SAGE Diabetes Guideline

• meta_data:

  Guideline_Metadata ()

  • identifier: SAGE Diabetes guideline
  • title: SAGE ADA Diabetes Guideline
  • version: 1.0
  • category:
    Care of clinical condition
  • developer: Julie Glasgow
• enrollment_criteria: presence of Problem Diabetes mellitus (disorder) [SNOMED CT]
• recommendation set:
  • Primary Care Clinic Visit
  • Diabetes guideline enrollment
  • Population Based Management

Recommendation Set (Activity Graph): Microalbuminuria checking subguideline

This subguideline handles elevated microalbumin levels and makes appropriate recommendations

1. Context: Start node Microalbumin checking SG

• precondition:
  most_recent Urine protein tests for SAGE DM [SAGE LOINC] Observation > 30.0 mg/24h (qualifier value) [SNOMED CT]
• new_session: false

3. Decision: Is their a DX of Microalbuminuria?

• decision_model:

  Alternative_Choice ()

  • alternative:
    Has DX of microalbuminuria, check for ACEI/ARB
  • recommendation_threshhold: 1
  • strict_rule_in:
    presence of Problem Microalbuminuria (finding) [SNOMED CT]

  Alternative_Choice ()

  • alternative:
    No DX of Microalbuminuria recommendations
  • strict_rule_out:
    presence of Problem Microalbuminuria (finding) [SNOMED CT]

5. Action: No DX of Microalbuminuria recommendations

• action_spec:

  Compound_Action ()

  • condition:
    most_recent Urine protein tests for SAGE DM [SAGE LOINC] Observation Prior to most recent microalbumin > 30.0 mg/24h (qualifier value) [SNOMED CT]
  • then

    Notify ( Notify MD new DX of Microalbuminuria )

    • label: Notify MD new DX of Microalbuminuria
    • communication_mode:
      Provider inbox communication protocol
    • addressee:
      Session_Owner
    • parameterized_string:
      This patient has had two consecutive elevations in microalbumin. Microalbuminuria has been added to the problem list.

    Message_Action ( Microalbuminuria with no allergy, recommend ACEI/ARB )

    • condition:
      ( AND
      • absence of MedicationOrder Angiotensin II Antagonist Oral Preparation for Hypertension [SAGE NDF-RT]
      • absence of MedicationOrder ACE Inhibitor Oral Preparation for Hypertension [SAGE NDF-RT]
      • absence of AdverseReaction: 'Allergic drug reaction (disorder) [SNOMED CT]' to 'Angiotensin-converting enzyme inhibitor agent (product) [SNOMED CT]'
      • absence of AdverseReaction: 'Allergic drug reaction (disorder) [SNOMED CT]' to 'Angiotensin II receptor antagonist (product) [SNOMED CT]'
      )
    • communication_mode:
      Patient inbox alert protocol
    • addressee:
      Session_Owner
    • message_content: This patient has an elevated urine albumin level. Please consider therapy with an ACE Inhibitor or ARB.

    Message_Action ( Microalbuminuria with no Rx, but ACEI allergy, rec ARB. )

    • condition:
      ( AND
      • absence of MedicationOrder Angiotensin II Antagonist Oral Preparation for Hypertension [SAGE NDF-RT]
      • presence of AdverseReaction: 'Allergic drug reaction (disorder) [SNOMED CT]' to 'Angiotensin-converting enzyme inhibitor agent (product) [SNOMED CT]'
      • absence of AdverseReaction: 'Allergic drug reaction (disorder) [SNOMED CT]' to 'Angiotensin II receptor antagonist (product) [SNOMED CT]'
      )
    • communication_mode:
      Patient inbox alert protocol
    • addressee:
      Session_Owner
    • message_content: This patient has an elevated urine albumin level. Please consider therapy with an ARB.

    Message_Action ( Microalbuminuria with no Rx, but ARB allergy, rec ACEI. )

    • condition:
      ( AND
      • absence of MedicationOrder ACE Inhibitor Oral Preparation for Hypertension [SAGE NDF-RT]
      • presence of AdverseReaction: 'Allergic drug reaction (disorder) [SNOMED CT]' to 'Angiotensin II receptor antagonist (product) [SNOMED CT]'
      • absence of AdverseReaction: 'Allergic drug reaction (disorder) [SNOMED CT]' to 'Angiotensin-converting enzyme inhibitor agent (product) [SNOMED CT]'
      )
    • communication_mode:
      Patient inbox alert protocol
    • addressee:
      Session_Owner
    • message_content: This patient has an elevated urine albumin level. Please consider therapy with an ACEI.

    Conclude ()

    • assertion:

      Problem ()

      code is subsumed by Microalbuminuria (finding) [SNOMED CT]
  • else

    Notify ( Notify MD of need for F/U microalbuminuria )

    • label: Notify MD of need for F/U microalbuminuria
    • communication_mode:
      Provider inbox communication protocol
    • addressee:
      Session_Owner
    • parameterized_string:
      This patient had an elevated urine microalbumin level and should have a F/U microalbumin assessment with in the next 1-3 months.

7. Action: Has DX of microalbuminuria, check for ACEI/ARB

• action_spec:

  Message_Action ( Microalbuminuria with no allergy, recommend ACEI/ARB )

  • condition:
    ( AND
    • absence of MedicationOrder Angiotensin II Antagonist Oral Preparation for Hypertension [SAGE NDF-RT]
    • absence of MedicationOrder ACE Inhibitor Oral Preparation for Hypertension [SAGE NDF-RT]
    • absence of AdverseReaction: 'Allergic drug reaction (disorder) [SNOMED CT]' to 'Angiotensin-converting enzyme inhibitor agent (product) [SNOMED CT]'
    • absence of AdverseReaction: 'Allergic drug reaction (disorder) [SNOMED CT]' to 'Angiotensin II receptor antagonist (product) [SNOMED CT]'
    )
  • communication_mode:
    Patient inbox alert protocol
  • addressee:
    Session_Owner
  • message_content: This patient has an elevated urine albumin level. Please consider therapy with an ACE Inhibitor or ARB.

  Message_Action ( Microalbuminuria with no Rx, but ACEI allergy, rec ARB. )

  • condition:
    ( AND
    • absence of MedicationOrder Angiotensin II Antagonist Oral Preparation for Hypertension [SAGE NDF-RT]
    • presence of AdverseReaction: 'Allergic drug reaction (disorder) [SNOMED CT]' to 'Angiotensin-converting enzyme inhibitor agent (product) [SNOMED CT]'
    • absence of AdverseReaction: 'Allergic drug reaction (disorder) [SNOMED CT]' to 'Angiotensin II receptor antagonist (product) [SNOMED CT]'
    )
  • communication_mode:
    Patient inbox alert protocol
  • addressee:
    Session_Owner
  • message_content: This patient has an elevated urine albumin level. Please consider therapy with an ARB.

  Message_Action ( Microalbuminuria with no Rx, but ARB allergy, rec ACEI. )

  • condition:
    ( AND
    • absence of MedicationOrder ACE Inhibitor Oral Preparation for Hypertension [SAGE NDF-RT]
    • presence of AdverseReaction: 'Allergic drug reaction (disorder) [SNOMED CT]' to 'Angiotensin II receptor antagonist (product) [SNOMED CT]'
    • absence of AdverseReaction: 'Allergic drug reaction (disorder) [SNOMED CT]' to 'Angiotensin-converting enzyme inhibitor agent (product) [SNOMED CT]'
    )
  • communication_mode:
    Patient inbox alert protocol
  • addressee:
    Session_Owner
  • message_content: This patient has an elevated urine albumin level. Please consider therapy with an ACEI.

Recommendation Set (Activity Graph): Primary Care Clinic Visit

This Recommendation Set encompasses a primary care clinic visit by a diabetic patient.

1. Context: Primary care clinic check-in

• triggering_events:

  Administrative_Event ( Outpatient clinic check-in event )

  • SAGE_event_type:
    Outpatient clinic check-in event
  • label: Outpatient clinic check-in event
  • act:
    Check-In
  • role:
    Outpatient (person) [SNOMED CT]
• precondition:
  presence of Problem Diabetes mellitus (disorder) [SNOMED CT]
• description: This is the Context in which a patient checks in to their primary care clinic.
• new_session: true
• clinical_context:

  Clinical_Context ()

  • clinical_setting:
    Outpatient primary care clinic
  • clinical_role:
    • Nurse
    • Physician

3. Action: Retrieve diabetes lab data items and calculate items due

• description: The SAGE engine determines which labs need to be ordered by the physician.
• subguideline:

  Subguideline ( Check diabetes lab data items subguideline )

  • description: This subguideline checks for Diabetes- related information in the patient record and calculates whether any are due at this time.
  • subrecommendations:
    Check diabetes lab data items
  • execution_type: SYNCHR

5. Action: Retrieve nursing-entered data items and calculate items due

• triggering_events:

  Clinical_Event ( Outpatient nurse accesses patient record )

  • SAGE_event_type:
    Outpatient nurse accesses patient record
  • label: Outpatient nurse accesses patient record
• description: SAGE determines whether nursing- entered information (vitals, height, weight, home glucose measurements) has been recorded yet for this visit.
• action_spec:

  Action_Set ( General (nursing-entered) information for nurse (inbox) )

  • action_spec:

    Message_Action ( Message to enter height )

    • condition:
      absence of Observation standing height (observable entity) [SNOMED CT] today
    • communication_mode:
      Patient inbox alert protocol
    • addressee:
      Outpatient care nurse
    • message_content: Enter height

    Message_Action ( Message to enter weight )

    • condition:
      absence of Observation Body weight only (SAGE DM) [SAGE SNOMED CT] today
    • communication_mode:
      Patient inbox alert protocol
    • addressee:
      Outpatient care nurse
    • message_content: Enter weight

    Message_Action ( Message to enter temperature )

    • condition:
      absence of Observation Body temperature (observable entity) [SNOMED CT] today
    • communication_mode:
      Patient inbox alert protocol
    • addressee:
      Outpatient care nurse
    • message_content: Enter temperature

    Message_Action ( Message to enter heart rate )

    • condition:
      absence of Observation Heart rate (observable entity) [SNOMED CT] today
    • communication_mode:
      Patient inbox alert protocol
    • addressee:
      Outpatient care nurse
    • message_content: Enter heart rate

    Message_Action ( Message to enter bp )

