value: cdc-opioid-guidance

system: http://terminology.hl7.org/CodeSystem/plan-definition-type

code: eca-rule

display: ECA Rule

define "Acute Pain Opioid Analgesic with Ambulatory Misuse Potential Prescriptions":
  ( Common."Is Opioid Analgesic with Ambulatory Misuse Potential?"( ContextPrescriptions ) ) AmbulatoryOpioidPrescription
    where Routines."Is Acute Pain Prescription?"( AmbulatoryOpioidPrescription )

define "Patient Is Being Prescribed Opioid Analgesic with Ambulatory Misuse Potential":
  exists( "Acute Pain Opioid Analgesic with Ambulatory Misuse Potential Prescriptions" )

// CDC 2022 General Inclusion Criteria
define "Age Less than 18 Years Is Enabled":
  true

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

// Sickle Cell
define "Sickle Cell Check Enabled":
  true

define "Sickle Cell Assumed Active":
  true

// 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 "Positive Sickle Cell Condition":
  if Config."Sickle Cell Check Enabled" and not Config."Sickle Cell Assumed Active"
    then (
      "US Core-Categorized Conditions" C
        where C.code in "Sickle Cell Diseases"
          and C.clinicalStatus in "Active Condition"
    ) else if Config."Sickle Cell Check Enabled" and Config."Sickle Cell Assumed Active"
        then (
          "US Core-Categorized Conditions" C
            where C.code in "Sickle Cell Diseases"
        )
      else null

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

// Active Cancer Treatment
define "Active Cancer Treatment Encounters Condition Is Enabled":
  true

// End of Opioid Naive Routine

/*
**  Routine #3
**  Active Cancer Treatment Routine
**
**  Definition                    | Answer to Proceed   | Details                                    | Data (Terminology) Requirement
**  ---------------------------------------------------------------------------------------------------------------------------------
**  Two office visits within the  | No                  | Look for a minimum of two distinct         | Office Visit
**  past 12 months                |                     | encounters within 12 months of the date    |
**                                |                     | of the current visit for which each of the |
**                                |                     | following is true:                         |
**                                |                     |   - the encounter diagnosis (primary or    |
**                                |                     |     secondary or co-morbidity diagnosis)   |
**                                |                     |     is listed in the CDC Malignant Cancer  |
**                                |                     |     Conditions value set                   |
**  ---------------------------------------------------------------------------------------------------------------------------------
**  Office visits with an         | No                  | The encounter is performed by an           | Oncology specialty
**  oncology specialist           |                     | oncologist as defined in the oncology      | designations (NUCC)
**  present                       |                     | specialty designations using the           |
**                                |                     | National Uniform Claim Committee           |
**                                |                     | (NUCC) classifications                     |
**  ---------------------------------------------------------------------------------------------------------------------------------
**  Office visits including CDC   | No                  | The encounter diagnosis (primary or        | CDC malignant cancer
**  malignant cancer              |                     | secondary or co-morbidity diagnosis)       | conditions
**  condition                     |                     | is listed in the CDC Malignant Cancer      |
**                                |                     | Conditions value set                       |
**  ----------------------------------------------------------------------------------------------------------------------------------
**
*/

define "Encounter Period":
  Interval[Today() - 12 months, Today())

define "USCore Encounter Cancer Diagnoses":
  [Condition: category in "Encounter Diagnosis Condition Category"] CancerDiagnoses
    where CancerDiagnoses.code in "CDC malignant cancer conditions"

// encounter-diagnosis, problem-list and health-concern Conditions
// define "US Core-Categorized Cancer Diagnoses":
//   Common."US Core-Categorized Conditions" C
//     where C.code in Common."CDC malignant cancer conditions"

// define "Encounters with Cancer Diagnosis During Encounter Period":
//   [Encounter] Encounter
//     with "US Core-Categorized Cancer Diagnoses" CancerDiagnosis
//     such that date from Encounter.period."start".value in day of "Encounter Period"
//       and EndsWith(CancerDiagnosis.encounter.reference, Encounter.id)

define "Encounters with Cancer Diagnosis During Encounter Period":
  [Encounter] Encounters
    where date from Encounters.period."start" in day of "Encounter Period"
      and exists (
        Common."USCore Encounter Cancer Diagnoses" CancerDiagnoses
          where EndsWith(CancerDiagnoses.encounter.reference, Encounters.id)
      )

define "Number of Encounters with Cancer Diagnosis During Encounter Period":
  Count ("Encounters with Cancer Diagnosis During Encounter Period")

define "Has Two or More Encounters with Cancer Diagnosis During Encounter Period":
  "Number of Encounters with Cancer Diagnosis During Encounter Period" >= 2

define "USCore Problem List Cancer Diagnoses":
  [Condition: category in "Problem List Condition Category"] CancerDiagnoses
    where CancerDiagnoses.code in "CDC malignant cancer conditions"

define "Has Active Cancer Diagnosis on Problem List":
  exists (
    Common."USCore Problem List Cancer Diagnoses" CancerDiagnoses
      where CancerDiagnoses.category in Common."Problem List Condition Category"
        and exists(
          CancerDiagnoses.clinicalStatus.coding ClinicalStatus
            where ClinicalStatus.code ~ 'active'
        )
  )

