library OpioidCDSCommon version '2022.1.0'
using FHIR version '4.0.1'
include FHIRHelpers version '4.0.1' called FHIRHelpers
include OMTKLogicMK2020 version '2022.1.0' called OMTKLogic
codesystem "LOINC": 'http://loinc.org'
codesystem "SNOMED": 'http://snomed.info/sct'
codesystem "Medication Request Category Codes": 'http://terminology.hl7.org/CodeSystem/medicationrequest-category'
codesystem "Medication Request Status Codes": 'http://hl7.org/fhir/medication-request-status'
codesystem "Condition Clinical Status Codes": 'http://terminology.hl7.org/CodeSystem/condition-clinical'
valueset "US Core Condition Category Codes": 'http://hl7.org/fhir/us/core/ValueSet/us-core-condition-category'
// Expression-based
valueset "Opioid analgesics with ambulatory misuse potential": 'http://fhir.org/guides/cdc/opioid-cds/ValueSet/opioid-analgesics-with-ambulatory-misuse-potential'
valueset "Extended release opioid with ambulatory misuse potential": 'http://fhir.org/guides/cdc/opioid-cds/ValueSet/extended-release-opioid-with-ambulatory-misuse-potential'
valueset "Buprenorphine and methadone medications": 'http://fhir.org/guides/cdc/opioid-cds/ValueSet/buprenorphine-and-methadone-medications'
// Enumerated-compose
valueset "Limited life expectancy conditions": 'http://fhir.org/guides/cdc/opioid-cds/ValueSet/limited-life-expectancy-conditions'
valueset "Therapies indicating end of life care": 'http://fhir.org/guides/cdc/opioid-cds/ValueSet/therapies-indicating-end-of-life-care'
valueset "Conditions likely terminal for opioid prescribing": 'http://fhir.org/guides/cdc/opioid-cds/ValueSet/conditions-likely-terminal-for-opioid-prescribing'
valueset "CDC malignant cancer conditions": 'http://fhir.org/guides/cdc/opioid-cds/ValueSet/cdc-malignant-cancer-conditions'
valueset "Oncology specialty designations (NUCC)": 'http://fhir.org/guides/cdc/opioid-cds/ValueSet/oncology-specialty-designations'
valueset "Opioid misuse disorders": 'http://fhir.org/guides/cdc/opioid-cds/ValueSet/opioid-misuse-disorders'
valueset "Substance misuse behavioral counseling": 'http://fhir.org/guides/cdc/opioid-cds/ValueSet/substance-misuse-behavioral-counseling'
valueset "Conditions documenting substance misuse": 'http://fhir.org/guides/cdc/opioid-cds/ValueSet/conditions-documenting-substance-misuse'
// Harvested from VSAC - OID: 2.16.842022.1.013883.3.464.1003.101.12.1001
// Reviewed with Terminology, 2020-02-05 - Value set name in VSAC is "Office Visit", need to verify suitability
valueset "Office Visit": 'http://fhir.org/guides/cdc/opioid-cds/ValueSet/office-visit'
valueset "Opioid counseling procedure": 'http://fhir.org/guides/cdc/opioid-cds/ValueSet/opioid-counseling-procedure'
/* Existing sets for first six recs */
valueset "Benzodiazepine medications": 'http://fhir.org/guides/cdc/opioid-cds/ValueSet/benzodiazepine-medications'
valueset "Non-opioid drug urine screening": 'http://fhir.org/guides/cdc/opioid-cds/ValueSet/non-opioid-drug-urine-screening'
valueset "Naloxone medications": 'http://fhir.org/guides/cdc/opioid-cds/ValueSet/naloxone-medications'
valueset "Opioid misuse assessment procedure": 'http://fhir.org/guides/cdc/opioid-cds/ValueSet/opioid-misuse-assessment-procedure'
valueset "Opioid drug urine screening": 'http://fhir.org/guides/cdc/opioid-cds/ValueSet/opioid-drug-urine-screening'
valueset "Hospice Disposition": 'http://fhir.org/guides/cdc/opioid-cds/ValueSet/hospice-disposition' // Harvested from VSAC - OID: 2.16.842022.1.013762.1.4.1108.15
valueset "Hospice Finding Codes": 'http://fhir.org/guides/cdc/opioid-cds/ValueSet/hospice-finding'
valueset "Hospice Procedure Codes": 'http://fhir.org/guides/cdc/opioid-cds/ValueSet/hospice-procedure'
valueset "Pain treatment plan": 'http://fhir.org/guides/cdc/opioid-cds/ValueSet/pain-treatment-plan'
valueset "Pain management procedure": 'http://fhir.org/guides/cdc/opioid-cds/ValueSet/pain-management-procedure'
valueset "PDMP review procedure": 'http://fhir.org/guides/cdc/opioid-cds/ValueSet/pdmp-review-procedure'
valueset "PDMP data reviewed finding": 'http://fhir.org/guides/cdc/opioid-cds/ValueSet/pdmp-data-reviewed-finding'
code "Community": 'community' from "Medication Request Category Codes"