    • condition:
      absence of Observation Blood pressure (observable entity) [SNOMED CT] today
    • communication_mode:
      Patient inbox alert protocol
    • addressee:
      Outpatient care nurse
    • message_content: Enter systolic and diastolic blood pressure

    Message_Action ( Message to enter respiratory rate )

    • condition:
      absence of Observation Self-monitoring of blood glucose (procedure) [SNOMED CT] today
    • communication_mode:
      Patient inbox alert protocol
    • addressee:
      Outpatient care nurse
    • message_content: Enter respirate rate

    Message_Action ( Message to enter home glucose )

    • condition:
      absence of Observation Self-monitoring of blood glucose (procedure) [SNOMED CT] today
    • communication_mode:
      Patient inbox alert protocol
    • addressee:
      Outpatient care nurse
    • message_content: Enter home glucose high and low values

7. Context: Physician accesses the patient record

• triggering_events:

  Clinical_Event ( Physician accesses the EMR )

  • SAGE_event_type:
    Outpatient clinical event
  • description: Physician access the EMR
  • label: Physician accesses the EMR
  • act:
    Access
  • object:
    Patient medical record
• description: The physician seeing the patient in clinic opens the patient record.
• new_session: false
• clinical_context:

  Clinical_Context ()

  • clinical_setting:
    Outpatient primary care clinic
  • clinical_role:
    • Nurse
    • Physician

9. Action: Retrieve physician-entered data items and calculate items due

• description: SAGE checks whether physical exam and history findings have been entered yet for this visit.
• action_spec:

  Action_Set ( Physian-entered information (inbox) )

  • action_spec:

    Compound_Action ()

    • condition:
      presence of ObservationObservation where 'Examination of foot (procedure) [SNOMED CT]' code = 'Done (qualifier value) [SNOMED CT]' During this visit
    • else

      Inquiry ( Prompt physician to perform foot exam )

      • data_entries:
        Foot exam status CEM
      • communication_mode:
        Patient inbox alert protocol
      • addressee:
        Session_Owner

    Compound_Action ()

    • condition:
      presence of Observation Finding of tobacco use and exposure (finding) [SNOMED CT] today
    • else

      Inquiry ( Prompt physician for smoking status )

      • data_entries:
        Smoking status CEM
      • communication_mode:
        Patient inbox alert protocol
      • addressee:
        Session_Owner

11. Context: Nurse accesses diabetes data set

• triggering_events:

  Clinical_Event ( Outpatient clinic nurse accesses diabetes data set )

  • SAGE_event_type:
    Outpatient clinic nurse accesses diabetes data set
  • description: An outpatient clinic nurse accesses this patient's diabetes data set
  • label: Outpatient clinic nurse accesses diabetes data set
• description: There is a set of data that is relevant to diabetes care, and the nurse accesses the functionality that allows him/her to view the entire data set.
• new_session: false

13. Context: Physician accesses diabetes data set

• triggering_events:

  Clinical_Event ( Outpatient Primary Care Doctor accesses diabetes data set )

  • SAGE_event_type:
    Outpatient primary care physician accesses diabetes data set
  • label: Outpatient Primary Care Doctor accesses diabetes data set
• description: There is a set of data that is relevant to diabetes care. Here, the physician accesses the functionality that allows him/her to view the entire data set.
• new_session: false

15. Action: Get diabetes data set for physician

• description: When the physician accesses the diabetes data set, all of its information is obtained from the patient record. This includes vitals, height, weight, history items, foot exam, retinal exam, cardiac signs/sx, home glucose review, and labs.
• action_spec:

  Action_Set ( Physician-entered information for physician (data set) )

  • action_spec:

    Conclusion ()

    • condition:
      absence of ObservationObservation where 'Examination of foot (procedure) [SNOMED CT]' code = 'Done (qualifier value) [SNOMED CT]' During this visit
    • assertion:
      Observation of 'Status of foot exam 'Due' Now

    Conclusion ()

    • condition:
      absence of Observation Finding of tobacco use and exposure (finding) [SNOMED CT] today
    • assertion:
      Observation of 'Smoking status due status 'Due' Now

17. Action: Get diabetes data set for nurse

• description: All diabetes data is obtained for display/prompting when the user is a nurse. Data items comprising the data set are established at localization, and will be displayed by the CIS's data set display utility. Unless data entry is required, the data items need not be explicitly modeled.
• action_spec:

  Action_Set ( General information for nurse (data set) )

  • action_spec:

    Conclusion ()

    • condition:
      absence of Observation Body weight only (SAGE DM) [SAGE SNOMED CT] today
    • assertion:
      Observation of 'Weight due status 'Due' Now

    Conclusion ()

    • condition:
      absence of Observation standing height (observable entity) [SNOMED CT] today
    • assertion:
      Observation of 'Height due status 'Due' Now

    Conclusion ()

    • condition:
      absence of Observation Heart rate (observable entity) [SNOMED CT] today
    • assertion:
      Observation of 'Heart rate due status 'Due' Now

    Conclusion ()

    • condition:
      absence of Observation Blood pressure (observable entity) [SNOMED CT] today
    • assertion:
      Observation of 'Systolic blood pressure due status 'Due' Now

    Conclusion ()

    • condition:
      absence of Observation Blood pressure (observable entity) [SNOMED CT] today
    • assertion:
      Observation of 'Diastolic blood pressure due status 'Due' Now

    Conclusion ()

    • condition:
      absence of Observation Body temperature (observable entity) [SNOMED CT] today
    • assertion:
      Observation of 'Temperature due status 'Due' Now

    Conclusion ()

    • condition:
      absence of Observation Respiratory rate (observable entity) [SNOMED CT] today
    • assertion:
      Observation of 'Respiratory rate due status 'Due' Now

    Conclusion ()

    • condition:
      absence of Observation Self-monitoring of blood glucose (procedure) [SNOMED CT] today
    • assertion:
      Observation of 'Home glucose low due status 'Due' Now

    Conclusion ()

    • condition:
      absence of Observation Self-monitoring of blood glucose (procedure) [SNOMED CT] today
    • assertion:
      Observation of 'Home glucose high due status 'Due' Now

19. Action: Retrieve consult-related information and calculate items due

• description: Check whether consults are indicated, and whether they have been done.
• action_spec:

  Message_Action ( Recommend referral to nephrologist if indicated )

  • condition:
    ( AND
    • ( OR
      • most_recent CREATININE CLEARANCE:VRAT:PT:DIAF:QN:[LOINC] Observation < 60.0 mL/min (qualifier value) [SNOMED CT]
      • most_recent CREATININE:SCNC:PT:SER/PLAS:QN: [LOINC] Observation > 2.0 mg/dL (qualifier value) [SNOMED CT]
      • ( AND
        • number_of Antihypertensive medications (SAGE DM) [SAGE NDF-RT] MedicationOrder Now >= 4
        • ( OR
          • ( NOT
            average Systolic blood pressure (observable entity) [SNOMED CT] Observation within 1.0 Year (qualifier value) [SNOMED CT] before Today (mid-night to midnight) in Most recent Systolic BP goal interval variable
            )
          • ( NOT
            average Diastolic blood pressure (observable entity) [SNOMED CT] Observation within 1.0 Year (qualifier value) [SNOMED CT] before Today (mid-night to midnight) in Most recent diastolic BP goal interval variable
            )
          )
        )
      • most_recent POTASSIUM:MCNC:PT:SER/PLAS:QN:[LOINC] Observation within 3.0 Month (qualifier value) [SNOMED CT] before NOW > 5.7 mg/dL (qualifier value) [SNOMED CT]
      )
    • absence of Referral Nephrologist (occupation) [SNOMED CT] Now
    )
  • communication_mode:
    Patient inbox alert protocol
  • addressee:
    Session_Owner
  • message_content: Consider referral to a nephrologist. (Please see indications.)

  Recommend_VMROrder ()

  • condition:
    absence of VMROrder Referral to ophthalmologist (procedure) [SNOMED CT]
  • order:
    VMR Order where code is subsumed by Referral to ophthalmologist (procedure) [SNOMED CT]
    • effectiveTime:
      Max of ?NOW or 12 months from time of last ophthalmology visit

21. Action: Cardiac risk reduction recommendations

• action_spec:

  Notify ( Suggest ACE-I if increased CV risk and indicated )

  • label: Suggest ACE-I if increased CV risk and indicated
  • condition:
    ( AND
    • Age > 55.0 Year (qualifier value) [SNOMED CT] )
    • absence of MedicationOrder ACE Inhibitor Oral Preparation for Hypertension [SAGE NDF-RT]
    • Absence of Absolute contraindication for ACE Inhibitor
    • ( OR
      • presence of Problem Acute myocardial infarction (disorder) [SNOMED CT]
      • presence of Problem Myocardial infarction (disorder) [SNOMED CT]
      • presence of Problem Hyperlipidemia (disorder) [SNOMED CT] Now
      • presence of Problem Microalbuminuria (finding) [SNOMED CT]
      • presence of Observation Tobacco user (finding) [SNOMED CT]
      )
    • ( NOT

      Comparison_Criterion ( Diastolic BP goal_high )

      average Diastolic blood pressure (observable entity) [SNOMED CT] Observation During this visit >=
      • label: Diastolic BP goal_high
      • language: Gello
      • functional_expression: ?DiastolicBPGoal.high
      )
    • ( NOT

      Comparison_Criterion ( Systolic BP goal_high )

      average Systolic blood pressure (observable entity) [SNOMED CT] Observation During this visit >=
      • label: Systolic BP goal_high
      • language: Gello
      • functional_expression: ?SystolicBPGoal.high
      )
    )
  • communication_mode:
    Provider inbox communication protocol
  • addressee:
    Session_Owner
  • parameterized_string:
    This patient is at increased risk for CV disease, so an ACE Inhibitor should be considered to reduce this risk.

