2016 CDC Guideline Recommendation #10 Order Sign Variation - Urine Drug Testing - Opioid Prescribing Support Implementation Guide v2016.4.0

Opioid Prescribing Support Implementation Guide
2016.4.0 - CI Build

Opioid Prescribing Support Implementation Guide, published by Centers for Disease Control and Prevention (CDC). This guide is not an authorized publication; it is the continuous build for version 2016.4.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/cqframework/opioid-cds-r4/ and changes regularly. See the Directory of published versions

2016 CDC Guideline Recommendation #10 Order Sign Variation - Urine Drug Testing

Recommendation #10:

When prescribing opioids for chronic pain, providers should use urine drug testing before starting opioid therapy and consider urine drug testing at least annually to assess for prescribed medications as well as other controlled prescription drugs and illicit drugs (recommendation category: B, evidence type: 4).

Note that this recommendation is represented in multiple variations where each variation corresponds to the CDS Hook by which it was meant to be triggered/evaluated. Use the tabs below to navigate to each variation.

Contents

Functional Description
For Chronic Pain
Opioid Review Useful
Content
Example Data/Requests

Functional Description

When

Provider is prescribing an opioid analgesic with ambulatory misuse potential in the outpatient setting:
Prescription is for treating chronic pain.
Opioid review is useful for this patient:

Patient is 18 or over
Patient does not have findings indicating limited life expectancy
Patient does not have orders for therapies indicating end of life care
Patient is not undergoing active cancer treatment:

Patient has had at least 2 office visits within the past 12 months with an oncology specialist present, or
Patient has had at least 2 office visits within the past 12 months with a CDC malignant cancer condition diagnosis

Urine drug screening has not been performed in last 12 months

Then

Recommend urine drug screening:

Will perform urine screening
Not for chronic pain management, snooze 3 months
N/A - see comment; snooze 3 months

The following table describes the flowchart decisions and sub-routines for the recommendation
Definition	Answer to Proceed	Details	Data (Terminology) Requirement
Opioid order for chronic pain?	Yes	See For Chronic Pain sub-routine
Opioid review useful?	Yes	See Opioid Review Useful sub-routine
Non-opioid drug urine screen test not performed within the last 12 months	Yes	No urine screening test performed within the last 12 months	Non-opioid drug urine screen
Opioid drug urine screen test not performed within the last 12 months?	Yes	No opioid drug urine screening test performed within the last 12 months	Opioid drug urine screen
Urine drug screen results contain cocaine or PCP?	Yes	Urine drug screen contains cocaine or PCP for 1 recommendation: Urine drug screen contains no cocaine or PCP for 2nd recommendation	Cocaine or PCP result in urine drug screen

Effective Data Requirements

For Chronic Pain

Definition	Answer to Proceed	Details	Data (Terminology) Requirement
Order for opioid analgesic with expected supply duration ≥ 28 days	Yes	Order for opioid analgesics with ambulatory misuse potential with a supply duration of ≥ 28 days	Opioid analgesics with ambulatory misuse potential

Opioid Review Useful

Definition	Answer to Proceed	Details	Data (Terminology) Requirement
Age < 18 years?	No	Calculate age from date of birth; exclude patients with age less than 18 years at the time of the prescription	Date of birth
Limited life expectancy conditions present?	No	Look for documented findings consistent with those listed in the limited life expectancy value set (terminal illness, bad prognosis, pre-terminal)	Limited life expectancy conditions
Order for therapies indicating end of life care in past 90 days?	No	Look for patients with an existing order for therapies indicating end of life care written within past 90 days	Therapies indicating end of life care
Active cancer treatment?	No	See Active Cancer Treatment sub-routine	See Active Cancer Treatment sub-routine
Conditions Likely Terminal for opioid prescribing present?	No	Look for patients with active conditions in the value set end-of-life-conditions	Conditions likely terminal for opioid prescribing

Definition	Answer to Proceed	Details	Data (Terminology) Requirement
Two office visits within the past 12 months?	No	Look for a minimum of two distinct 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 Visit
Office visits with an oncology specialist present?	No	• The encounter is performed by an oncologist as defined in the oncology specialty designations using the National Uniform Claim Committee (NUCC) classifications	Oncology specialty designations (NUCC)
Office visits including CDC malignant cancer condition?	No	• The encounter diagnosis (primary or secondary or co-morbidity diagnosis) is listed in the CDC Malignant Cancer Conditions value set	CDC malignant cancer conditions

Content

The following artifacts formalize the description of the logic and behavior defined by this recommendation.

Sign

Resource	Type	Description
2016 CDC Guideline Recommendation #10 Order Sign	PlanDefinition	Event-Condition-Action rule that implements behavior for 2016 CDC Guideline Recommendation #10 Order Sign
Recommendation #10 Order Sign - urine drug testing when prescribing opioids for chronic pain	Library	Defines the data requirements to support evaluation of recommendation #10 Order Sign
Opioid Terminology Management Knowledge-base Data (OMTK) Library	Library	CQL Library that provides logic for implementation of opioid management functionality including Milligram Morphine Equivalents (MME).
Opioid Terminology Management Knowledge-base (OMTK) Library	Library	CQL Library that provides logic for implementation of opioid management functionality including Milligram Morphine Equivalents (MME).
Common Opioid Decision Support Logic	Library	CQL Library that provides common logic for the recommendations
Common OpioidCDS Configuration Logic	Library	CQL Library that provides common configuration logic for the recommendations
Common OpioidCDS Routines Logic	Library	CQL Library that provides common routines logic for the recommendations
FHIRHelpers Conversion Logic	Library	CQL Library that defines functions to convert between FHIR data types and CQL system-defined types, as well as functions to support FHIRPath implementation

Example Data/Requests - order-sign hook

Description	CDS Hooks Request	Expected Response
Patient 18 or older. Patient is being prescribed 72 HR Fentanyl 0.075 MG/HR Transdermal System (RxNorm code 197696), once every 12 days for 30 days. This triggers the message that urine drug screening is recommended with the following three feedback options: i. Perform the screening ii. Indicate that the prescription is not for chronic pain management and snooze for 3 months iii. Indicate that it is not applicable, log a comment and snooze for 3 months.	Request JSON	Response JSON
Patient 18 or older. Patient is being prescribed 72 HR Fentanyl 0.075 MG/HR Transdermal System (RxNorm code 197696) and a urine screening with the prescence of Phencyclidine is present. This triggers the message "Positive Cocaine or PCP in Urine Screening" with a note explaining this may be a false positive or indicate recreational or addictive use.	Request JSON	Response JSON

Description

CDS Hooks Request

Expected Response

Patient 18 or older. Patient is being prescribed 72 HR Fentanyl 0.075 MG/HR Transdermal System (RxNorm code 197696), once every 12 days for 30 days. This triggers the message that urine drug screening is recommended with the following three feedback options:
i. Perform the screening
ii. Indicate that the prescription is not for chronic pain management and snooze for 3 months
iii. Indicate that it is not applicable, log a comment and snooze for 3 months.

Request JSON

Response JSON

Patient 18 or older. Patient is being prescribed 72 HR Fentanyl 0.075 MG/HR Transdermal System (RxNorm code 197696) and a urine screening with the prescence of Phencyclidine is present. This triggers the message "Positive Cocaine or PCP in Urine Screening" with a note explaining this may be a false positive or indicate recreational or addictive use.

Request JSON

Response JSON