v0.1.0) construída pelas ferramentas de compilação FHIR (HL7® FHIR® Standard). Veja o Diretório de versões publicadas

Tiers and Tracks

Implementation Tiers and Monitoring Tracks

HEARTLAND assigns two orthogonal designations: a facility implementation tier (driven by site resources) and a patient monitoring track (driven by patient access to technology).

Facility Implementation Tiers

Component	Tier 1 - Minimal	Tier 2 - Standard	Tier 3 - Advanced
Setting	Critical Access Hospital, 1-2 nurses	FQHC, community hospital	Regional referral center
Risk stratification	Score at discharge	Full CKM + Score	Full CKM + Score
GDMT	>=2 classes, prioritize SGLT2i + beta-blocker	Target all 4 classes in 14 days	Rapid-sequence initiation
Monitoring	Track B (Analog)	Dual-track A/B	Track A primary + RPM
Discharge education	Condensed teach-back (3 domains)	Full teach-back (8 domains)	Full teach-back
Follow-up	48-72 hour call, 14-day visit	48-hour call, 7-day visit, weekly x4	48-hour call, 7-day visit, frequent
Staffing	RN/MA + MD	RN champion, MA, PharmD	Full multidisciplinary team
CHW program	Alternative/Family	High-risk only	Full integration
Financial navigation	Generic Bridge	PAP pursuit + Generic Bridge	PAP pursuit + Generic Bridge
Quality metrics	Contact rates + basic GDMT initiation	Dose optimization + readmission reduction	Dose optimization + readmission reduction

Facility tier is captured via the heartland-facility-tier extension on Location, Organization, or CarePlan. Tier values come from the HeartlandImplementationTier code system: tier-1-minimal

tier-2-standard

tier-3-advanced.

Facility Self-Assessment

Use HeartlandFacilityTierQuestionnaire to support tier assignment. Five categorical items cover staffing model, PharmD availability, CHW program, monitoring technology, and financial navigation capacity. Tier mapping is qualitative: predominance of minimal answers maps to Tier 1; standard to Tier 2; advanced to Tier 3. The source protocol does not provide a formal scored rubric; this questionnaire is an operational instrument derived from Table 2.

Patient Monitoring Tracks

Track A (digital) and Track B (analog) follow identical clinical algorithms, differing only in data collection method.

Aspect	Track A - Digital	Track B - Analog
Symptom tracking	App-based, structured	Voice telephone calls
Devices	Bluetooth-enabled (scale, BP cuff, pulse oximeter)	Manual digital scale, BP cuff, paper diary
Data transmission	Automated to clinician dashboard	Manual entry by RN/MA after telephone visit

Track is captured via the heartland-monitoring-track-ext extension on CarePlan, with values from the HeartlandMonitoringTrack code system: digital-track-a

analog-track-b.

Patient Track Assignment

Use HeartlandPatientTrackQuestionnaire at intake. Decision logic from Table 4:

• Smartphone with reliable connectivity AND comfortable using apps -> Track A
• Reliable telephone access only -> Track B
• Smartphone without app comfort -> Hybrid (clinical judgment)

The Hozho Trial validated Track B as a primary effective intervention, not a fallback. Patients without smartphones receive equivalent clinical benefit from telephone-based titration.

Care Plan Structure

The HeartlandCarePlan profile organizes activities across five domains:

1. GDMT initiation/titration — class count and cadence per facility tier.
2. Remote monitoring schedule — frequency aligned with risk tier and monitoring track.
3. Post-discharge follow-up — call timing (48-72h vs 48h) and visit timing (14-day vs 7-day).
4. Discharge education — 3 condensed domains (Tier 1) or 8 comprehensive domains (Tier 2/3).
5. Patient assistance navigation — Generic Bridge and/or PAP pursuit.

See CarePlanExampleTier2 for a complete worked example.

Remote Monitoring Observations

The HeartlandRemoteMonitoringObservation profile constrains Observation for the four parameters captured by the basic monitoring kit (~$50-150):

Observation	LOINC	Default red-flag threshold
Body weight	29463-7	Gain >=2 lb (~0.9 kg)/24h or >=5 lb (~2.3 kg)/7d
Systolic BP	8480-6	<90 or >180 mmHg
Diastolic BP	8481-4	<50 or >110 mmHg
Oxygen saturation	59408-5	<90% on room air

Thresholds are encoded via Observation.referenceRange with referenceRange.text describing the rule. Defaults shown above are configurable per program; programs operating in altitudes above 5,000 ft, for instance, may justify a lower SpO2 threshold.

See ObservationExampleWeightRedFlag for a worked example.

Human Filter

All non-emergency alerts pass through licensed clinician telephone assessment before emergency department referral.

This principle prevents alert fatigue and false-positive ED cascades from raw device data. A single weight gain of 1.0 kg overnight does not auto-trigger ED transfer; it triggers a clinician call to assess the full clinical picture (intake, symptoms, recent diuretic adherence) before any escalation.