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Propose order-select hook #428
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29a58cb
Propose order-select hook
isaacvetter 61c97c2
tiny little change
isaacvetter 779a5c3
add proposed order-select hook to menu
isaacvetter b551f7a
fix mispelling of quantity
isaacvetter b7149de
clarify that this hook applies to any type of order
isaacvetter f12274b
rename `orders` to `draftOrders`
isaacvetter 73d0f3a
Merge branch 'master' into propose-order-select-hook
isaacvetter b191045
re-add maturity levels
isaacvetter 86520b6
Merge branch 'master' into propose-order-select-hook
kpshek b4b391a
clarify hook can re-fire
isaacvetter cd11408
Merge branch 'master' into propose-order-select-hook
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| # `order-select` | ||
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| | Metadata | Value | ||
| | ---- | ---- | ||
| | specificationVersion | 1.0 | ||
| | hookVersion | 0.1.0 | ||
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| ## Workflow | ||
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| The `order-select` hook fires when a clinician selects one or more orders to place for a patient, (including orders for medications, procedures, labs and other orders). | ||
| This hook is among the first workflow events for an order entering a draft status. | ||
| The context of this hook may include defaulted order details | ||
| as it occurs immediately upon the clinician selecting the order from the order catalogue of the CPOE, | ||
| but before she manually specifies order details (e.g. dose, quantity, route, etc). | ||
| Additionally, the context may include previously selected orders that are not yet signed from the same ordering session. | ||
| The `order-select` hook occurs after the clinician selects the order, but before she fills out (configures) the order. | ||
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| ## Context | ||
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| The context of this hook distinguishes between the list of unsigned orders from the clinician's ordering session, and one or orders just added to this list. The `selections` field contains a list of ids of these newly selected orders; the `draftOrders` Bundle contains an entry for all unsigned orders from this session, including newly selected orders. | ||
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| Field | Optionality | Prefetch Token | Type | Description | ||
| ----- | -------- | ---- | ---- | ---- | ||
| `userId` | REQUIRED | Yes | *string* | The id of the current user.<br />For this hook, the user is expected to be of type [Practitioner](https://www.hl7.org/fhir/practitioner.html).<br />For example, `Practitioner/123` | ||
| `patientId` | REQUIRED | Yes | *string* | The FHIR `Patient.id` of the current patient in context | ||
| `encounterId` | OPTIONAL | Yes | *string* | The FHIR `Encounter.id` of the current encounter in context | ||
| `selections` | REQUIRED | No| *array* | The FHIR id of the newly selected order(s).<br />The `selections` field references FHIR resources in the `orders` Bundle. For example, `MedicationRequest/103`. | ||
| `draftOrders` | REQUIRED | No | *object* | DSTU2 - FHIR Bundle of MedicationOrder, DiagnosticOrder, DeviceUseRequest, ReferralRequest, ProcedureRequest, NutritionOrder, VisionPrescription with _draft_ status <br/> STU3 - FHIR Bundle of MedicationRequest, ReferralRequest, ProcedureRequest, NutritionOrder, VisionPrescription with _draft_ status | ||
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| ### Examples | ||
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| ### Example (STU3) | ||
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| ```json | ||
| { | ||
| "context":{ | ||
| "userId":"Practitioner/123", | ||
| "patientId":"1288992", | ||
| "encounterId":"89284", | ||
| "selections": [ "NutritionOrder/pureeddiet-simple", "MedicationRequest/smart-MedicationRequest-103" ], | ||