  Notify ( Suggest Beta-blocker if Hx of MI )

  • label: Suggest Beta-blocker if Hx of MI
  • condition:
    ( AND
    • presence of Problem H/O: Myocardial infarction in last year (context-dependent category) [SNOMED CT]
    • absence of MedicationOrder Beta-Blocker Oral Preparation for Hypertension [SAGE NDF-RT]
    • Absence of Absolute contraindication for Beta-Blocker
    • ( NOT

      Comparison_Criterion ( Diastolic BP goal_high )

      average Diastolic blood pressure (observable entity) [SNOMED CT] Observation During this visit >=
      • label: Diastolic BP goal_high
      • language: Gello
      • functional_expression: ?DiastolicBPGoal.high
      )
    • ( NOT

      Comparison_Criterion ( Systolic BP goal_high )

      average Systolic blood pressure (observable entity) [SNOMED CT] Observation During this visit >=
      • label: Systolic BP goal_high
      • language: Gello
      • functional_expression: ?SystolicBPGoal.high
      )
    )
  • communication_mode:
    Provider inbox communication protocol
  • addressee:
    Session_Owner
  • parameterized_string:
    This patient has a history of MI, so a beta-blocker should be considered to reduce mortality risk.

23. Action: Check today's bp and issue appropriate alerts

• description: 1 - determine whether bp was measured today 2 - average with penultimate bp and check against goal values 3 - if high, inform physician perform logic on med/lifestyle recommendations
• subguideline:

  Subguideline ( Subguideline for hypertension checking and management )

  • description: This subguideline checks for and manages hypertension.
  • subrecommendations:
    Hypertension checking and management
  • execution_type: SYNCHR

25. Action: Out-of-goal notifications via inbox

• description: If any clinical parameters are out of goal, issue the appropriate notifications via the inbox.
• action_spec:

  Message_Action ( If HbA1C is out of goal range, notify physician via inbox )

  • condition:
    ( AND
    • ( NOT
      satisfy 'HEMOGLOBIN A1C.All_Clinical [SAGE LOINC]' goal
      )
    • presence of Observation HEMOGLOBIN A1C.All_Clinical [SAGE LOINC]
    )
  • communication_mode:
    Patient inbox alert protocol
  • addressee:
    Session_Owner
  • message_content: ALERT: This patient's HbA1C is above the target goal range.

  Message_Action ( Suggest adding Hyperlipidemia to problem list via inbox )

  • condition:
    ( AND
    • ( OR
      • ( NOT
        satisfy 'LDL Tests for SAGE DM [SAGE LOINC]' goal
        )
      • ( NOT
        satisfy 'Triglyceride tests for SAGE DM [SAGE LOINC]' goal
        )
      • ( NOT
        satisfy 'HDL Tests for SAGE DM [SAGE LOINC]' goal
        )
      )
    • absence of Problem Hyperlipidemia (disorder) [SNOMED CT] Now
    • presence of Observation LDL Tests for SAGE DM [SAGE LOINC]
    )
  • communication_mode:
    Patient inbox alert protocol
  • addressee:
    Session_Owner
  • message_content: Consider adding Hyperlipidemia to Problem List

  Notify ( If LDL out of goal, notify MD )

  • label: If LDL out of goal, notify MD
  • condition:
    ( AND
    • presence of Observation LDL Tests for SAGE DM [SAGE LOINC]
    • ( NOT
      satisfy 'LDL Tests for SAGE DM [SAGE LOINC]' goal
      )
    )
  • communication_mode:
    Provider inbox communication protocol
  • addressee:
    Session_Owner
  • parameterized_string:
    ALERT: This patient's LDL is above the goal target range.

27. Action: Display diabetes data set to nurse

• description: The clinical data set for Diabetes is displayed to the nurse. Items which are due should be highlighted.
• action_spec:

  Display ( Display diabetes clinical data set to Nurse )

  • display_data:

    Clinical_DataSet ( Diabetes clinic visit data set for nurse )

    • label: Diabetes clinic visit data set for nurse
    • clinical_data_elements:

      Clinical_Data_Element ( Weight )

      • label: Weight
      • clinical_expression_model:
        Patient weight CEM
      • chartable: true
      • criticality: Medium

      Clinical_Data_Element ( Cardiovascular signs/symptoms )

      • label: Cardiovascular signs/symptoms
      • clinical_expression_model:
        Cardiovascular disease signs or symptoms CEM
      • chartable: true
      • criticality: High

      Clinical_Data_Element ( Diastolic blood pressure )

      • label: Diastolic blood pressure
      • clinical_expression_model:
        Diastolic blood pressure CEM
      • orderable: false
      • chartable: true
      • criticality: High
      • goal_query:
        select most_recent value from Goal where code is subsumed by Diastolic blood pressure (observable entity) [SNOMED CT]

      Clinical_Data_Element ( Heart rate )

      • label: Heart rate
      • clinical_expression_model:
        Heart rate CEM
      • chartable: true
      • criticality: Low

      Clinical_Data_Element ( Height )

      • label: Height
      • clinical_expression_model:
        Patient height CEM
      • chartable: true
      • criticality: Low

      Clinical_Data_Element ( Home glucose high value )

      • label: Home glucose high value
      • clinical_expression_model:
        Home glucose high value CEM
      • chartable: true
      • criticality: High

      Clinical_Data_Element ( Home glucose low value )

      • label: Home glucose low value
      • clinical_expression_model:
        Home glucose low value CEM
      • chartable: true
      • criticality: High

      Clinical_Data_Element ( Respiratory rate )

      • label: Respiratory rate
      • clinical_expression_model:
        Respiratory rate CEM
      • chartable: true
      • criticality: Low

      Clinical_Data_Element ( Systolic blood pressure )

      • label: Systolic blood pressure
      • clinical_expression_model:
        Systolic blood pressure CEM
      • chartable: true
      • criticality: High
      • goal_query:
        select most_recent value from Goal where code is subsumed by Systolic blood pressure (observable entity) [SNOMED CT]

      Clinical_Data_Element ( Temperature )

      • label: Temperature
      • clinical_expression_model:
        Patient temperature CEM
      • chartable: true
      • criticality: Low
  • addressee:
    Nurse

29. Action: Aspirin therapy

• description: Check whether the patient is older than 21 and has macrovascular disease, or older than 40 and has other cardiovascular risk factors. If so, check for contraindications to aspirin therapy. If no contraindications, recommend aspirin therapy.
• subguideline:

  Subguideline ( Aspirin therapy subguideline )

  • description: Check whether the patient is older than 21 and has macrovascular disease, or older than 40 and has other cardiovascular risk factors. If so, check for contraindications to aspirin therapy. If no contraindications, recommend aspirin therapy.
  • subrecommendations:
    Aspirin Therapy for diabetic patients
  • execution_type: SYNCHR

31. Action: Smoking cessation counseling

• description: If the patient is a smoker or tobacco user, counsel them to quit.
• action_spec:

  Message_Action ( Remind physician to counsel pt to stop tobacco use )

  • condition:
    ( OR
    • presence of ObservationObservation where 'Finding of tobacco use and exposure (finding) [SNOMED CT]' code = 'Smoker (finding) [SNOMED CT]'
    • presence of ObservationObservation where 'Finding of tobacco use and exposure (finding) [SNOMED CT]' code = 'Tobacco user (finding) [SNOMED CT]'
    • presence of Problem Nicotine dependence (disorder) [SNOMED CT]
    )
  • communication_mode:
    Patient inbox alert protocol
  • addressee:
    Session_Owner
  • message_content: Please counsel this patient to end tobacco use.

Recommendation Set (Activity Graph): Check diabetes lab data items

This activity graph checks the patient record for initial data values and calculates what data is needed at this time.

1. Context: Start state for retrieving diabetes lab data

• description: This is the start node for the subguideline that retrieves diabetes lab data.
• new_session: false

3. Action: Check when creatinine due and whether WNL

• description: Creatinine should be within normal limits. It should be measured at the physician's discretion, but the guideline will establish default intervals.
• action_spec:

  Compound_Action ()

  • condition:
    ( AND
    • most_recent CREATININE:SCNC:PT:SER/PLAS:QN: [LOINC] Observation >= 0.6 mg/dL (qualifier value) [SNOMED CT]
    • most_recent CREATININE:SCNC:PT:SER/PLAS:QN: [LOINC] Observation <= 1.5 mg/dL (qualifier value) [SNOMED CT]
    )
  • then

    Order ( Order serum creatinine one year after last measurement )

    • condition:
      absence of VMROrder Creatinine measurement, serum (procedure) [SNOMED CT]
    code is subsumed by Creatinine measurement, serum (procedure) [SNOMED CT]
    • effectiveTime:
      Max of ?NOW or 12 months from time of last serum creatinine test
    • vmr_class:
      VMROrder

    Conclusion ()

    • assertion:
      Observation of 'Timing of next serum creatinine test 'Due' Max of ?NOW or 12 months from time of last serum creatinine test
  • else

    Order ( Order serum creatinine six months after last measurement )

    • condition:
      absence of VMROrder Creatinine measurement, serum (procedure) [SNOMED CT]
    code is subsumed by Creatinine measurement, serum (procedure) [SNOMED CT]
    • effectiveTime:
      Max of ?NOW or 6 months from time of last serum creatinine test
    • vmr_class:
      VMROrder

    Conclusion ()

    • assertion:
      Observation of 'Timing of next serum creatinine test 'Due' Max of ?NOW or 6 months from time of last serum creatinine test

5. Action: Check when HbA1C due and whether out of goal

• description: Obtain HbA1C values from the patient record and determine when another is due. Check whether HbA1C is out of goal (this affects when it is due).
• action_spec:

  Compound_Action ()

  • condition:
    satisfy 'HEMOGLOBIN A1C.All_Clinical [SAGE LOINC]' goal
  • then

    Order ( Order HbA1C 6 months from last measurement )

    • condition:
      absence of VMROrder Hemoglobin A1c measurement (procedure) [SNOMED CT]
    code is subsumed by HbA1c measurement (DCCT aligned) (procedure) [SNOMED CT]
    • effectiveTime:
      Max of ?NOW or 6 months from time of last HbA1C test
    • vmr_class:
      VMROrder

    Conclusion ()

    • assertion:
      Observation of 'Timing of next HbA1C test 'Due' Max of ?NOW or 6 months from time of last HbA1C test
  • else

    Order ( Order HbA1C 3 months from last measurement )

    • condition:
      absence of VMROrder HbA1c measurement (DCCT aligned) (procedure) [SNOMED CT] Max of ?NOW or 3 months from time of last HbA1C test
    code is subsumed by HbA1c measurement (DCCT aligned) (procedure) [SNOMED CT]
    • effectiveTime:
      Max of ?NOW or 3 months from time of last HbA1C test
    • vmr_class:
      VMROrder

    Conclusion ()

