value: cdc-opioid-guidance

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

code: eca-rule

display: ECA Rule

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" )

// 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"

// Recommendation 9
define "PDMP Data Not Reviewed in Past 90 Days Criteria Enabled":
  true

define "Look Back 90 Days":
  Interval[Today() - 90 days, Today()]

define "PDMP Data Not Reviewed in Past 90 Days":
  Config."PDMP Data Not Reviewed in Past 90 Days Criteria Enabled"
    and not (
      exists (
        [Procedure: Common."PDMP review procedure"] P
          where P.status ~ 'completed'
            and P.performed during "Look Back 90 Days"
      )
      or exists (
        [Observation: Common."PDMP data reviewed finding"] O
          where O.status in { 'final', 'amended' }
            and (
              if O.effective is FHIR.Period
                then (O.effective as FHIR.Period) during day of "Look Back 90 Days"
                else if O.effective is FHIR.dateTime
                  then date from O.effective in day of "Look Back 90 Days"
                  else false
          )
      )
    )

define "Inclusion Criteria":
  "Patient Is Being Prescribed Opioid Analgesic with Ambulatory Misuse Potential"
    and Routines."CDC 2022 Guideline General Inclusion Criteria"
    and "PDMP Data Not Reviewed in Past 90 Days"

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 Active Cancer Treatment Routine

/*
**  Routine #4
**  For Subacute or Chronic Pain Routine
**
**  Definition                  | Answer to Proceed   | Details                                        | Data (Terminology) Requirement
**  -----------------------------------------------------------------------------------------------------------------------------------
**  Order for opioid analgesic  | Yes                 | Order for opioid analgesics with ambulatory    | Opioid analgesics with
**  with expected supply        |                     | misuse potential with a supply duration of >=  | ambulatory misuse potential
**  duration >= 28 days         |                     | 28 days                                        |
**                              |                     |                                                |
**                              |                     | - Subacute definition = order for opioid       |
**                              |                     |   analgesics with ambulatory misuse            |
**                              |                     |   potential with a supply duration of one to   |
**                              |                     |   two months.                                  |
**                              |                     | - Chronic pain definition = order for opioid   |
**                              |                     |   analgesics with ambulatory misuse            |
**                              |                     |   potential with a supply duration of >= two   |
**                              |                     |   months.                                      |
**  -----------------------------------------------------------------------------------------------------------------------------------
**
*/

define function "Is Subacute or Chronic Pain Prescription?"(prescription FHIR.MedicationRequest):
  "Is Subacute or Chronic Pain Using Expected Supply Duration"(prescription)
    or "Is Subacute or Chronic Pain Using Validity Period"(prescription)

define function "Is Subacute or Chronic Pain Using Expected Supply Duration"(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 "Is Subacute or Chronic Pain Using Validity Period"(prescription FHIR.MedicationRequest):
  (
    prescription.dispenseRequest is not null
      and prescription.dispenseRequest.validityPeriod is not null
      and (
        days between prescription.dispenseRequest.validityPeriod.start and prescription.dispenseRequest.validityPeriod.end >= 28 
      )
  )

define function ToDateTime(value dateTime): value.value

define function ToString(value ProcedureStatus): value.value

define function ToInterval(period FHIR.Period):
    if period is null then
        null
    else
        if period."start" is null then
            Interval(period."start".value, period."end".value]
        else
            Interval[period."start".value, period."end".value]

define function ToString(value ObservationStatus): value.value

define function ToDateTime(value instant): value.value

Documentation

• 2022 CDC Clinical Practice Guideline for Prescribing Opioids for Pain