| "draftOrders":{ | ||
| "resourceType":"Bundle", | ||
| "entry":[ | ||
| { | ||
| "resource":{ | ||
| "resourceType":"NutritionOrder", | ||
| "id":"pureeddiet-simple", | ||
| "identifier":[ | ||
| { | ||
| "system":"http://goodhealthhospital.org/nutrition-requests", | ||
| "value":"123" | ||
| } | ||
| ], | ||
| "status":"draft", | ||
| "patient":{ | ||
| "reference":"Patient/1288992" | ||
| }, | ||
| "dateTime":"2014-09-17", | ||
| "orderer":{ | ||
| "reference":"Practitioner/example", | ||
| "display":"Dr Adam Careful" | ||
| }, | ||
| "oralDiet":{ | ||
| "type":[ | ||
| { | ||
| "coding":[ | ||
| { | ||
| "system":"http://snomed.info/sct", | ||
| "code":"226211001", | ||
| "display":"Pureed diet" | ||
| }, | ||
| { | ||
| "system":"http://goodhealthhospital.org/diet-type-codes", | ||
| "code":"1010", | ||
| "display":"Pureed diet" | ||
| } | ||
| ], | ||
| "text":"Pureed diet" | ||
| } | ||
| ], | ||
| "schedule":[ | ||
| { | ||
| "repeat":{ | ||
| "boundsPeriod":{ | ||
| "start":"2015-02-10" | ||
| }, | ||
| "frequency":3, | ||
| "period":1, | ||
| "periodUnit":"d" | ||
| } | ||
| } | ||
| ], | ||
| "texture":[ | ||
| { | ||
| "modifier":{ | ||
| "coding":[ | ||
| { | ||
| "system":"http://snomed.info/sct", | ||
| "code":"228055009", | ||
| "display":"Liquidized food" | ||
| } | ||
| ], | ||
| "text":"Pureed" | ||
| } | ||
| } | ||
| ], | ||
| "fluidConsistencyType":[ | ||
| { | ||
| "coding":[ | ||
| { | ||
| "system":"http://snomed.info/sct", | ||
| "code":"439021000124105", | ||
| "display":"Dietary liquid consistency - nectar thick liquid" | ||
| } | ||
| ], | ||
| "text":"Nectar thick liquids" | ||
| } | ||
| ] | ||
| }, | ||
| "supplement":[ | ||
| { | ||
| "type":{ | ||
| "coding":[ | ||
| { | ||
| "system":"http://snomed.info/sct", | ||
| "code":"442971000124100", | ||
| "display":"Adult high energy formula" | ||
| }, | ||
| { | ||
| "system":"http://goodhealthhospital.org/supplement-type-codes", | ||
| "code":"1040", | ||
| "display":"Adult high energy pudding" | ||
| } | ||
| ], | ||
| "text":"Adult high energy pudding" | ||
| }, | ||
| "productName":"Ensure Pudding 4 oz container", | ||
| "instruction":"Ensure Pudding at breakfast, lunch, supper" | ||
| } | ||
| ] | ||
| } | ||
| }, | ||
| { | ||
| "resource":{ | ||
| "resourceType":"MedicationRequest", | ||
| "id":"smart-MedicationRequest-103", | ||
| "meta":{ | ||
| "lastUpdated":"2018-04-30T13:25:40.845-04:00" | ||
| }, | ||
| "text":{ | ||
| "status":"generated", | ||
| "div":"<div xmlns=\"http://www.w3.org/1999/xhtml\">Amoxicillin 120 MG/ML / clavulanate potassium 8.58 MG/ML Oral Suspension (rxnorm: 617993)</div>" | ||
| }, | ||
| "status":"draft", | ||
| "intent":"order", | ||
| "medicationCodeableConcept":{ | ||
| "coding":[ | ||
| { | ||
| "system":"http://www.nlm.nih.gov/research/umls/rxnorm", | ||
| "code":"617993", | ||
| "display":"Amoxicillin 120 MG/ML / clavulanate potassium 8.58 MG/ML Oral Suspension" | ||
| } | ||
| ], | ||
| "text":"Amoxicillin 120 MG/ML / clavulanate potassium 8.58 MG/ML Oral Suspension" | ||
| }, | ||
| "subject":{ | ||
| "reference":"Patient/1288992" | ||
| }, | ||
| "dosageInstruction":[ | ||
| { | ||
| "text":"5 mL bid x 10 days", | ||
| "timing":{ | ||
| "repeat":{ | ||
| "boundsPeriod":{ | ||
| "start":"2005-01-04" | ||
| }, | ||
| "frequency":2, | ||
| "period":1, | ||
| "periodUnit":"d" | ||
| } | ||
| }, | ||
| "doseQuantity":{ | ||
| "value":5, | ||
| "unit":"mL", | ||
| "system":"http://unitsofmeasure.org", | ||
| "code":"mL" | ||
| } | ||
| } | ||
| ], | ||
| "dispenseRequest":{ | ||
| "numberOfRepeatsAllowed":1, | ||
| "quantity":{ | ||
| "value":1, | ||
| "unit":"mL", | ||
| "system":"http://unitsofmeasure.org", | ||
| "code":"mL" | ||
| }, | ||
| "expectedSupplyDuration":{ | ||
| "value":10, | ||
| "unit":"days", | ||
| "system":"http://unitsofmeasure.org", | ||
| "code":"d" | ||
| } | ||
| } | ||
| } | ||
| } | ||
| ] | ||
| } | ||
| } | ||
| } | ||
| ``` | ||
