Clinical Decision Support for Chronic Pain Management and Shared Decision-Making IG, published by CQF. This guide is not an authorized publication; it is the continuous build for version 0.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/cqframework/cds4cpm/ and changes regularly. See the Directory of published versions

Data Elements

Data Elements

This page details data elements used throughout the CDS4CPM Implementation Guide.

MyPAIN Data Elements and Terminology

Summary of MyPAIN minimum API usage (SHALL support data elements):

MyPAIN: GET [base]/Patient/1234 GET [base]/Questionnaire/MyPAIN-questionnaire POST [base]/QuestionnaireResponse

Input Data

MyPAIN uses input data that it receives from the calling application. MyPAIN will not be able to correctly display or save the data collected without this information.

Patient Retrieval

Implementations SHALL support retrieval of a Patient conforming to the US Core Patient Profile by patient ID: GET [base]/Patient/1234

MyPAIN Enrollment

CONSIDER: Implementations MAY support modeling patient enrollment as a Group resource, listing all patients explicitly. Searching would then be possible using the “member” search of the group, or we could define an $ismember operation if we want to ensure that users can only ask if a patient they know about is a member of the group (rather than having to retrieve the whole group).

Next Appointment

Implementations MAY support appointment searching as described by the patient scheduling use case. Specifically, appointment search:

GET [base]/Appointment?patient=[id]{&status=[status]}{&date=[date]{&date=[date]}}{&practitioner=[id]}

GET [base]/Appointment?patient=1234&status=booked&date=ge2020-05-01

This would retrieve all appointments, therefore implementers may want to consider just defining a $next-appointment operation to simplify both implementation and usage.

Questionnaire Retrieval

Implementations SHOULD support retrieval of a Questionnaire resource conforming to the Structured Data Capture (SDC) Questionnaire profile to describe the contents of the MyPAIN questionnaire:

Questionnaire read: GET [base]/Questionnaire/MyPAIN-questionnaire

Implementations MAY support retrieval of a Questionnaire by canonical URL and version:

Questionnaire search: GET [base]/Questionnaire?url=http://fhir.org/guides/cds4cpm/Questionnaire/MyPAIN-questionnaire

Output Data

These data elements represent the information and responses to the questionnaire that the patient fills out. These data are submitted at the end of the questionnaire to a designated location and later used in the Pain Manager Dashboard.

QuestionnaireResponse

Implementations SHALL support the creation of a QuestionnaireResponse, conforming to the SDC form filler, containing patient answers to questions in the MyPAIN questionnaire:

POST [base]/QuestionnaireResponse

In addition, implementations MAY support update of a QuestionnaireResponse and retrieval of an in-progress questionnaire response:

QuestionnaireResponse update: PUT [base]/QuestionnaireResponse/1234

QuestionnaireResponse search: GET [base]/QuestionnaireResponse?questionnaire=MyPAIN-questionnaire&patient=1234&status=in-progress

PainManager

Summary of PainManager minimum API usage (SHALL support data elements):

PainManager: GET [base]/Patient/1234 GET [base]/Observation?patient=1234&category=http://terminology.hl7.org/CodeSystem/observation-category|survey GET [base]/Observation?patient=1234&category=http://terminology.hl7.org/CodeSystem/observation-category|laboratory GET [base]/Observation?patient=1234&date=ge2019-09-19 GET [base]/Observation?patient=1234&code=http://fhir.org/guides/cqf/cds4cpm/CodeSystem/MyPAIN-questionnaire-codes|mpq-1000 GET [base]/MedicationRequest?patient=1234 GET [base]/MedicationRequest?patient=1234&authoredon=ge2019-09-19 GET [base]/Condition?patient=1234&category=http://terminology.hl7.org/CodeSystem/condition-category|problem-list-item GET [base]/Condition?patient=1234&category=http://terminology.hl7.org/CodeSystem/condition-category|encounter-diagnosis GET [base]/Condition?patient=1234&category=http://terminology.hl7.org/CodeSystem/condition-category|encounter-diagnosis&onset-date=ge2019-09-19

Input Data

Observations

Implementations SHALL support searching for Observation by patient, category, and, optionally, date:

GET [base]/Observation?patient=1234&category=http://terminology.hl7.org/CodeSystem/observation-category|survey

GET [base]/Observation?patient=1234&category=http://terminology.hl7.org/CodeSystem/observation-category|laboratory

GET [base]/Observation?patient=1234&date=ge2019-01-01

Implementations SHALL support searching for Observation by patient and code:

GET [base]/Observation?patient=1234&code=http://fhir.org/guides/cqf/cds4cpm/CodeSystem/MyPAIN-questionnaire-codes|mpq-1000

The PainManager application will then use Observations with the following terminologies:

Recommendation 10

When prescribing opioids for subacute or chronic pain, clinicians should consider the benefits and risks of toxicology testing to assess for prescribed medications as well as other prescribed and nonprescribed controlled substances (recommendation category: B; evidence type: 4).

