Encender

Encender is a software library written in the JavaScript programming language that implements the $apply operation from the Fast Healthcare Interoperability Resources (FHIR) standard. The $apply operation is defined for both PlanDefinition and ActivityDefinition resources, which are used to describe actions or groups of actions that are general in nature and not specific to any one patient. The name “Encender,” which is also the Spanish word for “to light or turn on,” was chosen for this library because the $apply operation takes the patient-agnostic PlanDefinition and ActivityDefinition resources and customizes them in the context of a specific patient's electronic health record. In other words, Encender "applies" FHIR PlanDefinition and ActivityDefinitions resources to a specific patient.

The $apply operation is central to how clinical decision support (CDS) can be implemented according to the guidance from the FHIR Clinical Reasoning Module (CRM) as well as the FHIR Clinical Guidelines Implementation Guide. Interoperable CDS with FHIR involves representing the possible CDS actions using a combination of PlanDefinition, ActivityDefinition, and other FHIR resources. Logical expressions are defined which are used to determine which CDS actions apply for a particular patient as well as to customize the actions for said patient. With Encender it is assumed the CDS logic is represented using the Clinical Quality Language (CQL). The figure below depicts the $apply operation that Encender implements.

Installation

Encender has been written for the NodeJs JavaScript runtime. It can be installed in an existing project using the npm package manager for NodeJs:

npm install encender

Key Dependencies

• CQL Worker - Used to asynchronously evaluate CQL expressions.
• CQL Execution Engine - A dependency of CQL Worker.
• CQL Execution FHIR Data Source - A dependency of CQL Worker.

Usage

Once it has been added as a dependency, it can be invoked as follows:

import { applyPlan } from 'encender';

// 1. Define planDefinitionObject to hold the JSON representation of the PlanDefinition 
//    resource to be applied.

// 2. Define patientReferenceString for the reference to the Patient resource for 
//    patient to which the PlanDefinition is being applied.

// 3. Define resolver(), a function that takes a FHIR reference and returns matching 
//    FHIR resources.
//    Encender provides simpleResolver(), a function that takes an array of FHIR 
//    resources and returns a resolver() function which can be used with applyPlan().

// 4. Define optional parameters and services and put them in an object called aux.

// **Encender is asynchronous.**
// Calling applyPlan() returns a CarePlan, a RequestGroup, and other FHIR resources.
const [CarePlan, RequestGroup, ...otherResources] = 
  await applyPlan(planDefinitionObject, patientReferenceString, resolver, aux);

CQL

Encender is able to execute CQL expressions referenced in PlanDefinition dynamicValue and condition elements. No type checking is done to make sure that the value returned from the CQL expression matches what is expected by the element being targeted by a dynamicValue. When specifying the path element of a dynamic value, users can include a .ofType(string) at the end of the path and Encender will attempt to stringify the CQL output. This can useful in cases where a CQL expression is generating a list or tuple and this must be serialized for an element with a string type.

Tests and Coverage

The test folder contains several examples for how to run Encender. Tests can be run at the command line by invoking npm run test after running npm install. Code test coverage can be calculated by running npm run coverage.

Examples

In addition to the examples in the test folder, here is a list of examples of using Encender in other projects:

• Cervical Cancer Screening and Management (CCSM) Clinical Decision Support (CDS) with Tests

Known Limitations and Caveats

The following aspects of the $apply operation have not been implemented yet:

• [ ] Support for Goal resources
• [ ] Support for all PlanDefinition.action elements, including timing and start and stop conditions
• [ ] Support for actions that reference Questionnaire resources
• [ ] Support for all ActivityDefinition elements, including participant, location, and transform.

License

(C) 2021 The MITRE Corporation. All Rights Reserved. Approved for Public Release: 21-1556. Distribution Unlimited.

Unless otherwise noted, the CCSM CDS is available under an Apache 2.0 license. It was produced by the MITRE Corporation for the Division of Cancer Prevention and Control, Centers for Disease Control and Prevention in accordance with the Statement of Work, contract number 75FCMC18D0047, task order number 75D30120F09743.