Generated Narrative: Library OpioidCDSR4Common

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text/cql

library OpioidCDSR4Common version '0.1.0'

using FHIR version '4.0.0'

include FHIRHelpers version '4.0.0' called FHIRHelpers
include OMTKLogic version '0.0.0' called OMTKLogic

codesystem "SNOMED": 'http://snomed.info/sct'
codesystem "Medication Request Category Codes": 'http://terminology.hl7.org/CodeSystem/medicationrequest-category'

valueset "Active Condition": 'http://hl7.org/fhir/uv/cpg/ValueSet/cpg-active-condition-vs'
valueset "Benzodiazepines": 'http://fhir.org/guides/cdc/opioid-cds/ValueSet/benzodiazepines-medications'
// TODO: Fix this name
valueset "End of Life Conditions": 'http://fhir.org/guides/cdc/opioid-cds/ValueSet/end-of-life-conditions'
// Harvested from VSAC - OID: 2.16.840.1.113762.1.4.1108.15
// NOTE: This harvest note is incorrect, none of the following 3 value sets contain any of the codes in the above referenced valueset
// Rob will construct an appropriate hospice value set aligned with current eCQM program usage and we will use that when available
valueset "Hospice Disposition": 'http://fhir.org/guides/cdc/opioid-cds/ValueSet/hospice-disposition'
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 "Illicit Drug Screening": 'http://fhir.org/guides/cdc/opioid-cds/ValueSet/illicit-drug-urine-screening'
// Harvested from VSAC - OID: 2.16.840.1.113883.3.526.3.1259
valueset "Limited Life Expectancy Conditions": 'http://fhir.org/guides/cdc/opioid-cds/ValueSet/limited-life-expectancy-conditions'
valueset "Long Acting Opioids": 'http://fhir.org/guides/cdc/opioid-cds/ValueSet/long-acting-opioids'
valueset "Naloxone": 'http://fhir.org/guides/cdc/opioid-cds/ValueSet/naloxone-medications'
valueset "Risk Assessment": 'http://fhir.org/guides/cdc/opioid-cds/ValueSet/opioid-abuse-assessment'
valueset "Opioid Drug Screening": 'http://fhir.org/guides/cdc/opioid-cds/ValueSet/opioid-urine-screening'
valueset "Ambulatory Abuse Potential Opioids": 'http://fhir.org/guides/cdc/opioid-cds/ValueSet/opioids-abused-in-ambulatory-care'
valueset "Substance Abuse": 'http://fhir.org/guides/cdc/opioid-cds/ValueSet/substance-abuse'

// TODO: Turn this into a valueset
code "Referral to Hospice": '306205009' from "SNOMED"
// TODO: Turn this into a valueset
code "Outpatient": 'outpatient' from "Medication Request Category Codes"

// TODO: Capture process decisions for long-term opioid use
define IsForChronicPain: true

define "Active Ambulatory Opioid Rx":
  [MedicationRequest: "Ambulatory Abuse Potential Opioids"] Rx
    where Rx.status = 'active'
      and ToCodes(Rx.category.coding) contains "Outpatient"

define "Active Ambulatory Benzodiazepine Rx":
  [MedicationRequest: "Benzodiazepines"] Rx
    where Rx.status = 'active'
      and ToCodes(Rx.category.coding) contains "Outpatient"

define "Active Ambulatory Naloxone Rx":
  [MedicationRequest: "Naloxone"] Rx
    where Rx.status = 'active'
      and ToCodes(Rx.category.coding) contains "Outpatient"

define "Ambulatory Opioid Rx":
  [MedicationRequest: "Ambulatory Abuse Potential Opioids"] Rx
      where ToCodes(Rx.category.coding) contains "Outpatient"

define "End of Life Assessment":
  // 1. Conditions indicating end of life or with limited life expectancy
  exists (
    (
      [Condition: "End of Life Conditions"] C
        where C.clinicalStatus in "Active Condition"
    )
    union
    (
      [Condition: code in "Limited Life Expectancy Conditions"] C
        where C.clinicalStatus in "Active Condition"
    )
  )
  // 2. Admitted/referred/discharged to hospice care
  or exists (
    (
      [ServiceRequest: code in "Referral to Hospice"] RR
        where RR.status in { 'active', 'completed' }
    )
    union
    (
      [ServiceRequest: code in "Hospice Procedure Codes"] P
        where P.status in { 'in-progress', 'completed' }
    )
    union
    (
      [ServiceRequest: code in "Hospice Procedure Codes"] E
        where E.status in { 'planned', 'arrived', 'in-progress', 'finished', 'onleave' }
    )
    union
    (
      [Observation: code in "Hospice Finding Codes"] O
        where not (O.status 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 in { 'planned', 'arrived', 'in-progress', 'finished', 'onleave' }
    )
  )