code "Active Condition": 'active' from "Condition Clinical Status Codes"
code "Active MedicationRequest": 'active' from "Medication Request Status Codes"
// TODO: code "Nonpharmacologic therapy and nonopioid pharmocologic": 'TODO' from "TODO"
context Patient
// TODO: Capture process decisions for long-term opioid use
define IsForChronicPain: true
define "Active Ambulatory Opioid Rx":
/* ("Get Active Ambulatory Medication Requests"([MedicationRequest: status in "Active MedicationRequest"])) Rx */
(
("Get Active Ambulatory Medication Requests"([MedicationRequest])) MR
where date from MR.authoredOn 2 years or less on or before Today()
and MR.medication is Reference or MR.medication in "Opioid analgesics with ambulatory misuse potential"
) Rx
let Med: [Medication: id in (Last(Split((Rx.medication as FHIR.Reference).reference, '/')))]
where not(Rx.medication is Reference) or Med.code in "Opioid analgesics with ambulatory misuse potential"
return
MedicationRequest {
id: Rx.id,
status: Rx.status,
intent: Rx.intent,
category: Rx.category,
medication: if Rx.medication is Reference then First(Med.code) else Rx.medication as CodeableConcept,
subject: Rx.subject,
recorder: Rx.recorder,
dosageInstruction: Rx.dosageInstruction,
dispenseRequest: Rx.dispenseRequest
}
define "Active Ambulatory Benzodiazepine Rx":
/* ("Get Active Ambulatory Medication Requests"([MedicationRequest: status in "Active MedicationRequest"])) Rx */
(
("Get Active Ambulatory Medication Requests"([MedicationRequest])) MR
where date from MR.authoredOn 2 years or less on or before Today()
and MR.medication is Reference or MR.medication in "Benzodiazepine medications"
) Rx
let Med: [Medication: id in (Last(Split((Rx.medication as FHIR.Reference).reference, '/')))]
where not(Rx.medication is Reference) or Med.code in "Benzodiazepine medications"
return
MedicationRequest {
id: Rx.id,
status: Rx.status,
intent: Rx.intent,
category: Rx.category,
medication: if Rx.medication is Reference then First(Med.code) else Rx.medication as CodeableConcept,
subject: Rx.subject,
recorder: Rx.recorder,
dosageInstruction: Rx.dosageInstruction,
dispenseRequest: Rx.dispenseRequest
}
define "Active Ambulatory Naloxone Rx":
/* ("Get Active Ambulatory Medication Requests"([MedicationRequest: status in "Active MedicationRequest"])) Rx */
(
("Get Active Ambulatory Medication Requests"([MedicationRequest])) MR
where date from MR.authoredOn 2 years or less on or before Today()
and MR.medication is Reference or MR.medication in "Naloxone medications"
) Rx
let Med: [Medication: id in (Last(Split((Rx.medication as FHIR.Reference).reference, '/')))]
where not(Rx.medication is Reference) or Med.code in "Naloxone medications"
return
MedicationRequest {
id: Rx.id,
status: Rx.status,
intent: Rx.intent,
category: Rx.category,
medication: if Rx.medication is Reference then First(Med.code) else Rx.medication as CodeableConcept,
subject: Rx.subject,
recorder: Rx.recorder,
dosageInstruction: Rx.dosageInstruction,
dispenseRequest: Rx.dispenseRequest
}
define function "Get Active Ambulatory Medication Requests" (value List<MedicationRequest>) returns List<MedicationRequest>:
value Rx
where Rx.status.value = 'active'
and exists (
Rx.category RxCategory
where FHIRHelpers.ToConcept(RxCategory) ~ "Community"
)
define function "Is Ambulatory Medication Request?" (value List<MedicationRequest>) returns List<MedicationRequest>:
value Rx
where exists (
Rx.category RxCategory
where FHIRHelpers.ToConcept(RxCategory) ~ "Community"
)
define function "Is Opioid Analgesic with Ambulatory Misuse Potential?"(value List<MedicationRequest>):
value Rx
let MedRef: if (Rx.medication is FHIR.Reference) then (Rx.medication as FHIR.Reference).reference else null,
Med: if MedRef is null then (Rx.medication as FHIR.CodeableConcept) else SingletonFrom([Medication: id in (Last(Split(MedRef, '/')))] Med return Med.code)
where Med in "Opioid analgesics with ambulatory misuse potential"
and exists (
Rx.category RxCategory
where FHIRHelpers.ToConcept(RxCategory) ~ "Community"
)
return
MedicationRequest {
id: Rx.id,
status: Rx.status,
intent: Rx.intent,
category: Rx.category,
medication: FHIR.CodeableConcept{ coding: Med.coding },
subject: Rx.subject,
authoredOn: Rx.authoredOn,
