Open cases under human review
MX
MaxArc Global Health Impact Platform
Advanced Patient Continuity & Follow-Up Dashboard
Program · Continuity · Follow-up accountability view
No patient lost to follow-up, no result left unactioned.
Accountability-oriented continuity across facilities and programs: continuity cases, referral chains, facility transfers, missed appointments, treatment-interruption risk, unresolved lab-result follow-through, outreach workload, and human-reviewed escalations for HIV, TB, malaria, and MCH — standalone-first, integration-ready, and low-bandwidth aware. AI assists review; authorized staff decide and consent is respected.
You are viewing the Advanced Patient Continuity & Follow-Up Dashboard
Privacy & access posture: Sample data is synthetic and non-identifiable. Patient identity and precise location must be protected. In a real deployment, authorized role-based access is required, restricted patient locator capability is handled separately, and there is no autonomous disclosure or cross-facility sharing without authorization. This is not a full EHR and remains separate from MaxTrax EHR. No public patient locator is created here.
Appointments overdue
Treatment interruption risk
Pending / unacknowledged
Result follow-through incomplete
Continuity across facilities
Pending / not-reached attempts
Open escalations
Lab follow-through completed
Continuity risk distribution
High
2
Medium
2
Low
1
Active continuity cases
| Case | Program | Facility | Care team role | Risk | Reason |
|---|---|---|---|---|---|
| CONT-9001 | HIV | Riverside Health Center | hiv-continuity-nurse | medium | routine viral-load follow-up |
| CONT-9002 | TB | District Referral Hospital | tb-program-officer | high | RIF-resistant TB result pending clinician action |
| CONT-9003 | Malaria | Riverside Health Center | clinical-officer | medium | confirm antimalarial dispensing and 3-day review |
| CONT-9004 | MCH | Hilltop Community Clinic | mch-coordinator | low | antenatal visit schedule adherence |
| CONT-9005 | HIV | Hilltop Community Clinic | hiv-continuity-nurse | high | possible treatment interruption after transfer |
Missed follow-ups
| Patient | Program | Type | Scheduled | Status |
|---|---|---|---|---|
| PT-DEMO-005 | HIV | art refill | 2026-06-15 | 21 days overdue |
| PT-DEMO-004 | MCH | antenatal visit | 2026-06-28 | 8 days overdue |
High-risk treatment interruptions
| Program | Risk | Signal | Recommended action |
|---|---|---|---|
| HIV | high · 86 | ART refill missed 21 days after inter-facility transfer with unreconciled records | prioritize outreach; reconcile transfer records; clinician review |
| TB | high · 78 | RIF-resistant TB result awaiting MDR-TB pathway start | expedite clinician authorization and referral acknowledgement |
| MCH | medium · 52 | antenatal visit missed by 8 days | outreach reminder; reschedule visit |
Referral chains
| Referral | Route | Program | Reason | Status |
|---|---|---|---|---|
| REF-4001 | District Referral Hospital → District Referral Hospital | TB | MDR-TB pathway initiation | pending |
| REF-4002 | Riverside Health Center → District Referral Hospital | HIV | specialist review for regimen | completed |
| REF-4003 | Hilltop Community Clinic → Riverside Health Center | HIV | continuity after relocation | unresolved |
Cross-facility transfers
| Patient | Route | Program | Date | Records |
|---|---|---|---|---|
| PT-DEMO-005 | Hilltop Community Clinic → Riverside Health Center | HIV | 2026-04-02 | unreconciled |
| PT-DEMO-002 | Riverside Health Center → District Referral Hospital | TB | 2026-05-09 | reconciled |
Lab-result follow-through
Continuity integrates lab-to-doctor results: every result must be acknowledged by a clinician and followed through. Gaps route to human review.
| Patient | Program | Lab result | Interpretation | Acknowledged | Follow-through |
|---|---|---|---|---|---|
| PT-DEMO-001 | HIV | RES-8001 | suppressed | acknowledged | complete |
| PT-DEMO-002 | TB | RES-8002 | rifampicin-resistant TB | unacknowledged | unresolved |
| PT-DEMO-003 | Malaria | RES-8003 | malaria positive | acknowledged | in-progress |
Outreach workload
| Case | Method | Attempts | Priority | Outcome |
|---|---|---|---|---|
| CONT-9005 | community health worker visit | 2 | high | not-reached |
| CONT-9004 | phone reminder | 1 | medium | reached |
| CONT-9002 | clinician callback | 1 | high | pending |
Escalated cases
- program lead — high-risk treatment interruption with failed outreach open
- clinical lead — RIF-resistant TB awaiting MDR-TB pathway open
AI-assisted risk signals
- treatment interruption — High interruption risk: ART refill 21 days overdue post-transfer with unreconciled records and failed outreach Next: escalate to HIV continuity nurse; reconcile records; repeat outreach. human decision required
- unresolved lab follow up — RIF-resistant TB result not yet acknowledged; MDR-TB referral pending Next: route to TB program officer for authorization and referral acknowledgement. human decision required
- unresolved referral — Inter-facility referral after relocation not acknowledged by receiving facility Next: confirm receiving-facility acknowledgement; reconcile transfer. human decision required
- missed follow up — Antenatal visit missed by 8 days Next: outreach reminder and reschedule.
- data quality anomaly — Transfer TRF-5001 records not reconciled between facilities Next: data steward reconciliation with authorized access. human decision required
AI posture
AI assists with
- identify missed-follow-up patterns
- flag likely treatment interruption
- prioritize outreach queues
- reconcile referral and transfer records
- identify unresolved lab-result follow-through
- surface data-quality anomalies
- support authorized staff review
AI must never
- autonomously diagnose
- autonomously change treatment
- autonomously close cases
- autonomously disclose patient information
- bypass consent, privacy, authorization, or human review
AI supports patient continuity review: it identifies patterns, flags risks, prioritizes outreach, reconciles records for review, and surfaces anomalies, but never diagnoses, changes treatment, closes cases, or discloses patient information on its own. Authorized role-based access, consent, human review, and an immutable audit trail remain mandatory.
Runtime boundary & posture
- Impact runtime:
impact.maxarchealth.comon127.0.0.1:3201. - Medical Library boundary remains separate at
library.maxarchealth.com(port3101) and is not used here. - MaxTrax EHR remains separate; this is not a full EHR and does not couple repositories.
- Standalone-first with synthetic local sample data; optional integration with EHR, OpenELIS, DHIS2, and FHIR.
- Restricted patient locator capability is handled separately; no public patient locator is created here.