Subject Not Required In Context Rx

[jeffeastman]

It doesn't appear to be required. Is this ok? It certainly makes it simpler to write tests if its not needed. I'll check if its required in prefetch next and add a comment.

Sending 'POST' request to URL: http://54.165.182.195:8080/cqf-ruler/cds-services/cdc-opioid-guidance
{
  "hook": "medication-prescribe",
  "hookInstance": "5bacb720-f493-4fe7-8750-c02595cbb72b",
  "fhirServer": "http://localhost:8080/cqf-ruler/baseDstu3",
  "user": "Practitioner-2516",
  "patient": "Patient-1121",
  "context": [
{
  "resourceType": "MedicationRequest",
  "status": "active",
  "medicationCodeableConcept": {
    "coding": [
      {
        "system": "http://www.nlm.nih.gov/research/umls/rxnorm",
        "code": "197696",
        "display": "fentaNYL 75 MCG/HR 3 Day Transdermal Patch"
      }
    ]
  },
  "authoredOn": "2017-01-01T00:00:00-05:00",
  "reasonCode": [
    {
      "coding": [
        {
          "system": "http://snomed.info/sct",
          "code": "82423001",
          "display": "Chronic pain"
        }
      ],
      "text": "Chronic pain"
    }
  ],
  "dosageInstruction": [
    {
      "text": "Apply once every three days for pain.",
      "timing": {
        "repeat": {
          "count": 1,
          "durationUnit": "d",
          "frequency": 1,
          "frequencyMax": 1,
          "period": 3
        }
      },
      "asNeededBoolean": false,
      "doseQuantity": {
        "value": 1,
        "unit": "tbl",
        "system": "http://unitsofmeasure.org",
        "code": "tbl"
      }
    }
  ],
  "dispenseRequest": {
    "quantity": {
      "value": 30,
      "unit": "day",
      "system": "http://unitsofmeasure.org",
      "code": "d"
    }
  }
}]
}

Response = 200
{
  "cards": [
    {},
    {
      "summary": "High risk for opioid overdose.",
      "detail": "Total morphine milligram equivalent (MME) exceeds recommended amount. Taper to less than 50."
    }
  ]
}

[jeffeastman]

Evidently not required in the prefetch either:

Sending 'POST' request to URL: http://54.165.182.195:8080/cqf-ruler/cds-services/cdc-opioid-guidance
{
  "hook": "medication-prescribe",
  "hookInstance": "5bacb720-f493-4fe7-8750-c02595cbb72b",
  "fhirServer": "http://localhost:8080/cqf-ruler/baseDstu3",
  "user": "Practitioner-2516",
  "patient": "Patient-1121",
  "context": [
{
  "resourceType": "MedicationRequest",
  "status": "active",
  "medicationCodeableConcept": {
    "coding": [
      {
        "system": "http://www.nlm.nih.gov/research/umls/rxnorm",
        "code": "197696",
        "display": "fentaNYL 75 MCG/HR 3 Day Transdermal Patch"
      }
    ]
  },
  "authoredOn": "2017-01-01T00:00:00-05:00",
  "reasonCode": [
    {
      "coding": [
        {
          "system": "http://snomed.info/sct",
          "code": "82423001",
          "display": "Chronic pain"
        }
      ],
      "text": "Chronic pain"
    }
  ],
  "dosageInstruction": [
    {
      "text": "Apply once every three days for pain.",
      "timing": {
        "repeat": {
          "count": 1,
          "durationUnit": "d",
          "frequency": 1,
          "frequencyMax": 1,
          "period": 3
        }
      },
      "asNeededBoolean": false,
      "doseQuantity": {
        "value": 1,
        "unit": "tbl",
        "system": "http://unitsofmeasure.org",
        "code": "tbl"
      }
    }
  ],
  "dispenseRequest": {
    "quantity": {
      "value": 30,
      "unit": "day",
      "system": "http://unitsofmeasure.org",
      "code": "d"
    }
  }
}],
  "prefetch": {
    "medication": {
      "resource": 
{
  "resourceType": "Bundle",
  "entry": [
    {
      "resource": {
        "resourceType": "MedicationRequest",
        "status": "active",
        "medicationCodeableConcept": {
          "coding": [
            {
              "system": "http://www.nlm.nih.gov/research/umls/rxnorm",
              "code": "197696",
              "display": "fentaNYL 75 MCG/HR 3 Day Transdermal Patch"
            }
          ]
        },
        "authoredOn": "2017-01-01T00:00:00-05:00",
        "reasonCode": [
          {
            "coding": [
              {
                "system": "http://snomed.info/sct",
                "code": "82423001",
                "display": "Chronic pain"
              }
            ],
            "text": "Chronic pain"
          }
        ],
        "dosageInstruction": [
          {
            "text": "Apply once every three days for pain.",
            "timing": {
              "repeat": {
                "count": 1,
                "durationUnit": "d",
                "frequency": 1,
                "frequencyMax": 1,
                "period": 3
              }
            },
            "asNeededBoolean": false,
            "doseQuantity": {
              "value": 1,
              "unit": "tbl",
              "system": "http://unitsofmeasure.org",
              "code": "tbl"
            }
          }
        ],
        "dispenseRequest": {
          "quantity": {
            "value": 30,
            "unit": "day",
            "system": "http://unitsofmeasure.org",
            "code": "d"
          }
        }
      }
    }
  ]
}
}
}

}

Response = 200
{
  "cards": [
    {},
    {
      "summary": "High risk for opioid overdose.",
      "detail": "Total morphine milligram equivalent (MME) exceeds recommended amount. Taper to less than 50."
    }
  ]
}

[c-schuler]

I don't believe this is an issue, especially for prefetch. Normally the prefetch is populated using the query string specified in the discovery response (see this example), which would require the subject to be specified for the specified resources.
I could add a check to validate the subject for the context resource, but I am not sure how valuable that would be.

[jeffeastman]

If the prefetch is empty then the patient in the hook request needs to be a valid PatientId, otherwise you have no way to search for other Rxs. Or, it might instead be required in the context Rx (it isn't currently).

[jeffeastman]

If the workflow is to first query all the Rx of the patient that are active (how is this computed? from the authoredOn date? This does not seem to be happening), then putting the active Rxs into the prefetch, it would seem the subject should be set in all of them.

But checking? Not helpful for testing but I can do it if necessary.

[c-schuler]

Well, subject is required by the MedicationRequest resource... I could add validation, but I am still unsure how valuable it would be.
Active medications are determined using the status property - see the query string for prefetch I referenced above.

[jeffeastman]

I wouldn't suggest validating the subject in any of the Rxs since they're not well formed without it and they would appear in the usual workflow (above). But if the prefetch is empty, where do you get the Patient.id from in the prefetch query?

Is this coming from the hook.patient field? I can't find it in the code.

[c-schuler]

Yes, it is coming from the request. Here is the code where the query string is built for medication-prescribe prefetch.

[jeffeastman]

I'm happy with the current implementation. Closing this issue now that my understanding is improved. Thanks