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K.0 Guideline Appropriate Ordering FHIR Implementation Guide (IG)

The Guideline Appropriate Ordering Profile supplies a mechanism by which EHR and departmental systems can evaluate orders to determine whether these orders conform to guidelines. The profile enables the results of the evaluation to be stored and transmitted, and the receiver of those results to verify that an order was evaluated with regard to appropriateness.

Under a new US law¹, starting in 2017, providers ordering imaging procedures must use physician approved appropriateness guidelines to reduce unnecessary imaging in patients for whom it is not appropriate. In order to be paid for Medicare outpatient care, facilities and physicians who perform certain imaging procedures (either the technical or the clinical component) have to be able to show that decision support was used in the ordering process². The European Society of Cardiology and the European Association of Cardiovascular Imaging have also identified a need for use of appropriateness criteria in cardiovascular imaging³.

K.0.1 Scope

This implementation guide is intended to support the use cases where a Clinical Decision Support is consulted during the processing of an order to ensure that the requested services are appropriate according to clinical guidelines at the time of order entry. It does not address orders proposed by a clinical decision support system because it is presumed that the CDS system has already ensured that any proposed service is clinically appropriate.

The focus of this guide is on ensuring that clinical decision support can be integrated into the ordering process. As far as this guide is concerned, the operation of CDS service itself is a black box. This guide does not specify how guidelines are selected during the evaluation, how the evaluation is performed, or the formats used to express the guidance in guidelines.

However, we are especially looking for feedback to ensure that this implementation guide is compatible withother mechanisms associated with clinical decision support, including CDS on FHIR. In particular, we are interested in comparing these two efforts, and understanding how to best provide CDS integration capabilities to EHR systems.

K.0.2 Conformance

This guide defines the following conformance statements. Systems implementing the actors described below should provide a conformance resource documenting their conformance to this implementation guide.

Actor	Description
Decision Support Service	The Decision Support Service actor implements the $evaluate operation computing whether an order is appropriate according to clinical guidelines.
Order Evaluation Requester	The Order Evaluation Requester actor invokes the $evaluate operation to determine whether an order is appropriate according to clinical guidelines.

K.0.3 Operations

This guide defines the following operations.

Operation	Description
[base]/Order/$evaluate	The evaluate operation examines an order, comparing it against known guidelines for appropriate use and returns the result of that evaluation to the caller.

K.0.4 Resource Profiles

This guide defines the following profiles.

Profile Name	Description
GAO Order	The Order resource references the request being evaluated (for diagnostic tests, medications, procedures, referrals).
GAO Patient	The patient resource is required to provide relevant demographics associated with the patient. Other details may be provided according to local implementation requirements.
GAO Practitioner	Profiles the practioner resource to require an identifer.
GAO Diagnostic Order	Profiles the diagnostic order to ensure that the services ordered can be identified and evaluated for appropriateness
GAO Medication Order	Profiles the medication order to ensure that the services ordered can be identified and evaluated for appropriateness
GAO Referral Request	Profiles the referral to ensure that the services ordered can be identified and evaluated for appropriateness
GAO Procedure Request	Profiles the procedure request to ensure that the services ordered can be identified and evaluated for appropraiteness
GAO Result	The result resource provides the result of the evaluation.
GAO Provenance	The provenance resource is profiled to support expression of the digital signature on a Result or Alternate.
GAO Alternate	The alternate resource provides the results of an evaluation for alternative treatements that may be suggested by the decision support service.
GAO Questionnaire	The Questionnaire resource is used to support an interactive question/answer implementation driven by the client. This interaction may result in a more favorable evaluation of the proposed order.
GAO Questionnaireresponse	A QuestionnaireAnswers resource is used to answer questions that have been asked in order to determine the appropriateness of the order. A requester may pre-emptively provide answers to questions for orders it suspects may be necessary.

K.0.5 Extensions

The following extensions have been defined to support the return of the evaluation result. These extensions are used within the GAO Result and GAO Alternate profiles on the Basic Resource.

Extension	Definition
gao-extension-score	An optional value which can be used to record a score associated with the evaluation process. The interpretation of this value may vary depending upon guidelines and Decision Support Service actors used. It is present to enable quality improvement efforts related to ordering.
gao-extension-period	Indicates the period over which the evaluation is valid.
gao-extension-practitioner	An identifier representing the ordering practitioner.
gao-extension-item	Describes an orderable service being evaluated.
gao-extension-device	Identifies the device performing the evaluation of the order
gao-extension-guideline	References the guidelines or policies under which the evaluation was created
gao-extension-signature	Enables a digital signature of the evaluation resource to be provided.

K.0.6 Value Sets and Terminologies

Name	Definition
Namespace: http://hl7.org/fhir/ValueSet
gao-answer-format	Codes indicating the types of questions allowed in a questionnaire for evaluation of orders against guidelines.
gao-evaluation-result-code	Codes indicating the appropriateness of an order based upon established clinical guidelines.

K.0.7 References

¹ H.R.4302. Protecting Access to Medicare Act of 2014. 03-JAN-15. Available on the web at http://www.gpo.gov/fdsys/pkg/BILLS-113hr4302enr/pdf/BILLS-113hr4302enr.pdf

² Burhmal, R. New Law Mandates Use of Imaging Appropriateness Criteria. RSNA. 01-JUN-14. Available on the web at http://rsna.org/NewsDetail.aspx?id=12360

³ Garbi, M et al. Appropriateness criteria for cardiovascular imaging use in heart failure: report of literature review. European Heart Journal – Cardiovascular Imaging (2015) 16, 147–153. 30-DEC-14. Available on the web at http://www.escardio.org/communities/EACVI/publications/Documents/EHJCI-appropriateness-criteria-garbi.pdf