    • assertion:
      Observation of 'Timing of next HbA1C test 'Due' Max of ?NOW or 3 months from time of last HbA1C test

7. Action: Check when microalbumin due and whether out of goal

• description: If microalbumin was done > 1 year ago, it is due now.
• action_spec:

  Compound_Action ()

  • condition:
    most_recent Urine protein tests for SAGE DM [SAGE LOINC] Observation <= 30.0 mg/24h (qualifier value) [SNOMED CT]
  • then

    Order ( Order microalbumin 12 months from last measurement )

    • condition:
      absence of VMROrder Urine albumin measurement (procedure) [SNOMED CT]
    code is subsumed by Urine microalbumin profile (procedure) [SNOMED CT]
    • effectiveTime:
      Max of ?NOW and 12 months from time of last microalbumin test
    • vmr_class:
      VMROrder

    Conclusion ()

    • assertion:
      Observation of 'Timing of next microalbumin test 'Due' Max of ?NOW and 12 months from time of last microalbumin test
  • else

    Order ( Order microalbumin 12 months from last measurement )

    • condition:
      absence of VMROrder Urine albumin measurement (procedure) [SNOMED CT]
    code is subsumed by Urine microalbumin profile (procedure) [SNOMED CT]
    • effectiveTime:
      Max of ?NOW and 12 months from time of last microalbumin test
    • vmr_class:
      VMROrder
• subguideline:

  Subguideline ( Microalbumin Checking Subguideline )

  • subrecommendations:
    Microalbuminuria checking subguideline
  • execution_type: SYNCHR

9. Action: Check whether hyperlipidemia labs due and whether out of goal

• description: This invokes logic that checks whether the hyperlipidemia screening/management labs (LDL, HDL, and triglycerides) have been done.
• subguideline:

  Subguideline ( Subguideline for lipid checking )

  • description: This subguideline performs checking for lipid values.
  • subrecommendations:
    Decision map for lipid checking
  • execution_type: SYNCHR

11. Decision: Previous HbA1C value exists?

• description: Determine whether this patient has ever had a HbA1C measured.
• decision_model:

  Alternative_Choice ()

  • alternative:
    No previous HbA1C; order now
  • recommendation_threshhold: 1
  • strict_rule_in:
    absence of Observation HEMOGLOBIN A1C.All_Clinical [SAGE LOINC]

  Alternative_Choice ()

  • alternative:
    Check when HbA1C due and whether out of goal
  • recommendation_threshhold: 0
  • strict_rule_out:
    absence of Observation HEMOGLOBIN A1C.All_Clinical [SAGE LOINC]

13. Action: No previous HbA1C; order now

• description: This patient has never had HbA1C measured. Order it now.
• action_spec:

  Order ( Order HbA1C )

  • condition:
    absence of VMROrder Hemoglobin A1c measurement (procedure) [SNOMED CT]
  code is subsumed by HbA1c measurement (DCCT aligned) (procedure) [SNOMED CT]
  • effectiveTime:
    Now
  • vmr_class:
    VMROrder

15. Decision: Previous creatinine value exists?

• description: Determine whether this patient has ever had their serum creatinine measured.
• decision_model:

  Alternative_Choice ()

  • alternative:
    No previous creatinine; order now
  • recommendation_threshhold: 1
  • strict_rule_in:
    absence of Observation CREATININE:SCNC:PT:SER/PLAS:QN: [LOINC]

  Alternative_Choice ()

  • alternative:
    Check when creatinine due and whether WNL
  • strict_rule_out:
    absence of Observation CREATININE:SCNC:PT:SER/PLAS:QN: [LOINC]

17. Action: No previous creatinine; order now

• description: This patient has never had a serum creatinine measured. Order it now.
• action_spec:

  Order ( Order serum creatinine )

  • condition:
    absence of VMROrder Creatinine measurement, serum (procedure) [SNOMED CT]
  code is subsumed by Creatinine measurement, serum (procedure) [SNOMED CT]
  • effectiveTime:
    Now
  • vmr_class:
    VMROrder

19. Decision: Previous microalbumin value exists?

• description: Determine whether this patient has ever had their urine albumin measured.
• decision_model:

  Alternative_Choice ()

  • alternative:
    No previous microalbumin; order now
  • recommendation_threshhold: 1
  • strict_rule_in:
    absence of Observation Urine protein tests for SAGE DM [SAGE LOINC]

  Alternative_Choice ()

  • alternative:
    Check when microalbumin due and whether out of goal
  • strict_rule_out:
    absence of Observation Urine protein tests for SAGE DM [SAGE LOINC]

21. Action: No previous microalbumin; order now

• description: This patient has never had their urine albumin measured; order now.
• action_spec:

  Order ( Order Microalbumin )

  • condition:
    absence of VMROrder Urine albumin measurement (procedure) [SNOMED CT]
  code is subsumed by Urine microalbumin profile (procedure) [SNOMED CT]
  • effectiveTime:
    Now
  • vmr_class:
    VMROrder

Recommendation Set (Activity Graph): Diabetes guideline enrollment

When a patient is first enrolled in the Diabetes guideline, the default goal values for clinical parameters are set. The user receives a prompt to enter diabetes onset date, enter type of diabetes (I or II), and order a Diabetes Education session.

1. Context: Patient enrolled in Diabetes guideline

• triggering_events:

  Administrative_Event ( Patient is enrolled in the Diabetes Mellitus guideline )

  • SAGE_event_type:
    Patient is enrolled in the Diabetes Mellitus guideline
  • label: Patient is enrolled in the Diabetes Mellitus guideline

  Administrative_Event ( Patient is enrolled in a care support guideline )

  • SAGE_event_type:
    Patient is enrolled in a care support guideline
  • label: Patient is enrolled in a care support guideline
• description: The patient is enrolled, whether manually or automatically, in the Diabetes guideline.
• new_session: true

3. Action: Initialize HbA1C goal

• description: The HbA1C default goal range is < 7%.
• action_spec:
  absence of Goal HEMOGLOBIN A1C.All_Clinical [SAGE LOINC] set GoalGoal for 'HEMOGLOBIN A1C.All_Clinical [SAGE LOINC]' as ( , 7.0) Percent (property) [SNOMED CT]within after NOW

5. Action: Initialize systolic blood pressure goal

• description: Sets systolic bp goal to < 130
• action_spec:
  set GoalGoal for 'Systolic blood pressure (observable entity) [SNOMED CT]' as 90.0, 130.0 mmHg (qualifier value) [SNOMED CT]within after NOW

7. Action: Initialize diastolic blood pressure goal

• description: Set diastolic bp goal to < 80
• action_spec:
  set GoalGoal for 'Diastolic blood pressure (observable entity) [SNOMED CT]' as 30.0, 80.0 mmHg (qualifier value) [SNOMED CT]within after NOW

9. Action: Initialize lipid goals

• description: Initialize lipid goals to: LDL < 100 mg/dL; triglycerides < 150 mg/dL; HDL > 45 mg/dL if male and > 55 mg/dL if female
• subguideline:

  Subguideline ( Subguideline to initialize lipid goals )

  • description: This subguideline initializes lipid goals for a diabetic patient.
  • subrecommendations:
    Decision map to set lipid goals
  • execution_type: SYNCHR

11. Action: Order diabetes education session

• description: A diabetes education session is arranged for this new diabetic patient.
• action_spec:

  Order ( Order Diabetes Education )

  code is subsumed by Diabetic patient education (regime/therapy) [SNOMED CT]
  • effectiveTime:
    Now
  • vmr_class:
    VMROrder

13. Action: Apply diabetes logic to this patient

• description: This newly-enrolled patient will now have the full logic of the diabetes clinic visit scenario applied.
• subguideline:

  Subguideline ( Diabetes logic for newly enrolled patient subguideline )

  • description: This subguideline performs the full set of diabetes management logic on this patient.
  • subrecommendations:
    Diabetes logic for newly-enrolled patient
  • execution_type: SYNCHR

Recommendation Set (Activity Graph): Hypertension checking and management

The guideline checks whether the BP has been entered today. If not, the clinician is notified. If so, if the BP is below goal than this is noted. If the BP is above goal, then the problem list is checked for Hypertension. If HTN, then the HTN recommendation subguideline is triggered. If the pt does not have HTN, the Elevated BP subguideline is triggered.

1. Context: Start node for hypertension

• description: Start node
• new_session: false

3. Decision: Was blood pressure taken today?

• description: Was blood pressure taken today?
• decision_model:

  Alternative_Choice ()

  • alternative:
    Blood pressure is missing; inform clinician
  • recommendation_threshhold: 1
  • strict_rule_in:
    • absence of Observation Systolic blood pressure (observable entity) [SNOMED CT] today
    • absence of Observation Diastolic blood pressure (observable entity) [SNOMED CT] today

  Alternative_Choice ()

  • alternative:
    Is today's average BP below goal?
  • recommendation_threshhold: 2
  • strict_rule_in:
    • presence of Observation Systolic blood pressure (observable entity) [SNOMED CT] today
    • presence of Observation Diastolic blood pressure (observable entity) [SNOMED CT] today

5. Action: Blood pressure is missing; inform clinician

• description: Blood pressure is missing; inform clinician
• action_spec:

  Message_Action ( Inform clinician that BP is missing )

  • communication_mode:
    Patient inbox alert protocol
  • addressee:
    Session_Owner
  • message_content: No blood pressure has been recorded for this patient today. This information is necessary for evaluation.