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"
      or "Has Active Cancer Diagnosis on Problem List"
  else false

// CDC 2022 General Inclusion Criteria
define "End-Stage Disease Criteria Enabled":
  true

define "Conditions Likely Terminal for Opioid Prescribing":
  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 "CDC 2022 Guideline General Inclusion Criteria":
  not "Patient Age Less Than 18"
    and not "Condition Positive for Sickle Cell"
    and not "Is Active Cancer Treatment?"
    and not "Conditions Likely Terminal for Opioid Prescribing"

// Opioid Naive
define "Opioid Naive Prescription Condition Is Enabled":
  true

// Subroutine 2 - Past Medications
define "Can the implementing EHR support queries for past medications by date range?":
  true

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>{}

// End of CDC 2022 General Inclusion Criteria Routine

/*
**  Routine #2
**  Opioid Naive Routine
**
**  Definition                    | Answer to Proceed   | Details                                           | Data (Terminology) Requirement
**  ----------------------------------------------------------------------------------------------------------------------------------------
**  Opioid analgesics with        | No                  | Look for an existing prescription (order) for     | Opioid analgesics with
**  ambulatory misuse potential   |                     | opioid that is in the value set for opioid with   | ambulatory misuse potential
**  prescription in past 90 days  |                     | ambulatory abuse potential authored               |
**  excluding the previous 24     |                     | within the past 90 days (excluding previous 24    |
**  hours                         |                     | hours)                                            |
**  ----------------------------------------------------------------------------------------------------------------------------------------
**  Opioid analgesics with        | No                  | Look for evidence of active medication on         | Opioid analgesics with
**  ambulatory misuse potential   |                     | the medication list that is in the value set      | ambulatory misuse potential
**  reported in past 90 days      |                     | for opioid with ambulatory care abuse             |
**  excluding previous 24 hours*  |                     | potential                                         |
**  ----------------------------------------------------------------------------------------------------------------------------------------
**  Opioid analgesics with        | No                  | Look for evidence of a dispensing event for       | Opioid analgesics with
**  ambulatory misuse potential   |                     | medication that is in the value set for opioid    | ambulatory misuse potential
**  dispensing event in past 90   |                     | with ambulatory use potential occurring           |
**  days excluding previous 24    |                     | within the past 90 days (excluding previous 24    |
**  hours                         |                     | hours)                                            |
**  ----------------------------------------------------------------------------------------------------------------------------------------
**  *Future consideration: Current algorithm addresses only orders (prescriptions).
**
**  Note – orders use RxNorm, but medication lists and dispensed medication will
**  require an NDC value set and/or local mapping of NDC to RxNorm to enable this element
**
*/

define "Prescription/Dispense Inclusion Period":
  Interval[Now() - 90 days, Now() - 24 hours]

define "Opioid RX with Ambulatory Abuse Potential In Past 90 Days":
  Common."Active Ambulatory Opioid Rx" Rx
      where Rx.authoredOn during day of "Prescription/Dispense Inclusion Period"

define "Has Opioid RX with Ambulatory Abuse Potential In Past 90 Days":
    if (Config."Opioid Naive Prescription Condition Is Enabled") then
      exists ("Opioid RX with Ambulatory Abuse Potential In Past 90 Days")
    else false

// NOTE: 2020-02-05: Review direction of MedicationStatement resource (US-Core focusing on MedicationRequest i/o Statement)
// NOTE: 2020-04-21: MedicationStatement a) Shouldn't be use since guidance/direction from USCore is targeting MedicationUse in R5, and b) Breaks in the publisher
/* define "Reports of Opioid with Ambulatory Care Abuse Potential Reported in Past 90 Days":
    [MedicationStatement: Common."Opioid analgesics with ambulatory misuse potential"] Statement
        where Statement.status in {'active', 'completed'}
            and Statement.effective during day of "Report Inclusion Period" */

/* define "Has Report of Opioid with Ambulatory Care Abuse Potential Reported in Past 90 Days":
    Config."Opioid Naive Report Condition Is Enabled"
        and exists ("Reports of Opioid with Ambulatory Care Abuse Potential Reported in Past 90 Days") */

define "Opioid Dispense with Ambulatory Abuse Potential In Past 90 Days":
    [MedicationDispense: Common."Opioid analgesics with ambulatory misuse potential"] OpioidDispense
        where OpioidDispense.whenHandedOver during day of "Prescription/Dispense Inclusion Period"
            and OpioidDispense.status = 'completed'

define "Has Opioid Dispense with Ambulatory Abuse Potential In Past 90 Days":
  if (Config."Opioid Naive Prescription Condition Is Enabled") then
    exists ("Opioid Dispense with Ambulatory Abuse Potential In Past 90 Days")
  else false

