value: cdc-opioid-guidance

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

code: eca-rule

display: ECA Rule

define "Get Summary":
  if "Is Recommendation Applicable?"
    then 'Regularly Evaluate the Benefits and Risks of Opioid Therapy'
  else null

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

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

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 "Risk Assessment Interval":
  Interval[Today() - 91 days, Today() - 1 day]

define "Opioid Risk Assessment in Past 90 Days":
  [Procedure: Common."Opioid misuse assessment procedure"] riskAssessment
    where start of (riskAssessment.performed as FHIR.Period) in day of "Risk Assessment Interval"

define "Previous 10 Days Interval":
  Interval[Today() - 10 days, Today()]

define "Encounter Interval":
  Interval[Today() - 12 months - 1 days, Today() - 1 day]

define "Prescribed Opioids for 7 of Past 10 Days with an Encounter":
  Common."Days on Opioids during Period"( "Previous 10 Days Interval" ) >= 7
    and exists (
      [Encounter: Common."Office Visit"] AmbulatoryEncounter
        where AmbulatoryEncounter.period during "Encounter Interval"
    )

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 "Inclusion Criteria":
  "Patient Is Being Prescribed Opioid Analgesic with Ambulatory Misuse Potential"
    and Routines."Is Opioid Review Useful?"
    and not exists ( "Opioid Risk Assessment in Past 90 Days" )
    and (
      "Prescribed Opioids for 7 of Past 10 Days with an Encounter"
        or Common."Prescribed Opioids for 21 or more of 30 Days for each of the past 3 Months"
    )

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
      'Recommend that clinicians evaluate benefits and risks with patients within 1-4 weeks of starting opioid therapy for subacute or chronic pain or of dosage escalation. Clinicians should also regularly reevaluate the benefits and risks of continued opioid therapy with patients.

[Consult Recommendation 7 of the 2022 CDC Clinical Practice Guideline for additional guidance](https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm#Recommendation7)'
  else null

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

Documentation

• 2022 CDC Clinical Practice Guideline for Prescribing Opioids for Pain
• MME Conversion Tables