7. Action: Has HTN Dx, above goal, make hypertension recommendations

• description: Go get recommendations for patient with elevated BP and known HTN.
• subguideline:

  Subguideline ( Hypertension recommendation subguideline )

  • description: This subguideline should be used when the patient's blood pressure is above the goal level and medication recommendations are desired with existing treatment noted.
  • subrecommendations:
    Perform Synch 5 Hypertension Logic
  • execution_type: SYNCHR

9. Action: Blood pressure within goal, record this observation.

• description: Current average blood pressure is under goal. Record observation of this. Incomplete at present
• action_spec:

  Conclusion ()

  • assertion:
    Observation of 'Blood pressure goal status 'Goal achieved (finding) [SNOMED CT]'

11. Decision: Is today's average BP below goal?

• description: ?
• decision_model:

  Alternative_Choice ()

  • alternative:
    Blood pressure within goal, record this observation.
  • recommendation_threshhold: 2
  • strict_rule_in:
    • ( NOT

      Comparison_Criterion ( Diastolic BP goal_high )

      average Diastolic blood pressure (observable entity) [SNOMED CT] Observation During this visit >=
      • label: Diastolic BP goal_high
      • language: Gello
      • functional_expression: ?DiastolicBPGoal.high
      )
    • ( NOT

      Comparison_Criterion ( Systolic BP goal_high )

      average Systolic blood pressure (observable entity) [SNOMED CT] Observation During this visit >=
      • label: Systolic BP goal_high
      • language: Gello
      • functional_expression: ?SystolicBPGoal.high
      )

  Alternative_Choice ()

  • alternative:
    Today's visit average BP above goal - make recommendations
  • recommendation_threshhold: 1
  • strict_rule_in:

    Comparison_Criterion ( Diastolic BP goal_high )

    average Diastolic blood pressure (observable entity) [SNOMED CT] Observation During this visit >=
    • label: Diastolic BP goal_high
    • language: Gello
    • functional_expression: ?DiastolicBPGoal.high

    Comparison_Criterion ( Systolic BP goal_high )

    average Systolic blood pressure (observable entity) [SNOMED CT] Observation During this visit >=
    • label: Systolic BP goal_high
    • language: Gello
    • functional_expression: ?SystolicBPGoal.high

13. Decision: Today's visit average BP above goal - make recommendations

• description: HTN on Pbm List, is there a BP value >1 day ago?
• decision_model:

  Alternative_Choice ()

  • alternative:
    Has HTN Dx, above goal, make hypertension recommendations
  • recommendation_threshhold: 1
  • strict_rule_in:
    presence of Problem Hypertensive disorder, systemic arterial (disorder) [SNOMED CT]

  Alternative_Choice ()

  • alternative:
    Does NOT have HTN DX, BP above goal, make recommendations
  • recommendation_threshhold: 1
  • strict_rule_in:
    absence of Problem Hypertensive disorder, systemic arterial (disorder) [SNOMED CT]

15. Action: Does NOT have HTN DX, BP above goal, make recommendations

• subguideline:

  Subguideline ( Recommendations for elevated BP (no HTN DX) )

  • subrecommendations:
    Subguideline for elevated BP (no HTN) recommendations
  • execution_type: SYNCHR

Recommendation Set (Activity Graph): Population Based Management

This activity graph includes logic for population management. The outcome will be a single saved order session containing all needed orders and labelled as originating from the SAGE Diabetes population-based management guideline.

1. Context: Begin Population Management

• triggering_events:

  Periodic_Time_Event ( Sunday mn every other wk Periodic Time event )

  • SAGE_event_type:
    Sunday midnight every other week
  • description: This event will fire just after midnight, every other Sunday night (early morning, actually)
  • label: Sunday mn every other wk Periodic Time event
  • periodic_time_specification:

    PeriodicIntervalOfTime ( Sunday a.m. midnight, every other week )

    • label: Sunday a.m. midnight, every other week

  Periodic_Time_Event ( Every five minutes )

  • SAGE_event_type:
    Every five minutes
  • description: This event will fire every five minutes.
  • label: Every five minutes
  • periodic_time_specification:

    PeriodicIntervalOfTime ( every 5 minutes )

    • label: every 5 minutes

  Periodic_Time_Event ( Every ten seconds )

  • SAGE_event_type:
    Every ten seconds
  • description: This event will fire every ten seconds.
  • label: Every ten seconds
  • periodic_time_specification:

    PeriodicIntervalOfTime ( Every ten seconds )

    • label: Every ten seconds
• description: Batch population management
• new_session: true
• informatics_context:

  Informatics_Context ( DM population engine )

  • label: DM population engine
  • knowledge_base_utilities:
    Population model alerting engine

3. Decision: Check if visit is due

• description: Check whether a visit must be scheduled now
• decision_model:

  Alternative_Choice ()

  • alternative:
    A1C at goal, visit due, visit not ordered, order
  • recommendation_threshhold: 3
  • strict_rule_in:
    • satisfy 'HEMOGLOBIN A1C.All_Clinical [SAGE LOINC]' goal
    • Number of PCP visits within last 6 months variable equals 0 )
    • Number of PCP visits ordered for the next month variable equals 0 )
  • strict_rule_out:
    ( NOT
    satisfy 'LDL Tests for SAGE DM [SAGE LOINC]' goal
    )

  Alternative_Choice ()

  • alternative:
    A1C or LDL not at goal, no visit within 3 months, non-ordered, order visit
  • recommendation_threshhold: 3
  • strict_rule_in:
    • ( OR
      • ( NOT
        satisfy 'HEMOGLOBIN A1C.All_Clinical [SAGE LOINC]' goal
        )
      • ( NOT
        satisfy 'LDL Tests for SAGE DM [SAGE LOINC]' goal
        )
      )
    • Number of PCP visits within last 3 months variable equals 0 )
    • Number of PCP visits ordered for the next month variable equals 0 )

5. Action: A1C at goal, visit due, visit not ordered, order

• description: Patient with DM and A1C is at goal, but no visit in the last 6 months and none ordered in the next month, so add a visit with the PCP to the PCP's saved order session.
• action_spec:

  Schedule_Appointment ( Schedule a visit )

  code is subsumed by Evaluation and management of established outpatient in office or other outpatient facility (procedure) [SNOMED CT]
  • withAgent:
  • effectiveTime:
    Now

7. Action: A1C or LDL not at goal, no visit within 3 months, non-ordered, order visit

• description: Patient with DM and either A1C or LDL are not at goal, so add visit with the primary care provider to the PCP's saved order session.
• action_spec:

  Schedule_Appointment ( Schedule a visit )

  code is subsumed by Evaluation and management of established outpatient in office or other outpatient facility (procedure) [SNOMED CT]
  • withAgent:
  • effectiveTime:
    Now

9. Decision: Check if microalbumin testing due

• description: Checks to see if any urine protein test has been performed in the last yr, or if any urine protein test in ordered within the next month.
• decision_model:

  Alternative_Choice ()

  • alternative:
    Microalbumin testing due, order
  • recommendation_threshhold: 2
  • strict_rule_in:
    • absence of VMROrder Urine protein tests for SAGE DM [SAGE LOINC] within 1.0 Month (qualifier value) [SNOMED CT] after NOW
    • absence of Observation Urine protein tests for SAGE DM [SAGE LOINC] within 1.0 Year (qualifier value) [SNOMED CT] before Today (mid-night to midnight)

11. Action: Microalbumin testing due, order

• description: Has DM, and no urine protein tests performed in the last year and no pending order for urine protein...so add microalbumin test to the PCP's saved order session.
• action_spec:

  Order ( Order Microalbumin )

  • condition:
    absence of VMROrder Urine albumin measurement (procedure) [SNOMED CT]
  code is subsumed by Urine microalbumin profile (procedure) [SNOMED CT]
  • effectiveTime:
    Now
  • vmr_class:
    VMROrder

13. Decision: Check if lipid profile is due

• description: 4 alternatives (1. Out of goal lipid due at three months 2. Hyperlipidemia at goal check at 6 months 3. No hyperlipidemia at goal check at 12 onths 4. No hyperlip. and has low risk lipids check lipids at 24 months)
• decision_model:

  Alternative_Choice ()

  • alternative:
    Without hyperlipidemia, at goal, not low risk, not ordered, order
  • recommendation_threshhold: 4
  • strict_rule_in:
    • absence of Problem Hyperlipidemia (disorder) [SNOMED CT] Now
    • satisfy 'LDL Tests for SAGE DM [SAGE LOINC]' goal
    • absence of Observation LDL Tests for SAGE DM [SAGE LOINC] within 1.0 Year (qualifier value) [SNOMED CT] before Today (mid-night to midnight)
    • absence of VMROrder Lipid panel (procedure) [SNOMED CT] within 1.0 Month (qualifier value) [SNOMED CT] after NOW
  • strict_rule_out:
    ( AND
    • satisfy 'HDL Tests for SAGE DM [SAGE LOINC]' goal
    • satisfy 'LDL Tests for SAGE DM [SAGE LOINC]' goal
    • satisfy 'Triglyceride tests for SAGE DM [SAGE LOINC]' goal
    )

  Alternative_Choice ()

  • alternative:
    Hyperlip, in goal, LDL due, not ordered, order
  • recommendation_threshhold: 4
  • strict_rule_in:
    • presence of Problem Hyperlipidemia (disorder) [SNOMED CT] Now
    • satisfy 'LDL Tests for SAGE DM [SAGE LOINC]' goal
    • absence of VMROrder Lipid panel (procedure) [SNOMED CT] within 1.0 Month (qualifier value) [SNOMED CT] after NOW
    • absence of Observation LDL Tests for SAGE DM [SAGE LOINC] within 6.0 Month (qualifier value) [SNOMED CT] before NOW

  Alternative_Choice ()

  • alternative:
    Lipids out of goal, LDL due, not ordered, order
  • recommendation_threshhold: 3
  • strict_rule_in:
    • absence of Observation LDL Tests for SAGE DM [SAGE LOINC] within 3.0 Month (qualifier value) [SNOMED CT] before NOW
    • ( NOT
      satisfy 'LDL Tests for SAGE DM [SAGE LOINC]' goal
      )
    • absence of VMROrder Lipid panel (procedure) [SNOMED CT] within 1.0 Month (qualifier value) [SNOMED CT] after NOW

  Alternative_Choice ()

  • alternative:
    Without hyperlipidemia, at goal, low risk, not ordered, order
  • recommendation_threshhold: 5
  • strict_rule_in:
    • absence of Problem Hyperlipidemia (disorder) [SNOMED CT] Now
    • satisfy 'LDL Tests for SAGE DM [SAGE LOINC]' goal
    • ( AND
      • satisfy 'HDL Tests for SAGE DM [SAGE LOINC]' goal
      • satisfy 'LDL Tests for SAGE DM [SAGE LOINC]' goal
      • satisfy 'Triglyceride tests for SAGE DM [SAGE LOINC]' goal
      )
    • absence of VMROrder Lipid panel (procedure) [SNOMED CT] within 1.0 Month (qualifier value) [SNOMED CT] after NOW
    • absence of Observation LDL Tests for SAGE DM [SAGE LOINC] within 2.0 Year (qualifier value) [SNOMED CT] before Today (mid-night to midnight)