"Urine drug screen for pain management": 'http://fhir.org/guides/cdc/opioid-cds-r4/ValueSet/non-opioid-drug-urine-screening'
"Urine drug screen for pain management": 'http://fhir.org/guides/cdc/opioid-cds-r4/ValueSet/drug-urine-screening'

Pain Assessments

"Pain severity Wong-Baker FACES Scale": '38221-8' from http://loinc.org
"Mean score [PEG]": '91147-9' from http://loinc.org
"Pain Enjoyment General Activity (PEG) Assessment LEGACY": 'PEGASSESSMENT' from http://cds.ahrq.gov/cdsconnect/pms
"Total score [STarT Back]": '91351-7' from http://loinc.org
"STarT Back Screening Tool LEGACY": 'STARTBACK' from http://cds.ahrq.gov/cdsconnect/pms
"MyPAIN Questionnaire Codes": 'http://fhir.org/guides/cqf/cds4cpm/CodeSystem/MyPAIN-questionnaire-codes'

Risk Considerations

"Morphine Milligram Equivalent (MME)": 'MME' from http://cds.ahrq.gov/cdsconnect/pms
"Urine drug screen for pain management": '2.16.840.1.113762.1.4.1032.28'
"Risk assessments relevant to pain management": '2.16.840.1.113762.1.4.1032.55'
"Single question r/t ETOH use": 'SQETOHUSE' from http://cds.ahrq.gov/cdsconnect/pms
"Single question r/t drug use": 'SQDRUGUSE' from http://cds.ahrq.gov/cdsconnect/pms

MedicationRequest

Implementations SHALL support search for MedicationRequest by patient, returning medication requests conformant to the US Core MedicationRequest profile:

GET [base]/MedicationRequest?patient=1234

Implementations SHOULD support search for MedicationRequest by patient, filtered with authoredOn, returning medication requests conformant to the US Core MedicationRequest profile:

GET [base]/MedicationRequest?patient=1234&authoredon=ge2019

For implementations that want to support Morphine Milligram Equivalents (MME) calculation using MedicationRequest resources, the MMEMedicationRequest profile is required.

The PainManager application will then use MedicationRequest information for medications in the following value sets:

Chronic Pain (Recommendations 3, 8, and 10)

Recommendation 3

When starting opioid therapy for acute, subacute, or chronic pain, clinicians should prescribe immediate-release opioids instead of extended-release and long-acting (ER/LA) opioids (recommendation category: A; evidence type: 4).

Recommendation 8

Before starting and periodically during continuation of opioid therapy, clinicians should evaluate risk for opioid-related harms and discuss risk with patients. Clinicians should work with patients to incorporate into the management plan strategies to mitigate risk, including offering naloxone (recommendation category: A; evidence type: 4).

"Opioid analgesics with ambulatory misuse potential": 'http://fhir.org/guides/cdc/opioid-cds/ValueSet/opioid-analgesics-with-ambulatory-misuse-potential'
"Benzodiazepine medications": 'http://fhir.org/guides/cdc/opioid-cds/ValueSet/benzodiazepine-medications'
"Naloxone medications": 'http://fhir.org/guides/cdc/opioid-cds/ValueSet/naloxone-medications'

Recommendation 11

When prescribing opioids for subacute or chronic pain, clinicians should consider the benefits and risks of toxicology testing to assess for prescribed medications as well as other prescribed and nonprescribed controlled substances (recommendation category: B; evidence type: 4).

