Cooking with CQL 069 - Colorectal Cancer Concepts
===

背景
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- llustration of FHIR- and CQL-based knowledge artifacts that provide quality measurement and decision support implementations of the US Preventive Services Task Force Recommendation on Colorectal Cancer Screening.
- The artifacts are built using the approach and methodology of the FHIR Clinical Guidelines IG (CPG).
- The U.S. Preventive Services Task Force (2016) recommends screening for colorectal cancer starting at age 50 years and continuing until age 75 years. This is a Grade A recommendation (U.S. Preventive Services Task Force, 2016).

https://github.com/cqframework/cqf-ccc/tree/master

程式架構
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- 計算範例
- CDS(ColorectalCancerScreeningCDS)
- CQM(ColorectalCancerScreeningCQM)
- HEDIS(ColorectalCancerScreeningHEDIS)
- 共用程式庫
- Elements(ColorectalCancerElements)
- Valueset(ColorectalCancerConcepts)

程式邏輯
---
以ColorectalCancerScreeningCQM計算Numerator為例：

匯入ColorectalCancerElements

include ColorectalCancerElements called CCE
define "Numerator":
  CCE."Has Appropriate Colorectal Cancer Screening"

Numerator計算邏輯(ColorectalCancerElements.cql定義可重複使用的Elements)，以下五個條件任一個成立，numerator即設定為True(需要做篩檢)。

graph LR;
;Numerator-->Has_Appropriate_Colorectal_Cancer_Screening;
Has_Appropriate_Colorectal_Cancer_Screening-->Fecal_Occult_Blood_Test_Result_Within_1_Year;
Fecal_Occult_Blood_Test_Result_Within_1_Year-->Fecal_Occult_Blood_Test_Result;
Has_Appropriate_Colorectal_Cancer_Screening-->Fecal_Immunochemical_Test_DNA_Result_Within_3_Years;
Fecal_Immunochemical_Test_DNA_Result_Within_3_Years-->Fecal_Immunochemical_Test_DNA_Result;
Has_Appropriate_Colorectal_Cancer_Screening-->CT_Colonography_Performed_Within_5_Years;
CT_Colonography_Performed_Within_5_Years-->CT_Colonography_Performed;
Has_Appropriate_Colorectal_Cancer_Screening-->Flexible_Sigmoidoscopy_Performed_Within_5_Years;
Flexible_Sigmoidoscopy_Performed_Within_5_Years-->Flexible_Sigmoidoscopy_Performed;
Has_Appropriate_Colorectal_Cancer_Screening-->Colonoscopy_Performed_Within_10_Years;
Colonoscopy_Performed_Within_10_Years-->Colonoscopy_Performed;

ColorectalCancerConcepts.cql定義Colorectal Cancer Concepts計算所需要的valueset

include ColorectalCancerConcepts called Cx

每一個Element的計算邏輯。一般而言，資料來源為某一個FHIR Resource，計算邏輯則是該resource必須符合的條件。

- Fecal Occult Blood Test Result(糞便潛血檢查結果)

define "Fecal Occult Blood Test Result":
  [Observation: Cx."Fecal Occult Blood Test (FOBT)"] FecalOccultResult
		where FecalOccultResult.status in {'final', 'amended', 'corrected', 'preliminary'}
			and FecalOccultResult.value is not null

- Fecal Immunochemical Test DNA Result(糞便免疫化學檢測DNA結果)

define "Fecal Immunochemical Test DNA Result":
  [Observation: Cx."FIT DNA"] FitDNA
		where FitDNA.status in {'final', 'amended', 'corrected', 'preliminary'}
			and FitDNA.value is not null

- CT Colonography Performed(進行CT大腸造影)

define "CT Colonography Performed":
  [Procedure: Cx."CT Colonography"] Colonography
    where Colonography.status = 'completed'

- Flexible Sigmoidoscopy Performed(進行柔性乙狀結腸鏡檢查)

define "Flexible Sigmoidoscopy Performed":
  [Procedure: Cx."Flexible Sigmoidoscopy"] FlexibleSigmoidoscopy
		where FlexibleSigmoidoscopy.status = 'completed'

- Colonoscopy Performed(進行大腸鏡檢查)

define "Colonoscopy Performed":
  [Procedure: Cx."Colonoscopy"] Colonoscopy
		where Colonoscopy.status = 'completed'

測試結果
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案例一：原始資料procedure.code.coding.code=44392(符合valueset中Colonoscopy的定義)，procedure.status='complete'。但執行日期為2011-12-30(不符合Colonoscopy Performed Within 10 Years條件)，故Numerator判定為False。

Patient=Patient(id=denom-EXM130)
Initial Population=true
Denominator=true
Numerator=false
Denominator Exclusion=false

案例一：原始資料procedure.code.coding.code=44388(符合valueset中Colonoscopy的定義)，procedure.status='complete'。但執行日期為2015-01-01(符合Colonoscopy Performed Within 10 Years條件)，故Numerator判定為True。

Patient=Patient(id=numer-EXM130)
Initial Population=true
Denominator=true
Numerator=true
Denominator Exclusion=false

結論
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雖然CQL的訴求是Domian User使用的語言，但最底層(資料整合部分)還是有些差距，比較好的做法是將相關邏輯整理成獨立的Element，讓撰寫CQL的人直接使用。因此，標準化就變得很重要，期待未來應該有越來越多的標準程式庫出現。