define function Prescriptions(Orders List<MedicationRequest>):
  Orders O
    let
      // NOTE: Assuming medication is specified as a CodeableConcept with a single RxNorm code
      rxNormCode: ToCode(O.medication.coding[0]),
      medicationName: OMTKLogic.GetMedicationName(rxNormCode),
      // NOTE: Assuming a single dosage instruction element
      dosageInstruction: O.dosageInstruction[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 dosageInstruction.doseAndRate[0].dose is FHIR.Range
            then ToString(ToQuantity(dosageInstruction.doseAndRate[0].dose.low))
                          + '-' + ToString(ToQuantity(dosageInstruction.doseAndRate[0].dose.high))
                          + dosageInstruction.doseAndRate[0].dose.high.unit.value
            else ToString(ToQuantity(dosageInstruction.doseAndRate[0].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.value,
      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.value then ' PRN' else ''),
      // TODO: Shouldn't need the ToQuantity here...
      dose: if dosageInstruction.doseAndRate[0].dose is FHIR.Range
            then ToQuantity(dosageInstruction.doseAndRate[0].dose.high)
            else ToQuantity(dosageInstruction.doseAndRate[0].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 ProbableDaysInRange(Orders List<MedicationRequest>, daysPast Integer, numDaysInDaysPast Integer):
  Orders orders
    let
      frequency: orders.dosageInstruction[0].timing.repeat.frequency.value,
      period: orders.dosageInstruction[0].timing.repeat.period.value,
      periodDays: GetPeriodDays(orders.dosageInstruction[0].timing.repeat.periodUnit.value),
      dosesPerDay:
        if (frequency / (period * periodDays)) >= 1.0
        then 1.0
        else frequency / (period * periodDays),
      repeat: orders.dispenseRequest.numberOfRepeatsAllowed.value,
      supplyDuration: GetDurationInDays(orders.dispenseRequest.expectedSupplyDuration),
      validityPeriod: days between orders.dispenseRequest.validityPeriod."start".value and Today(),
      endDifference:
        if orders.dispenseRequest.validityPeriod."end".value < Today()
        then days between orders.dispenseRequest.validityPeriod."end".value and Today()
        else 0
    return
      if (repeat * supplyDuration) < numDaysInDaysPast then false
      else
        (dosesPerDay * ((repeat * supplyDuration) / validityPeriod) * (daysPast - endDifference)) >= numDaysInDaysPast

define function GetPeriodDays(value System.String):
  case
    when value = 'a' then 365.0
    when value = 'mo' then 30.0
    when value = 'h' then 1.0/24.0
    when value = 'min' then 1.0/24.0*60.0
    when value = 's' then 1.0/24.0*60.0*60.0
    when value = 'ms' then 1.0/24.0*60.0*60.0*1000.0
    else 1.0
  end

  define function GetDurationInDays(value FHIR.Duration):
    case
      when StartsWith(value.unit.value, 'a') then value.value.value * 365.0
      when StartsWith(value.unit.value, 'mo') then value.value.value * 30.0
      when StartsWith(value.unit.value, 'wk') then value.value.value * 7.0
      when StartsWith(value.unit.value, 'd') then value.value.value
      when StartsWith(value.unit.value, 'h') then value.value.value / 24.0
      when StartsWith(value.unit.value, 'min') then value.value.value / 60.0 / 24.0
      when StartsWith(value.unit.value, 's') then value.value.value / 60.0 / 60.0 / 24.0
      when StartsWith(value.unit.value, 'ms') then value.value.value / 60.0 / 60.0 / 24.0 / 1000.0
      else Message(1000, true, 'Undefined', 'Error', 'Unsupported duration unit')
    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.coding)).rxNormCode.display

/*
*  Conversion Functions
*/

define function ToCode(coding FHIR.Coding):
  System.Code {
    code: coding.code.value,
    system: coding.system.value,
    version: coding.version.value,
    display: coding.display.value
  }

define function ToCodes(coding List<FHIR.Coding>):
  coding c return ToCode(c)

define function ToRxNormCode(coding List<FHIR.Coding>):
  singleton from (
    coding C where C.system = 'http://www.nlm.nih.gov/research/umls/rxnorm'
  )

define function ToQuantity(quantity FHIR.Quantity):
  System.Quantity { value: quantity.value.value, unit: quantity.unit.value }

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