"Opioid analgesics with ambulatory misuse potential": 'http://fhir.org/guides/cdc/opioid-cds/ValueSet/opioid-analgesics-with-ambulatory-misuse-potential'
"Benzodiazepine medications": 'http://fhir.org/guides/cdc/opioid-cds/ValueSet/benzodiazepine-medications'

Historical Treatments

"Opioid Pain Medications": '2.16.840.1.113762.1.4.1032.34'
"Non opioid pain medications": '2.16.840.1.113762.1.4.1032.26'
"Stool softeners and laxatives": '2.16.840.1.113762.1.4.1032.44'

Risk Considerations

"Benzodiazepine medications": '2.16.840.1.113762.1.4.1032.43'
"Naloxone medications": '2.16.840.1.113762.1.4.1032.42'

Conditions

Clinical intent is to look for conditions that may be risk factors or to provide relevant information about pain management for the patient.

Implementations SHALL support searching for Condition by patient and category, returning conditions conformant to the US Core Condition profile.

Condition search by patient, and category of problem-list-item:

GET [base]/Condition?patient=1234&category=http://terminology.hl7.org/CodeSystem/condition-category|problem-list-item

Condition search by patient, and category of encounter-diagnosis:

GET [base]/Condition?patient=1234&category=http://terminology.hl7.org/CodeSystem/condition-category|encounter-diagnosis

Condition search by patient, category, and onset-date:

GET [base]/Condition?patient=1234&category=http://terminology.hl7.org/CodeSystem/condition-category|encounter-diagnosis&onset-date=ge2019

The PainManager application will then use Conditions with code values in the following value sets:

Opioid Review Useful (Recommendations 3, 8, 10, and 11)

Recommendation 3:

When starting opioid therapy for acute, subacute, or chronic pain, clinicians should prescribe immediate-release opioids instead of extended-release and long-acting (ER/LA) opioids (recommendation category: A; evidence type: 4).

Recommendation 8:

Before starting and periodically during continuation of opioid therapy, clinicians should evaluate risk for opioid-related harms and discuss risk with patients. Clinicians should work with patients to incorporate into the management plan strategies to mitigate risk, including offering naloxone (recommendation category: A; evidence type: 4).

Recommendation 10:

When prescribing opioids for subacute or chronic pain, clinicians should consider the benefits and risks of toxicology testing to assess for prescribed medications as well as other prescribed and nonprescribed controlled substances (recommendation category: B; evidence type: 4).

Recommendation 11:

When prescribing opioids for subacute or chronic pain, clinicians should consider the benefits and risks of toxicology testing to assess for prescribed medications as well as other prescribed and nonprescribed controlled substances (recommendation category: B; evidence type: 4).

"Limited life expectancy conditions": 'http://fhir.org/guides/cdc/opioid-cds/ValueSet/limited-life-expectancy-conditions-enum'
"Conditions likely terminal for opioid prescribing": 'http://fhir.org/guides/cdc/opioid-cds/ValueSet/conditions-likely-terminal-for-opioid-prescribing-enum'

Active Cancer Treatment (Recommendations 3, 8, 10, and 11)

Recommendation 3:

When starting opioid therapy for acute, subacute, or chronic pain, clinicians should prescribe immediate-release opioids instead of extended-release and long-acting (ER/LA) opioids (recommendation category: A; evidence type: 4).

Recommendation 8:

Before starting and periodically during continuation of opioid therapy, clinicians should evaluate risk for opioid-related harms and discuss risk with patients. Clinicians should work with patients to incorporate into the management plan strategies to mitigate risk, including offering naloxone (recommendation category: A; evidence type: 4).

Recommendation 10:

When prescribing opioids for subacute or chronic pain, clinicians should consider the benefits and risks of toxicology testing to assess for prescribed medications as well as other prescribed and nonprescribed controlled substances (recommendation category: B; evidence type: 4).

Recommendation 11:

When prescribing opioids for subacute or chronic pain, clinicians should consider the benefits and risks of toxicology testing to assess for prescribed medications as well as other prescribed and nonprescribed controlled substances (recommendation category: B; evidence type: 4).