// NOTE: MedicationStatement-dependent logic comment out due to bug in Publisher not supporting MedicationStatement in AllTypes.
define "Is Opioid Naive?":
    not ("Has Opioid RX with Ambulatory Abuse Potential In Past 90 Days")
    /* and not ("Has Report of Opioid with Ambulatory Care Abuse Potential Reported in Past 90 Days") */
    and not ("Has Opioid Dispense with Ambulatory Abuse Potential In Past 90 Days")

define "Inclusion Criteria":
  "Patient Is Being Prescribed Opioid Analgesic with Ambulatory Misuse Potential"
    and Routines."CDC 2022 Guideline General Inclusion Criteria"
    and Routines."Is Opioid Naive?"

define "Exclusion Criteria":
  false

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

define function "Is Opioid Analgesic with Ambulatory Misuse Potential?"(value List<MedicationRequest>):
  ("Get MedicationRequest Medication as Code"(value)) Rx
    where Rx.medication in "Opioid analgesics with ambulatory misuse potential" 
      and Rx.category in "Community"

define function "Get MedicationRequest Medication as Code"(value List<MedicationRequest>):
  value Rx
    let Med: 
      if Rx.medication is Reference then singleton from (
        [Medication] M
          where M.id = (Last(Split((Rx.medication as FHIR.Reference).reference, '/')))
      ) else null
    return 
      MedicationRequest {
        id: Rx.id,
        status: Rx.status,
        intent: Rx.intent,
        category: Rx.category,
        medication: if Rx.medication is Reference then Med.code else Rx.medication as CodeableConcept,
        subject: Rx.subject,
        authoredOn: Rx.authoredOn,
        recorder: Rx.recorder,
        dosageInstruction: Rx.dosageInstruction,
        dispenseRequest: Rx.dispenseRequest
      }

define function ToString(value string): value.value

define function ToConcept(concept FHIR.CodeableConcept):
    if concept is null then
        null
    else
        System.Concept {
            codes: concept.coding C return ToCode(C),
            display: concept.text.value
        }

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

// End of For Subacute or Chronic Pain Routine

/*
**  Routine #5
**  For Acute Pain Routine
**
**  Definition                  | Answer to Proceed   | Details                                        | Data (Terminology) Requirement
**  -----------------------------------------------------------------------------------------------------------------------------------
**  Order for opioid analgesics | Yes                 | Look for an existing prescription (order) for  | Opioid analgesics with
**  with ambulatory misuse      |                     | opioid analgesics with ambulatory abuse        | ambulatory misuse potential
**  potential of duration < 28  |                     | potential of duration < 28 days                |
**  days                        |                     |                                                |
**  -----------------------------------------------------------------------------------------------------------------------------------
**
*/

// should allow DateTime precision, but not working in the Ruler specifically
define function "Is Acute Pain Prescription?"(prescription FHIR.MedicationRequest):
  prescription.dispenseRequest is not null
    and prescription.dispenseRequest.expectedSupplyDuration is not null
    and Common.GetDurationInDays( prescription.dispenseRequest.expectedSupplyDuration ) < 28 days

define function GetDurationInDays(value FHIR.Duration):
  if value is null then null
  else
    case
      when value.code.value ~ 'a' then System.Quantity{ value: value.value.value * 365.0, unit: 'days' }
      when value.code.value ~ 'mo' then System.Quantity{ value: value.value.value * 30.0, unit: 'days' }
      when value.code.value ~ 'wk' then System.Quantity{ value: value.value.value * 7.0, unit: 'days' }
      when value.code.value ~ 'd' then System.Quantity{ value: value.value.value, unit: 'days' }
      when value.code.value ~ 'h' then System.Quantity{ value: value.value.value / 24.0, unit: 'days' }
      when value.code.value ~ 'min' then System.Quantity{ value: value.value.value / 60.0 / 24.0, unit: 'days' }
      when value.code.value ~ 's' then System.Quantity{ value: value.value.value / 60.0 / 60.0 / 24.0, unit: 'days' }
      when value.code.value ~ 'ms' then System.Quantity{ value: value.value.value / 60.0 / 60.0 / 24.0 / 1000.0, unit: 'days' }
      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 ToDateTime(value dateTime): value.value

define function "Get Active Ambulatory Medication Requests" (value List<MedicationRequest>) returns List<MedicationRequest>:
  value Rx
    where Rx.status.value = 'active'
      and Rx.category in "Community"

define function ToString(value MedicationDispenseStatus): value.value

Documentation

• 2022 CDC Clinical Practice Guideline for Prescribing Opioids for Pain