15. Action: Without hyperlipidemia, at goal, not low risk, not ordered, order

• description: Patient with DM, LDL at goal and not having low risk lipid values, has no LDL in last yr and none ordered. Add lipid panel to PCP's saved order session.
• action_spec:

  Order ( Order lipid profile )

  code is subsumed by Fasting lipid profile (procedure) [SNOMED CT]
  • effectiveTime:
    Now
  • vmr_class:
    VMROrder

17. Action: Hyperlip, in goal, LDL due, not ordered, order

• description: Patient with DM and Hyperlipidemia with LDL at goal, but no LDL in last 6 months and none ordered -- so add lipid profile to the PCP's saved order session.
• action_spec:

  Order ( Order lipid profile )

  code is subsumed by Fasting lipid profile (procedure) [SNOMED CT]
  • effectiveTime:
    Now
  • vmr_class:
    VMROrder

19. Action: Lipids out of goal, LDL due, not ordered, order

• description: If lipids are out of goal then due at three months. Since no LDL done in last three months and none ordered, add a lipid profile to the PCP's saved order session.
• action_spec:

  Order ( Order lipid profile )

  code is subsumed by Fasting lipid profile (procedure) [SNOMED CT]
  • effectiveTime:
    Now
  • vmr_class:
    VMROrder

21. Action: Without hyperlipidemia, at goal, low risk, not ordered, order

• description: Patient with DM, no hyperlipidemia and low risk lipid values needs recheck LDL at 24 months. No LDL in the last 2 yrs, and none ordered for the next month, so add a lipid profile to the PCP's saved order session.
• action_spec:

  Order ( Order lipid profile )

  code is subsumed by Fasting lipid profile (procedure) [SNOMED CT]
  • effectiveTime:
    Now
  • vmr_class:
    VMROrder

23. Decision: Check if A1c due

• description: If HbA1C is out of goal, it must be measured every 3 months; if in goal, every 6 months.
• decision_model:

  Alternative_Choice ()

  • alternative:
    HBA1C out of goal, due now, order
  • recommendation_threshhold: 3
  • strict_rule_in:
    • absence of Observation HEMOGLOBIN A1C.All_Clinical [SAGE LOINC] within 3.0 Month (qualifier value) [SNOMED CT] before NOW
    • absence of VMROrder HbA1c measurement (DCCT aligned) (procedure) [SNOMED CT] within 1.0 Month (qualifier value) [SNOMED CT] after NOW
    • ( NOT
      satisfy 'HEMOGLOBIN A1C.All_Clinical [SAGE LOINC]' goal
      )

  Alternative_Choice ()

  • alternative:
    HBA1C in goal, due now, order
  • recommendation_threshhold: 3
  • strict_rule_in:
    • satisfy 'HEMOGLOBIN A1C.All_Clinical [SAGE LOINC]' goal
    • absence of VMROrder HbA1c measurement (DCCT aligned) (procedure) [SNOMED CT] within 1.0 Month (qualifier value) [SNOMED CT] after NOW
    • absence of Observation HEMOGLOBIN A1C.All_Clinical [SAGE LOINC] within 6.0 Month (qualifier value) [SNOMED CT] before NOW

25. Action: HBA1C out of goal, due now, order

• description: HbA1C out of goal and due. Add HbA1C order to PCP's saved order session.
• action_spec:

  Order ( Order HbA1C )

  • condition:
    absence of VMROrder Hemoglobin A1c measurement (procedure) [SNOMED CT]
  code is subsumed by HbA1c measurement (DCCT aligned) (procedure) [SNOMED CT]
  • effectiveTime:
    Now
  • vmr_class:
    VMROrder

27. Action: HBA1C in goal, due now, order

• description: HbA1C in goal and due. Add HbA1C order to PCP's saved order session.
• action_spec:

  Order ( Order HbA1C )

  • condition:
    absence of VMROrder Hemoglobin A1c measurement (procedure) [SNOMED CT]
  code is subsumed by HbA1c measurement (DCCT aligned) (procedure) [SNOMED CT]
  • effectiveTime:
    Now
  • vmr_class:
    VMROrder

29. Decision: Check if retinal exam due

• description: Checking for a retinal exam in the last year or if one is ordered for the next month....if not then order one. Looking back for procedure-ophthalmologic exam, looking forward for referral for ophthalmologist
• decision_model:

  Alternative_Choice ()

  • alternative:
    Retinal exam due now, order
  • recommendation_threshhold: 2
  • strict_rule_in:
    • absence of Referral Referral to ophthalmologist (procedure) [SNOMED CT] within 1.0 Month (qualifier value) [SNOMED CT] after NOW
    • ( AND
      • absence of Encounter Ophthalmic examination and evaluation (procedure) [SNOMED CT] within 1.0 Year (qualifier value) [SNOMED CT] before Today (mid-night to midnight)
      • absence of Reported outside eye exam date CEM Retinal eye exam date - pt or other report within 1.0 Year (qualifier value) [SNOMED CT] before Today (mid-night to midnight)
      )

31. Action: Retinal exam due now, order

• description: DM with no eye exam in last year and none ordered...so add ophth. exam order to PCP's saved order session.
• action_spec:

  Make_Referral ( Make referral to ophthalmologist )

  code is subsumed by Referral to ophthalmologist (procedure) [SNOMED CT]
  • withAgent:

    Agent ()

    • name:

      EntityName ( Any Ophthalmologist )

      • label: Any Ophthalmologist
  • vmr_class:
    • Referral
    • Referral

Recommendation Set (Activity Graph): Diabetes logic for newly-enrolled patient

Diabetes logic, the same as that applied during a diabetes clinic visit, is applied to this patient.

1. Context: Start node for new pt subguideline

• description: Dummy start node.
• new_session: false

3. Action: Retrieve diabetes lab data items and calculate items due

• description: The SAGE engine determines which labs need to be ordered by the physician.
• subguideline:

  Subguideline ( Check diabetes lab data items subguideline )

  • description: This subguideline checks for Diabetes- related information in the patient record and calculates whether any are due at this time.
  • subrecommendations:
    Check diabetes lab data items
  • execution_type: SYNCHR

5. Action: Out-of-goal notifications via inbox

• description: If any clinical parameters are out of goal, issue the appropriate notifications via the inbox.
• action_spec:

  Message_Action ( If HbA1C is out of goal range, notify physician via inbox )

  • condition:
    ( AND
    • ( NOT
      satisfy 'HEMOGLOBIN A1C.All_Clinical [SAGE LOINC]' goal
      )
    • presence of Observation HEMOGLOBIN A1C.All_Clinical [SAGE LOINC]
    )
  • communication_mode:
    Patient inbox alert protocol
  • addressee:
    Session_Owner
  • message_content: ALERT: This patient's HbA1C is above the target goal range.

  Message_Action ( Suggest adding Hyperlipidemia to problem list via inbox )

  • condition:
    ( AND
    • ( OR
      • ( NOT
        satisfy 'LDL Tests for SAGE DM [SAGE LOINC]' goal
        )
      • ( NOT
        satisfy 'Triglyceride tests for SAGE DM [SAGE LOINC]' goal
        )
      • ( NOT
        satisfy 'HDL Tests for SAGE DM [SAGE LOINC]' goal
        )
      )
    • absence of Problem Hyperlipidemia (disorder) [SNOMED CT] Now
    • presence of Observation LDL Tests for SAGE DM [SAGE LOINC]
    )
  • communication_mode:
    Patient inbox alert protocol
  • addressee:
    Session_Owner
  • message_content: Consider adding Hyperlipidemia to Problem List

  Notify ( If LDL out of goal, notify MD )

  • label: If LDL out of goal, notify MD
  • condition:
    ( AND
    • presence of Observation LDL Tests for SAGE DM [SAGE LOINC]
    • ( NOT
      satisfy 'LDL Tests for SAGE DM [SAGE LOINC]' goal
      )
    )
  • communication_mode:
    Provider inbox communication protocol
  • addressee:
    Session_Owner
  • parameterized_string:
    ALERT: This patient's LDL is above the goal target range.

7. Action: Retrieve physician-entered data items and calculate items due

• description: SAGE checks whether physical exam and history findings have been entered yet for this visit.
• action_spec:

  Action_Set ( Physian-entered information (inbox) )

  • action_spec:

    Compound_Action ()

    • condition:
      presence of ObservationObservation where 'Examination of foot (procedure) [SNOMED CT]' code = 'Done (qualifier value) [SNOMED CT]' During this visit
    • else

      Inquiry ( Prompt physician to perform foot exam )

      • data_entries:
        Foot exam status CEM
      • communication_mode:
        Patient inbox alert protocol
      • addressee:
        Session_Owner

    Compound_Action ()

    • condition:
      presence of Observation Finding of tobacco use and exposure (finding) [SNOMED CT] today
    • else

      Inquiry ( Prompt physician for smoking status )

      • data_entries:
        Smoking status CEM
      • communication_mode:
        Patient inbox alert protocol
      • addressee:
        Session_Owner

9. Action: Cardiac risk reduction recommendations

• action_spec:

  Notify ( Suggest ACE-I if increased CV risk and indicated )

  • label: Suggest ACE-I if increased CV risk and indicated
  • condition:
    ( AND
    • Age > 55.0 Year (qualifier value) [SNOMED CT] )
    • absence of MedicationOrder ACE Inhibitor Oral Preparation for Hypertension [SAGE NDF-RT]
    • Absence of Absolute contraindication for ACE Inhibitor
    • ( OR
      • presence of Problem Acute myocardial infarction (disorder) [SNOMED CT]
      • presence of Problem Myocardial infarction (disorder) [SNOMED CT]
      • presence of Problem Hyperlipidemia (disorder) [SNOMED CT] Now
      • presence of Problem Microalbuminuria (finding) [SNOMED CT]
      • presence of Observation Tobacco user (finding) [SNOMED CT]
      )
    • ( NOT

      Comparison_Criterion ( Diastolic BP goal_high )

      average Diastolic blood pressure (observable entity) [SNOMED CT] Observation During this visit >=
      • label: Diastolic BP goal_high
      • language: Gello
      • functional_expression: ?DiastolicBPGoal.high
      )
    • ( NOT

      Comparison_Criterion ( Systolic BP goal_high )

      average Systolic blood pressure (observable entity) [SNOMED CT] Observation During this visit >=
      • label: Systolic BP goal_high
      • language: Gello
      • functional_expression: ?SystolicBPGoal.high
      )
    )
  • communication_mode:
    Provider inbox communication protocol
  • addressee:
    Session_Owner
  • parameterized_string:
    This patient is at increased risk for CV disease, so an ACE Inhibitor should be considered to reduce this risk.