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| ### Example (DSTU2) | ||
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| ```json | ||
| "context":{ | ||
| "userId":"Practitioner/123", | ||
| "patientId":"1288992", | ||
| "encounterId":"89284", | ||
| "selections":[ "NutritionOrder/nest-patient-1-NUTR1", "MedicationOrder/smart-MedicationOrder-103" ], | ||
| "draftOrders":{ | ||
| "resourceType":"Bundle", | ||
| "entry":[ | ||
| { | ||
| "resource":{ | ||
| "resourceType":"NutritionOrder", | ||
| "id":"nest-patient-1-NUTR1", | ||
| "patient":{ | ||
| "reference":"Patient/1288992" | ||
| }, | ||
| "orderer":{ | ||
| "display":"Dr Adam Careful" | ||
| }, | ||
| "identifier":[ | ||
| { | ||
| "system":"http://goodhealthhospital.org/nutrition-orders", | ||
| "value":"123" | ||
| } | ||
| ], | ||
| "dateTime":"2014-09-17", | ||
| "status":"draft", | ||
| "oralDiet":{ | ||
| "type":[ | ||
| { | ||
| "coding":[ | ||
| { | ||
| "system":"http://snomed.info/sct", | ||
| "code":"435801000124108", | ||
| "display":"Texture modified diet" | ||
| }, | ||
| { | ||
| "system":"http://goodhealthhospital.org/diet-type-codes", | ||
| "code":"1010", | ||
| "display":"Texture modified diet" | ||
| } | ||
| ], | ||
| "text":"Texture modified diet" | ||
| } | ||
| ], | ||
| "schedule":[ | ||
| { | ||
| "repeat":{ | ||
| "boundsPeriod":{ | ||
| "start":"2015-02-10" | ||
| }, | ||
| "frequency":3, | ||
| "period":1, | ||
| "periodUnits":"d" | ||
| } | ||
| } | ||
| ], | ||
| "texture":[ | ||
| { | ||
| "modifier":{ | ||
| "coding":[ | ||
| { | ||
| "system":"http://snomed.info/sct", | ||
| "code":"228049004", | ||
| "display":"Chopped food" | ||
| } | ||
| ], | ||
| "text":"Regular, Chopped Meat" | ||
| }, | ||
| "foodType":{ | ||
| "coding":[ | ||
| { | ||
| "system":"http://snomed.info/sct", | ||
| "code":"22836000", | ||
| "display":"Vegetable" | ||
| } | ||
| ], | ||
| "text":"Regular, Chopped Meat" | ||
| } | ||
| } | ||
| ] | ||
| } | ||
| } | ||
| }, | ||
| { | ||
| "resource":{ | ||
| "resourceType":"MedicationOrder", | ||
| "id":"smart-MedicationOrder-103", | ||
| "status":"draft", | ||
| "patient":{ | ||
| "reference":"Patient/1288992" | ||
| }, | ||
| "medicationCodeableConcept":{ | ||
| "coding":[ | ||
| { | ||
| "system":"http://www.nlm.nih.gov/research/umls/rxnorm", | ||
| "code":"617993", | ||
| "display":"Amoxicillin 120 MG/ML / clavulanate potassium 8.58 MG/ML Oral Suspension" | ||
| } | ||
| ], | ||
| "text":"Amoxicillin 120 MG/ML / clavulanate potassium 8.58 MG/ML Oral Suspension" | ||
| }, | ||
| "dosageInstruction":[ | ||
| { | ||
| "text":"5 mL bid x 10 days", | ||
| "timing":{ | ||
| "repeat":{ | ||
| "boundsPeriod":{ | ||
| "start":"2005-01-04" | ||
| }, | ||
| "frequency":2, | ||
| "period":1, | ||
| "periodUnits":"d" | ||
| } | ||
| }, | ||
| "doseQuantity":{ | ||
| "value":5, | ||
| "unit":"mL", | ||
| "system":"http://unitsofmeasure.org", | ||
| "code":"mL" | ||
| } | ||
| } | ||
| ], | ||
| "dispenseRequest":{ | ||
| "numberOfRepeatsAllowed":1, | ||
| "quantity":{ | ||
| "value":1, | ||
| "unit":"mL", | ||
| "system":"http://unitsofmeasure.org", | ||
| "code":"mL" | ||
| }, | ||
| "expectedSupplyDuration":{ | ||
| "value":10, | ||
| "unit":"days", | ||
| "system":"http://unitsofmeasure.org", | ||
| "code":"d" | ||
| } | ||
| } | ||
| } | ||
| } | ||
| ] | ||
| } | ||
| } | ||
| ``` | ||
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| ## Change Log | ||
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| Version | Description | ||
| ---- | ---- | ||
| 0.1.0 | Initial Release | ||
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This distinction is unclear to me -- is it proposing that clinician-supplied details like dosing would not be passed along with this hook? I'm concerned that we're deprecating a simple model (an in-progress hook that re-fires any time an in-progress order changes) in favor of a complex model (#418) *but we've only introducing support for one step of the complex model.
