value: cdc-opioid-guidance

system: PlanDefinitionType

code: eca-rule

display: ECA Rule

define "Get Summary":
  if "Is Recommendation Applicable?"
    then 'Patient has active prescriptions for opioid pain medication and benzodiazepines'
  else null

define "Active Ambulatory Benzodiazepine Rx":
    if Config."Can the implementing EHR support queries for past medications by date range?" then
      (
        "Get MedicationRequest Medication as Code"("Get Active Ambulatory Medication Requests"([MedicationRequest]))
      ) Rx
        where date from Rx.authoredOn 2 years or less on or before Today()
          and Rx.medication in "Benzodiazepine medications"
    else
         List<FHIR.MedicationRequest>{}

define "Active Ambulatory Opioid Rx":
    if Config."Can the implementing EHR support queries for past medications by date range?" then
      (
        "Get MedicationRequest Medication as Code"("Get Active Ambulatory Medication Requests"([MedicationRequest]))
      ) Rx
        where date from Rx.authoredOn 2 years or less on or before Today()
          and Rx.medication in "Opioid analgesics with ambulatory misuse potential"
    else
        List<FHIR.MedicationRequest>{}

define "Patient Age Less Than 18":
  if (Config."Age Less than 18 Years Is Enabled") then
    AgeInYearsAt(Today()) < 18
  else
    false

define "Patient Age Less Than 18":
  if (Config."Age Less than 18 Years Is Enabled") then
    AgeInYearsAt(Today()) < 18
  else
    false

define "Condition Positive for Sickle Cell":
      if (Config."Sickle Cell Check Enabled") then
        exists(
            Common."Positive Sickle Cell Condition"
        )  else
        false

// 3. Medications indicating end of life
    /* or exists (
      "Medications Indicating End of Life"
    ) */
define "US Core-Categorized Conditions":
  [Condition: category in "Encounter Diagnosis Condition Category"]
    union [Condition: category in "Problem List Condition Category"]
    union [Condition: category in "US Core Health Concern Condition Category"]

define "Conditions Indicating End Of Life Present":
  exists (
    Common."US Core-Categorized Conditions" LLEC
      where LLEC.code in Common."Limited life expectancy conditions"
        and LLEC.clinicalStatus in Common."Active Condition"
  )

define "Service Requests":
   [ServiceRequest] SR
    return SR

/*
**  Routine #1
**  Opioid Review Useful Routine
**
**  Definition              | Answer to Proceed   | Details                                      | Data (Terminology) Requirement
**  ------------------------------------------------------------------------------------------------------------------------------------
**  Age < 18 years?         | No                  | Calculate age from date of birth; exclude    | Date of birth
**                          |                     | patients with age less than 18 years at the  |
**                          |                     | time of the prescription                     |
**  ------------------------------------------------------------------------------------------------------------------------------------
**  Evidence of             | No                  | Look for documented findings consistent      | Sickle cell disease conditions
**  sickle cell disease?    |                     | with those listed in the sickle cell         |
**                          |                     | value set                                    |
**  ------------------------------------------------------------------------------------------------------------------------------------
**  Limited life            | No                  | Look for documented findings consistent      | Limited life expectancy conditions
**  expectancy conditions   |                     | with those listed in the limited life        |
**  present?                |                     | expectancy value set (terminal illness, bad  |
**                          |                     | prognosis, pre-terminal)                     |
**  ------------------------------------------------------------------------------------------------------------------------------------
**  Order for therapies     | No                  | Look for patients with an existing order for | Therapies indicating end of life care
**  indicating end of life  |                     | therapies indicating end of life care        |
**  care in past 90 days?   |                     | written within past 90 days                  |
**  ------------------------------------------------------------------------------------------------------------------------------------
**  Active cancer           | No                  | See sub-routine 3                            | See sub-routine 3
**  treatment?              |                     |                                              |
**  ------------------------------------------------------------------------------------------------------------------------------------
**  Conditions Likely       | No                  | Look for patients with active conditions in  | Conditions likely terminal for opioid
**  Terminal for opioid     |                     | the value set end-of-life-conditions         | prescribing
**  prescribing present?    |                     |                                              |
**  ------------------------------------------------------------------------------------------------------------------------------------
**
*/
define "Palliative Care Lookback Period":
  Interval[Today() - 90 days, Today()]