"CDC malignant cancer conditions": 'http://fhir.org/guides/cdc/opioid-cds/ValueSet/cdc-malignant-cancer-conditions-enum'

Pertinent Medical History

"Conditions associated with chronic pain": '2.16.840.1.113762.1.4.1032.37'
"Pregnancy": '2.16.840.1.113883.3.526.3.378'
"Pregnancy (New ICD10 codes published in 2018 and 2019)": '2.16.840.1.113762.1.4.1032.80'
"Major Depression": '2.16.840.1.113883.3.464.1003.105.12.1007'
"Depression Diagnosis ICD9": '2.16.840.1.113883.3.600.143'
"Anxiety": '2.16.840.1.113762.1.4.1032.52'
"Anxiety Disorders ICD9": '2.16.840.1.113883.3.1240.2017.3.2.1015'
"Substance use disorder": '2.16.840.1.113883.3.464.1003.106.11.1010'
"Suicide Attempt": '2.16.840.1.113762.1.4.1032.102'
"Sleep-disordered breathing": '2.16.840.1.113762.1.4.1032.53'
"Kidney Failure": '2.16.840.1.113883.3.464.1003.109.12.1028'
"Chronic Liver Disease": '2.16.840.1.113883.3.464.1003.199.12.1035'
"Liver Disease": '2.16.840.1.113762.1.4.1047.42'

Encounters

In addition to condition resources, some systems may support the use of the reasonCode element of an Encounter to indicate the reason for the visit, and these may be exposed using standard condition terminologies.

Implementations MAY support encounter reason codes, using the US Core Encounter profile.

GET [base]/Encounter?patient-1234&status=finished

Active Cancer Treatment (Recommendations 3, 8, 10, and 11)

"Office Visit": 'http://fhir.org/guides/cdc/opioid-cds/ValueSet/office-visit'

Pertinent Medical History

"Conditions associated with chronic pain": '2.16.840.1.113762.1.4.1032.37'
"Pregnancy": '2.16.840.1.113883.3.526.3.378'
"Pregnancy (New ICD10 codes published in 2018 and 2019)": '2.16.840.1.113762.1.4.1032.80'
"Major Depression": '2.16.840.1.113883.3.464.1003.105.12.1007'
"Depression Diagnosis ICD9": '2.16.840.1.113883.3.600.143'
"Anxiety": '2.16.840.1.113762.1.4.1032.52'
"Anxiety Disorders ICD9": '2.16.840.1.113883.3.1240.2017.3.2.1015'
"Substance use disorder": '2.16.840.1.113883.3.464.1003.106.11.1010'
"Suicide Attempt": '2.16.840.1.113762.1.4.1032.102'
"Sleep-disordered breathing": '2.16.840.1.113762.1.4.1032.53'
"Kidney Failure": '2.16.840.1.113883.3.464.1003.109.12.1028'
"Chronic Liver Disease": '2.16.840.1.113883.3.464.1003.199.12.1035'
"Liver Disease": '2.16.840.1.113762.1.4.1047.42'

NOTE: The PainManager application does not use this approach, so it does not require this capability to be supported at this time. We retain the documentation here for completeness.

Procedure

Implementations SHOULD support searching for Procedures by Patient and code, returning Procedures conformant to the US Core Procedure profile:

GET [base]/Procedure?patient=123&code=http://snomed.info/sct|35637008

Recommendation 3:

When starting opioid therapy for acute, subacute, or chronic pain, clinicians should prescribe immediate-release opioids instead of extended-release and long-acting (ER/LA) opioids (recommendation category: A; evidence type: 4).

"Opioid counseling procedure": 'http://fhir.org/guides/cdc/opioid-cds/ValueSet/opioid-counseling-procedure'

ServiceRequest

Implementations MAY support searching for ServiceRequests by Patient and code:

GET [base]ServiceRequest?patient=123&code=http://snomed.info/sct|35637008

NOTE: There is no US Core profile for the ServiceRequest resource at this time.

Opioid Review Useful (Recommendations 3, 8, 10, and 11)

"Therapies indicating end of life care": 'http://fhir.org/guides/cdc/opioid-cds/ValueSet/therapies-indicating-end-of-life-care-enum'

Recommendation 3:

When starting opioid therapy for acute, subacute, or chronic pain, clinicians should prescribe immediate-release opioids instead of extended-release and long-acting (ER/LA) opioids (recommendation category: A; evidence type: 4).

"Opioid counseling procedure": 'http://fhir.org/guides/cdc/opioid-cds/ValueSet/opioid-counseling-procedure'

Historical Treatments

"Non pharmacologic treatments for chronic pain": '2.16.840.1.113762.1.4.1032.36'

PractitionerRole

Implementations SHOULD support read of PractitionerRole.

GET [base]/PractitionerRole/123

The Pain Manager application will use the following terminologies for PractitionerRole:

"Oncology specialty designations (NUCC)": 'http://fhir.org/guides/cdc/opioid-cds/ValueSet/oncology-specialty-designations-enum'