  Notify ( Suggest Beta-blocker if Hx of MI )

  • label: Suggest Beta-blocker if Hx of MI
  • condition:
    ( AND
    • presence of Problem H/O: Myocardial infarction in last year (context-dependent category) [SNOMED CT]
    • absence of MedicationOrder Beta-Blocker Oral Preparation for Hypertension [SAGE NDF-RT]
    • Absence of Absolute contraindication for Beta-Blocker
    • ( NOT

      Comparison_Criterion ( Diastolic BP goal_high )

      average Diastolic blood pressure (observable entity) [SNOMED CT] Observation During this visit >=
      • label: Diastolic BP goal_high
      • language: Gello
      • functional_expression: ?DiastolicBPGoal.high
      )
    • ( NOT

      Comparison_Criterion ( Systolic BP goal_high )

      average Systolic blood pressure (observable entity) [SNOMED CT] Observation During this visit >=
      • label: Systolic BP goal_high
      • language: Gello
      • functional_expression: ?SystolicBPGoal.high
      )
    )
  • communication_mode:
    Provider inbox communication protocol
  • addressee:
    Session_Owner
  • parameterized_string:
    This patient has a history of MI, so a beta-blocker should be considered to reduce mortality risk.

11. Action: Retrieve consult-related information and calculate items due

• description: Check whether consults are indicated, and whether they have been done.
• action_spec:

  Message_Action ( Recommend referral to nephrologist if indicated )

  • condition:
    ( AND
    • ( OR
      • most_recent CREATININE CLEARANCE:VRAT:PT:DIAF:QN:[LOINC] Observation < 60.0 mL/min (qualifier value) [SNOMED CT]
      • most_recent CREATININE:SCNC:PT:SER/PLAS:QN: [LOINC] Observation > 2.0 mg/dL (qualifier value) [SNOMED CT]
      • ( AND
        • number_of Antihypertensive medications (SAGE DM) [SAGE NDF-RT] MedicationOrder Now >= 4
        • ( OR
          • ( NOT
            average Systolic blood pressure (observable entity) [SNOMED CT] Observation within 1.0 Year (qualifier value) [SNOMED CT] before Today (mid-night to midnight) in Most recent Systolic BP goal interval variable
            )
          • ( NOT
            average Diastolic blood pressure (observable entity) [SNOMED CT] Observation within 1.0 Year (qualifier value) [SNOMED CT] before Today (mid-night to midnight) in Most recent diastolic BP goal interval variable
            )
          )
        )
      • most_recent POTASSIUM:MCNC:PT:SER/PLAS:QN:[LOINC] Observation within 3.0 Month (qualifier value) [SNOMED CT] before NOW > 5.7 mg/dL (qualifier value) [SNOMED CT]
      )
    • absence of Referral Nephrologist (occupation) [SNOMED CT] Now
    )
  • communication_mode:
    Patient inbox alert protocol
  • addressee:
    Session_Owner
  • message_content: Consider referral to a nephrologist. (Please see indications.)

  Recommend_VMROrder ()

  • condition:
    absence of VMROrder Referral to ophthalmologist (procedure) [SNOMED CT]
  • order:
    VMR Order where code is subsumed by Referral to ophthalmologist (procedure) [SNOMED CT]
    • effectiveTime:
      Max of ?NOW or 12 months from time of last ophthalmology visit

13. Action: Check today's bp and issue appropriate alerts

• description: 1 - determine whether bp was measured today 2 - average with penultimate bp and check against goal values 3 - if high, inform physician perform logic on med/lifestyle recommendations
• subguideline:

  Subguideline ( Subguideline for hypertension checking and management )

  • description: This subguideline checks for and manages hypertension.
  • subrecommendations:
    Hypertension checking and management
  • execution_type: SYNCHR

15. Context: Physician accesses diabetes data set

• triggering_events:

  Clinical_Event ( Outpatient Primary Care Doctor accesses diabetes data set )

  • SAGE_event_type:
    Outpatient primary care physician accesses diabetes data set
  • label: Outpatient Primary Care Doctor accesses diabetes data set
• description: There is a set of data that is relevant to diabetes care. Here, the physician accesses the functionality that allows him/her to view the entire data set.
• new_session: false

17. Action: Aspirin therapy

• description: Check whether the patient is older than 21 and has macrovascular disease, or older than 40 and has other cardiovascular risk factors. If so, check for contraindications to aspirin therapy. If no contraindications, recommend aspirin therapy.
• subguideline:

  Subguideline ( Aspirin therapy subguideline )

  • description: Check whether the patient is older than 21 and has macrovascular disease, or older than 40 and has other cardiovascular risk factors. If so, check for contraindications to aspirin therapy. If no contraindications, recommend aspirin therapy.
  • subrecommendations:
    Aspirin Therapy for diabetic patients
  • execution_type: SYNCHR

19. Action: Smoking cessation counseling

• description: If the patient is a smoker or tobacco user, counsel them to quit.
• action_spec:

  Message_Action ( Remind physician to counsel pt to stop tobacco use )

  • condition:
    ( OR
    • presence of ObservationObservation where 'Finding of tobacco use and exposure (finding) [SNOMED CT]' code = 'Smoker (finding) [SNOMED CT]'
    • presence of ObservationObservation where 'Finding of tobacco use and exposure (finding) [SNOMED CT]' code = 'Tobacco user (finding) [SNOMED CT]'
    • presence of Problem Nicotine dependence (disorder) [SNOMED CT]
    )
  • communication_mode:
    Patient inbox alert protocol
  • addressee:
    Session_Owner
  • message_content: Please counsel this patient to end tobacco use.

21. Action: Get diabetes data set for physician

• description: When the physician accesses the diabetes data set, all of its information is obtained from the patient record. This includes vitals, height, weight, history items, foot exam, retinal exam, cardiac signs/sx, home glucose review, and labs.
• action_spec:

  Action_Set ( Physician-entered information for physician (data set) )

  • action_spec:

    Conclusion ()

    • condition:
      absence of ObservationObservation where 'Examination of foot (procedure) [SNOMED CT]' code = 'Done (qualifier value) [SNOMED CT]' During this visit
    • assertion:
      Observation of 'Status of foot exam 'Due' Now

    Conclusion ()

    • condition:
      absence of Observation Finding of tobacco use and exposure (finding) [SNOMED CT] today
    • assertion:
      Observation of 'Smoking status due status 'Due' Now

Recommendation Set (Activity Graph): Aspirin Therapy for diabetic patients

These recommendations follow the 2004 ADA "Aspirin Therapy in Diabetes" guideline. If the patient has no contraindications and is > 40 yo, or > 20 yo with CVD, HTN, tobacco use, dyslipidemia, albuminuria, FHx of CVD, or Hx of MI, vascular bypass procedure, stroke, TIA, PVD, claudication, or angina, aspirin therapy should be considered.

1. Context: Patient 21 yo or older

• precondition:
  • Age > 20.0 Year (qualifier value) [SNOMED CT] )
• description: Start node for ASA therapy, with precondition that patient age >20.
• new_session: true

3. Decision: Yes -- check for ASA contraindications

• description: Checks for Aspirin or NSAID hypersensitivity, recent GI bleed, or coagulation disorder
• decision_model:

  Alternative_Choice ()

  • alternative:
    No ASA contraindications; recommend ASA
  • recommendation_threshhold: 1
  • strict_rule_in:
    • Age > 20.0 Year (qualifier value) [SNOMED CT] )
  • strict_rule_out:
    • presence of AdverseReaction: 'Allergic drug reaction (disorder) [SNOMED CT]' to 'Non-steroidal anti-inflammatory agent (product) [SNOMED CT]'
    • presence of Problem Coagulation factor deficiency syndrome (disorder) [SNOMED CT]
    • presence of Problem Gastrointestinal hemorrhage (disorder) [SNOMED CT] within 3.0 Month (qualifier value) [SNOMED CT] before NOW

5. Decision: None; age > 40 yo?

• description: If the patient is > 40 yo and there are no contraindications, the clinician should consider aspirin therapy.
• decision_model:

  Alternative_Choice ()

  • alternative:
    Yes -- check for ASA contraindications
  • recommendation_threshhold: 1
  • strict_rule_in:
    • Age > 40.0 Year (qualifier value) [SNOMED CT] )

  Alternative_Choice ()

  • alternative:
    No; any aspirin-indicating risk factors?
  • recommendation_threshhold: 1
  • strict_rule_in:
    • Age <= 40.0 Year (qualifier value) [SNOMED CT] )

7. Action: No ASA contraindications; recommend ASA

• description: Recommend starting aspirin at 75 to 325 mg/day in this patient
• action_spec:

  Message_Action ( Aspirin recommendation )

  • communication_mode:
    Patient inbox alert protocol
  • addressee:
    Session_Owner
  • message_content: This patient has indications for aspirin therapy, and has not been prescribed aspirin. Please consider starting aspirin therapy at 75 to 325 mg/day.