recorder: Rx.recorder,
dosageInstruction: Rx.dosageInstruction,
dispenseRequest: Rx.dispenseRequest
}
define function "Is Benzodiazepine?"(value List<MedicationRequest>):
value Rx
let MedRef: if (Rx.medication is FHIR.Reference) then (Rx.medication as FHIR.Reference).reference else null,
Med: if MedRef is null then (Rx.medication as FHIR.CodeableConcept) else SingletonFrom([Medication: id in (Last(Split(MedRef, '/')))] Med return Med.code)
where Med in "Benzodiazepine medications"
and exists (
Rx.category RxCategory
where FHIRHelpers.ToConcept(RxCategory) ~ "Community"
)
return
MedicationRequest {
id: Rx.id,
status: Rx.status,
intent: Rx.intent,
category: Rx.category,
medication: FHIR.CodeableConcept{ coding: Med.coding },
subject: Rx.subject,
authoredOn: Rx.authoredOn,
recorder: Rx.recorder,
dosageInstruction: Rx.dosageInstruction,
dispenseRequest: Rx.dispenseRequest
}
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"
)
// 3. Medications indicating end of life
/* or exists (
"Medications Indicating End of Life"
) */
define "Conditions Indicating End of Life or With Limited Life Expectancy":
(
[Condition: category in "US Core Condition Category Codes"] C
where C.code in "Conditions likely terminal for opioid prescribing"
and exists (
C.clinicalStatus.coding Coding
where FHIRHelpers.ToCode(Coding) ~ "Active Condition"
)
)
union
(
[Condition: category in "US Core Condition Category Codes"] C
where C.code in "Limited life expectancy conditions"
and exists (
C.clinicalStatus.coding Coding
where FHIRHelpers.ToCode(Coding) ~ "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
(
[ServiceRequest: code in "Hospice Procedure Codes"] E
where E.status.value in { 'planned', 'arrived', 'in-progress', 'finished', 'onleave' }
)
union
(
[Observation: code in "Hospice Finding Codes"] O
where not (O.status.value in { 'unknown', 'entered-in-error', 'cancelled' })
)
union
(
[Encounter] E
where
(
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 "Medications Indicating End of Life":
(
[MedicationAdministration: "End Of Life Opioids"] MA
where MA.status.value in { 'in-progress', 'on-hold', 'completed' }
)
union
(
[MedicationDispense: "End Of Life Opioids"] MD
where MD.status.value in { 'preparation', 'in-progress', 'on-hold', 'completed' }
)
union
(
[MedicationRequest: "End Of Life Opioids"] MR
where MR.status.value in { 'active', 'completed' }
)
union
(
[MedicationStatement: "End Of Life Opioids"] MS
where MS.status.value in { 'active', 'completed', 'intended' }
)
*/
define "Previous 10 Days Interval":
Interval[Today() - 10 days, Today()]
define "First Month":
Interval[Today() - 3 months, Today() - 2 months]
define "Second Month":
Interval[Today() - 2 months, Today() - 1 months]
define "Third Month":
Interval[Today() - 1 months, Today()]
define "Prescribed Opioids for 21 or more of 30 Days for each of the past 3 Months":
"Days on Opioids during Period"("First Month") >= 21
and "Days on Opioids during Period"("Second Month") >= 21
and "Days on Opioids during Period"("Third Month") >= 21
define function "Prescription Relevant Period"(prescription FHIR.MedicationRequest):
if (
prescription.authoredOn is not null and prescription.dispenseRequest is not null
and prescription.dispenseRequest.expectedSupplyDuration is not null
)
then Interval[
date from prescription.authoredOn,
date from prescription.authoredOn + System.Quantity{ value: GetDurationInDays(prescription.dispenseRequest.expectedSupplyDuration), unit: 'days' }
]
else null
define function "Days on Opioids during Period"(period Interval<Date>):
Sum(
(
collapse (
[MedicationRequest: "Opioid analgesics with ambulatory misuse potential"] OpioidPrescription
return "Prescription Relevant Period"( OpioidPrescription ) intersect period
)
) OpioidUseInterval
return days between start of OpioidUseInterval and end of OpioidUseInterval
)
define function Prescriptions(Orders List<MedicationRequest>):
Orders O
let
// NOTE: Assuming medication is specified as a CodeableConcept with a single RxNorm code
rxNormCode: FHIRHelpers.ToCode((O.medication as FHIR.CodeableConcept).coding[0]),
medicationName: OMTKLogic.GetMedicationName(rxNormCode),
// NOTE: Assuming a single dosage instruction element