This strikes me as a net reduction in functionality without simplifying the problem.
it is possible I have misunderstood the intention of this hook, in which case it would be good to clarify here and in the definition.
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Hey @jmandel ,
I think that you definitely understand the intention of this hook. It fires as early as possible in the ordering workflow and will not contain clinician-specified details. It's contrasted with the
order-sign, which fires at the last possible step in the ordering workflow and does contain all details.Neither med-prescribe nor order-review are documented nor, per my impression, understood nor implemented to behave in the way you're describing (frequent re-firing).
The Jan, 30th CDS WG call talked through a potential
order-accepthook which would implement an additional middle step betweenorder-selectandorder-signand represent some intermediate point at which the provider tentatively accepted order details, but before she signed.There was a problem hiding this comment.
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@jmandel / @isaacvetter - What if this hook was invoked both when then order is first selected and then also can be invoked each time the clinician specifies/selects a new detail?
FWIW, Cerner's current CPOE functionality today only triggers CDS when the order is first selected and then upon signing the order. So, exactly as how @isaacvetter has proposed here today. So, we wouldn't be able to support this in-progress hooking today.
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FWIW, the sandbox implements them this way -- which is "code as documentation". (Seriously though, it's been the only way that developers have been able to use/test the functionality, so it's what people expect/believe about how the hook works.)
From my perspective right now, this change is introducing a more complicated system and reducing functionality. I can be led to reason, though! Could you help articulate the value it's introducing?
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@jmandel - What I was trying to ask/propose is what if we documented
order-selectat behaving in the way you describe but keep flexibility if a CPOE system only wanted to invokeorder-selectwhen the user first selects the order. Basically, I'm trying to strike a balance between the reality of some major CPOE systems today and what a re-envisioned (or newer) CPOE system should be capable of doing.There was a problem hiding this comment.
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We're talking in circles :-)
I obviously think the behavior is important even if it has historically been under-specified. I'm trying to prevent the behavior from be being specified out of existence, by instead clarifying our language in a way that affirms the behavior.
In my opinion, very little or none of this advice should ever pop up an alert; that's up to each CDS client to define, of course. In any case, I think we both agree that popping up alerts in the middle of workflow makes for a frustrating UX.
To be clear, @kpshek's proposed language wouldn't require you to re-trigger the hook if you thought it would mean a performance hit within your system. It proposed an option.
Re: applying decision support at order signing, this is in my opinion a very late stage at which to be introducing changes to a dose. Much better to provide feedback early and often (and ambiently, rather than interruptively, if I can use adjectives loosely).
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Yes, it is a proposed option that wouldn't require re triggering every time. But the option was discussed in the HL7 call, and as far as I could tell there were two conclusions
order-detail-select/order-accepthook. If we do that, then @kpshek 's proposed language will conflict with that hook. So if this need is there, a separate hook needs to be written up.order-selectandorder-signhooks can be published and marked as deprecatingmedication-prescribeandorder-reviewwithout this new hook being written up. The writing up of the new hook can be deferred till later, until good thought and use-cases can be factored into it.(Also, pop-up vs, a div that appears in line is not very different with regard to distraction. I meant them all by one appellation of popup).
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PS: Josh, I myself was the person who suggested in the HL7 call that we should allow order-select hook to fire at the time of accepting order edits. I was convinced by others in the call that a spearate hook is the better option. It's in the minutes:
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Based on my own comment in the pull request for
order-sign#429 (comment), I am withdrawing my disagreement with adding the below to the description oforder-selectin the interest of closure.There was a problem hiding this comment.
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Awesome!
@jmandel, when you get a chance, will you please re-review/approve and resolve, if appropriate?
Then I'll merge ... and we'll have our first proposed hook since 2015 or so! 🎉