define "Order For Palliative Care In Past 90 Days":
  exists (
    Common."Service Requests" SR
    where SR.status in { 'active', 'completed'}
      and SR.intent in {'proposal', 'plan,', 'directive', 'order', 'original-order', 'reflex-order', 'filler-order', 'instance-order'}
      and FHIRHelpers.ToDateTime(SR.authoredOn) during day of "Palliative Care Lookback Period"
      and SR.code in Common."Therapies indicating end of life care"
  )

define "Is Active Cancer Treatment?":
  if (Config."Active Cancer Treatment Encounters Condition Is Enabled") then
      "Has Two or More Encounters with Cancer Diagnosis During Encounter Period"
    else
      false

define "Conditions Including Cancer To Exclude Opioid Management Indicating End-Stage Disease Present":
  if (Config."End-Stage Disease Criteria Enabled") then
    exists (
      Common."US Core-Categorized Conditions" EOLC
        where EOLC.code in Common."Conditions likely terminal for opioid prescribing"
          and EOLC.clinicalStatus in Common."Active Condition"
    )
  else
    false

define "Is Opioid Review Useful?":
  not "Patient Age Less Than 18"
    and not "Condition Positive for Sickle Cell"
    and not "Conditions Indicating End Of Life Present"
    and not "Order For Palliative Care In Past 90 Days"
    and not "Is Active Cancer Treatment?"
    and not "Conditions Including Cancer To Exclude Opioid Management Indicating End-Stage Disease Present"

define "Inclusion Criteria":
  (
    exists (Common."Active Ambulatory Benzodiazepine Rx")
      and exists (Common."Active Ambulatory Opioid Rx")
  )
    and not Common."Patient Age Less Than 18"
    and Routines."Is Opioid Review Useful?"

define "Conditions Indicating End of Life or With Limited Life Expectancy":
  (
    "US Core-Categorized Conditions" C
      where C.code in "Conditions likely terminal for opioid prescribing"
        and C.clinicalStatus in "Active Condition"
  )
  union
  (
    "US Core-Categorized Conditions" C
      where C.code in "Limited life expectancy conditions"
        and C.clinicalStatus in "Active Condition"
  )

define "Admitted/Referred/Discharged to Hospice Care":
  (
    [Procedure: code in "Hospice Procedure Codes"] P
      where P.status.value in { 'in-progress', 'completed' }
  )
  union
  (
    "Service Requests" SR
      where SR.code in "Hospice Procedure Codes"
        and SR.status.value in { 'active', 'completed' }
  )
  union
  (
    if (Config."Hospice Findings Exclusion Enabled") then
      [Observation: code in "Hospice Finding Codes"] O
        where not (O.status.value in { 'unknown', 'entered-in-error', 'cancelled' })
    else
      {}
  )
  union
  (
    [Encounter] E
      where date from E.period.start 1 year or less on or before Today()
        and (
          if E.hospitalization.dischargeDisposition.coding is null
              or not exists (E.hospitalization.dischargeDisposition.coding)
            then false
          else E.hospitalization.dischargeDisposition in "Hospice Disposition"
        )
        and E.status.value in { 'planned', 'arrived', 'in-progress', 'finished', 'onleave' }
  )

define "End of Life Assessment":
    // 1. Conditions indicating end of life or with limited life expectancy
    exists (
      "Conditions Indicating End of Life or With Limited Life Expectancy"
    )
    // 2. Admitted/referred/discharged to hospice care
    or exists (
      "Admitted/Referred/Discharged to Hospice Care"
    )

define "Exclusion Criteria":
  Common."End of Life Assessment"

define "Is Recommendation Applicable?":
  "Inclusion Criteria"
    and not "Exclusion Criteria"

define "Get Detail":
  if "Is Recommendation Applicable?"
    then 'Avoid prescribing opioid pain medication and benzodiazepines concurrently whenever possible'
  else null

define "Get Indicator":
  if "Is Recommendation Applicable?"
    then 'warning'
  else null