dosageInstruction: O.dosageInstruction[0],
// NOTE: Assuming a single dose and rate element
doseAndRate: dosageInstruction.doseAndRate[0],
repeat: dosageInstruction.timing.repeat,
frequency: Coalesce(repeat.frequencyMax.value, repeat.frequency.value),
period: System.Quantity { value: repeat.period.value, unit: repeat.periodUnit.value },
doseDescription:
Coalesce(
// There should be a conversion from FHIR.SimpleQuantity to System.Quantity
if doseAndRate.dose is FHIR.Range
then ToString((doseAndRate.dose as FHIR.Range).low)
+ '-' + ToString((doseAndRate.dose as FHIR.Range).high)
+ (doseAndRate.dose as FHIR.Range).high.unit.value
else ToString(FHIRHelpers.ToQuantity(doseAndRate.dose)),
''
),
frequencyDescription:
ToString(dosageInstruction.timing.repeat.frequency.value) +
Coalesce(
'-' + ToString(dosageInstruction.timing.repeat.frequencyMax.value),
''
)
return {
rxNormCode: rxNormCode,
isDraft: O.status.value = 'draft',
// NOTE: Assuming asNeeded is expressed as a boolean
isPRN: dosageInstruction.asNeeded,
prescription:
if dosageInstruction.text is not null then
medicationName + ' ' + dosageInstruction.text.value
else
// TODO: Shouldn't need the .value here on asNeededBoolean
medicationName + ' ' + doseDescription + ' q' + frequencyDescription + (if dosageInstruction.asNeeded then ' PRN' else ''),
dose: if doseAndRate.dose is FHIR.Range
then (doseAndRate.dose as FHIR.Range).high
else FHIRHelpers.ToQuantity(doseAndRate.dose),
dosesPerDay: Coalesce(OMTKLogic.ToDaily(frequency, period), 1.0)
}
define function MME(prescriptions List<MedicationRequest>):
(Prescriptions(prescriptions)) P
let mme: SingletonFrom(OMTKLogic.CalculateMMEs({ { rxNormCode: P.rxNormCode, doseQuantity: P.dose, dosesPerDay: P.dosesPerDay } }))
return {
rxNormCode: P.rxNormCode,
isDraft: P.isDraft,
isPRN: P.isPRN,
prescription: P.prescription,
dailyDose: mme.dailyDoseDescription,
conversionFactor: mme.conversionFactor,
mme: mme.mme
}
define function TotalMME(prescriptions List<MedicationRequest>):
System.Quantity {
value: Sum((MME(prescriptions)) M return M.mme.value),
unit: 'mg/d'
}
define function GetDurationInDays(value FHIR.Duration):
if value is null then null
else
case
when value.code.value ~ 'a' then value.value.value * 365.0
when value.code.value ~ 'mo' then value.value.value * 30.0
when value.code.value ~ 'wk' then value.value.value * 7.0
when value.code.value ~ 'd' then value.value.value
when value.code.value ~ 'h' then value.value.value / 24.0
when value.code.value ~ 'min' then value.value.value / 60.0 / 24.0
when value.code.value ~ 's' then value.value.value / 60.0 / 60.0 / 24.0
when value.code.value ~ 'ms' then value.value.value / 60.0 / 60.0 / 24.0 / 1000.0
when value.code.value is null then Message(1000, true, 'Undefined', 'Error', 'Duration unit code is null')
else Message(1000, true, 'Undefined', 'Error', 'Unsupported duration unit code: ' + value.code.value)
end
define function GetIngredient(rxNormCode Code):
OMTKLogic.GetIngredients(rxNormCode).ingredientName
define function GetIngredients(rxNormCodes List<Code>):
rxNormCodes rnc return GetIngredient(rnc)
define function GetMedicationNames(medications List<MedicationRequest>):
medications M
return OMTKLogic.GetIngredients(ToRxNormCode((M.medication as FHIR.CodeableConcept).coding)).rxNormCode.display
/*
* Conversion Functions
*/
define function CodeableConceptsToString(concepts List<FHIR.CodeableConcept>):
concepts c return CodeableConceptToString(c)
define function CodingToString(coding FHIR.Coding):
if (coding is null)
then null
else
'Code {' &
'code: ' & coding.code &
'system: ' & coding.system &
'version: ' & coding.version &
'display: ' & coding.display &
'}'
define function CodeableConceptToString(concept FHIR.CodeableConcept):
if (concept is null or concept.coding is null)
then null
else
'CodeableConcept {' &
'Coding: [' &
Combine(concept.coding Coding return CodingToString(Coding), ',')
& ']'
& '}'
define function ToCodes(coding List<FHIR.Coding>):
coding c return FHIRHelpers.ToCode(c)
define function ToRxNormCode(coding List<FHIR.Coding>):
singleton from (
coding C where C.system = 'http://www.nlm.nih.gov/research/umls/rxnorm'
)
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