9. Decision: Check for Aspirin therapy

• description: If there is no aspirin order, check for indications.
• decision_model:

  Alternative_Choice ()

  • alternative:
    None; age > 40 yo?
  • recommendation_threshhold: 1
  • strict_rule_in:
    absence of MedicationOrder Aspirin (product) [SNOMED CT]

11. Decision: No; any aspirin-indicating risk factors?

• description: Check whether patient has CVD, HTN, tobacco use, dyslipidemia, albuminuria, FHx of CVD, or Hx of MI, vascular bypass procedure, stroke, TIA, PVD, claudication, or angina
• decision_model:

  Alternative_Choice ()

  • alternative:
    Yes -- check for ASA contraindications
  • recommendation_threshhold: 1
  • strict_rule_in:
    • presence of Family history of (contextual qualifier) (context-dependent category) [SNOMED CT]Observation Coronary artery disease (disorder) [SNOMED CT]
    • presence of Problem Hypertensive disorder, systemic arterial (disorder) [SNOMED CT]
    • ( OR
      • presence of ObservationObservation where 'Finding of tobacco use and exposure (finding) [SNOMED CT]' code = 'Smoker (finding) [SNOMED CT]'
      • presence of ObservationObservation where 'Finding of tobacco use and exposure (finding) [SNOMED CT]' code = 'Tobacco user (finding) [SNOMED CT]'
      • presence of Problem Nicotine dependence (disorder) [SNOMED CT]
      )
    • presence of Problem Hyperlipidemia (disorder) [SNOMED CT] Now
    • presence of Problem Proteinuria of value for diabetes management (SAGE DM) [SAGE SNOMED CT]
    • presence of Problem Coronary arteriosclerosis (disorder) [SNOMED CT]
    • ( OR
      • presence of Problem Myocardial infarction (disorder) [SNOMED CT]
      • presence of Problem H/O: Myocardial infarction in last year (context-dependent category) [SNOMED CT]
      )
    • ( OR
      • presence of Problem Cerebrovascular accident (disorder) [SNOMED CT]
      • presence of Problem History of - stroke (context-dependent category) [SNOMED CT]
      )
    • ( OR
      • presence of Problem Transient ischemic attack (disorder) [SNOMED CT]
      • presence of Problem History of - TIA (context-dependent category) [SNOMED CT]
      )
    • presence of Problem Peripheral vascular disease (disorder) [SNOMED CT]
    • presence of Procedure Creation of vascular bypass (procedure) [SNOMED CT]
    • presence of Problem Claudication (finding) [SNOMED CT]
    • presence of Problem Angina (disorder) [SNOMED CT]

Recommendation Set (Activity Graph): Perform Synch 5 Hypertension Logic

Check for Stage I or Stage II hypertension, and recommend one or two therapies as appropriate.

1. Context: Start node for Synch 5 hypertension logic

• precondition:
  ( OR

  Comparison_Criterion ( Diastolic BP goal_high )

  average Diastolic blood pressure (observable entity) [SNOMED CT] Observation During this visit >=
  • label: Diastolic BP goal_high
  • language: Gello
  • functional_expression: ?DiastolicBPGoal.high

  Comparison_Criterion ( Systolic BP goal_high )

  average Systolic blood pressure (observable entity) [SNOMED CT] Observation During this visit >=
  • label: Systolic BP goal_high
  • language: Gello
  • functional_expression: ?SystolicBPGoal.high
  )
• description: This subguideline should be used when the patient's blood pressure is above the goal level and medication recommendations are desired with existing treatment noted. So the precondition is their BP is above goal.
• new_session: false

3. Decision: Is patient a Stage I or a Stage II hypertensive?

• description: Check whether the patient is a Stage I or Stage II hypertensive.
• decision_model:

  Alternative_Choice ()

  • alternative:
    Stage I; is patient taking antihypertensives?
  • recommendation_threshhold: 0
  • strict_rule_out:

    Comparison_Criterion ( Add 10 mmHg to diastolic goal )

    average Diastolic blood pressure (observable entity) [SNOMED CT] Observation During this visit >=
    • label: Add 10 mmHg to diastolic goal
    • language: Gello
    • functional_expression: ?DiastolicBPGoal.high.PLUS(PhysicalQuantity.new(10,CodedValue.new("SNOMED CT",259018001)))

    Comparison_Criterion ( Add 20 mmHg to Systolic goal )

    average Systolic blood pressure (observable entity) [SNOMED CT] Observation During this visit >=
    • label: Add 20 mmHg to Systolic goal
    • language: Gello
    • functional_expression: ?SystolicBPGoal.high.PLUS(PhysicalQuantity.new(20,CodedValue.new("SNOMED CT",259018001)))

  Alternative_Choice ()

  • alternative:
    Stage II; is patient taking antihypertensives?
  • recommendation_threshhold: 1
  • strict_rule_in:

    Comparison_Criterion ( Add 10 mmHg to diastolic goal )

    average Diastolic blood pressure (observable entity) [SNOMED CT] Observation During this visit >=
    • label: Add 10 mmHg to diastolic goal
    • language: Gello
    • functional_expression: ?DiastolicBPGoal.high.PLUS(PhysicalQuantity.new(10,CodedValue.new("SNOMED CT",259018001)))

    Comparison_Criterion ( Add 20 mmHg to Systolic goal )

    average Systolic blood pressure (observable entity) [SNOMED CT] Observation During this visit >=
    • label: Add 20 mmHg to Systolic goal
    • language: Gello
    • functional_expression: ?SystolicBPGoal.high.PLUS(PhysicalQuantity.new(20,CodedValue.new("SNOMED CT",259018001)))

5. Action: Stage I, no antihypertensives

• description: The patient is a Stage I hypertensive, and is on no medications. Recommend the appropriate order set.
• action_spec:

  Recommend_OrderSet ( Recommend order set for Stage I with no antihypertensives )

  • label: Recommend order set for Stage I with no antihypertensives
  • description: Recommend order set for Stage I with no antihypertensives
  • order_set:
    Hypertension -- Stage I -- no current antihypertensive therapy

7. Decision: Stage I; is patient taking antihypertensives?

• description: The patient is a Stage I hypertensive. Are they already taking antihypertensive agents?
• decision_model:

  Alternative_Choice ()

  • alternative:
    Stage I, no antihypertensives
  • recommendation_threshhold: 1
  • strict_rule_in:
    ( NOT
    number_of Antihypertensive medications (SAGE DM) [SAGE NDF-RT] MedicationOrder >= 1
    )

  Alternative_Choice ()

  • alternative:
    Stage I, taking antihypertensives
  • recommendation_threshhold: 1
  • strict_rule_in:
    number_of Antihypertensive medications (SAGE DM) [SAGE NDF-RT] MedicationOrder >= 1

9. Decision: Stage II; is patient taking antihypertensives?

• description: The patient is a Stage II hypertensive. Check whether they are already taking antihypertensive agents.
• decision_model:

  Alternative_Choice ()

  • alternative:
    Stage II, no antihypertensives
  • recommendation_threshhold: 1
  • strict_rule_in:
    ( NOT
    number_of Antihypertensive medications (SAGE DM) [SAGE NDF-RT] MedicationOrder >= 1
    )

  Alternative_Choice ()

  • alternative:
    Stage II, taking antihypertensives
  • recommendation_threshhold: 1
  • strict_rule_in:
    number_of Antihypertensive medications (SAGE DM) [SAGE NDF-RT] MedicationOrder >= 1

11. Action: Stage I, taking antihypertensives

• description: The patient is a Stage I hypertensive, and is on at least one antihypertensive medication. Recommend the appropriate order set.
• action_spec:

  Recommend_OrderSet ( Recommend order set for Stage I on antihypertensives )

  • label: Recommend order set for Stage I on antihypertensives
  • description: Recommend order set for Stage I on antihypertensives
  • order_set:
    Hypertension -- Stage I -- currently on antihypertensive therapy

13. Action: Stage II, taking antihypertensives

• description: The patient is a Stage II hypertensive, and is already on antihypertensive medications. Recommend adding/increasing dose of 2 medications.
• action_spec:

  Recommend_OrderSet ( Recommend order set for Stage II on antihypertensives )

  • label: Recommend order set for Stage II on antihypertensives
  • description: Recommend order set for Stage II on antihypertensives
  • order_set:
    Hypertension -- Stage II -- currently on antihypertensive therapy

15. Action: Stage II, no antihypertensives

• description: The patient is a Stage II hypertensive, and yet is on no antihypertensive medications. Recommend the order set which instructs the user to choose two antihypertensive meds.
• action_spec:

  Recommend_OrderSet ( Recommend order set for Stage II with no antihypertensives )

  • label: Recommend order set for Stage II with no antihypertensives
  • description: Recommend order set for Stage II with no antihypertensives
  • order_set:
    Hypertension -- Stage II -- no current antihypertensive therapy

Recommendation Set (Decision Map): Subguideline for elevated BP (no HTN) recommendations

This subguideline makes recommendations for patients with elevated blood pressure, but no current diagnosis of HTN.

1. Decision Context: Start Node for Elevated BP with no HTN DX

3. Decision: Was the average BP at the last visit elevated?

• decision_model:

  Alternative_Choice ()

  • alternative:
    Is the average BP greater than 180/110?
  • strict_rule_out:

    Comparison_Criterion ( Time interval of last encounter that has BP )

    average Diastolic blood pressure (observable entity) [SNOMED CT] Observation
    • label: Time interval of last encounter that has BP
    • aggregation_operator: most_recent
    • selection_attribute:
      effectiveTime
    • vmr_specification:
      Encounter where
      • effectiveTime:
        select most_recent effectiveTime from Observation of 'Diastolic blood pressure (observable entity) [SNOMED CT] ' ' Time before current encounter
    >=
    • label: Diastolic BP goal_high
    • language: Gello
    • functional_expression: ?DiastolicBPGoal.high

    Comparison_Criterion ( Time interval of last encounter that has BP )

    average Systolic blood pressure (observable entity) [SNOMED CT] Observation
    • label: Time interval of last encounter that has BP
    • aggregation_operator: most_recent
    • selection_attribute:
      effectiveTime
    • vmr_specification:
      Encounter where
      • effectiveTime:
        select most_recent effectiveTime from Observation of 'Diastolic blood pressure (observable entity) [SNOMED CT] ' ' Time before current encounter
    >=
    • label: Systolic BP goal_high
    • language: Gello
    • functional_expression: ?SystolicBPGoal.high

  Alternative_Choice ()

  • alternative:
    Two consecutive occasions with elevated BP. Dx HTN. Notify MD
  • recommendation_threshhold: 1
  • strict_rule_in:

    Comparison_Criterion ( Time interval of last encounter that has BP )

    average Diastolic blood pressure (observable entity) [SNOMED CT] Observation
    • label: Time interval of last encounter that has BP
    • aggregation_operator: most_recent
    • selection_attribute:
      effectiveTime
    • vmr_specification:
      Encounter where
      • effectiveTime:
        select most_recent effectiveTime from Observation of 'Diastolic blood pressure (observable entity) [SNOMED CT] ' ' Time before current encounter
    >=
    • label: Diastolic BP goal_high
    • language: Gello
    • functional_expression: ?DiastolicBPGoal.high

    Comparison_Criterion ( Time interval of last encounter that has BP )

    average Systolic blood pressure (observable entity) [SNOMED CT] Observation
    • label: Time interval of last encounter that has BP
    • aggregation_operator: most_recent
    • selection_attribute:
      effectiveTime
    • vmr_specification:
      Encounter where
      • effectiveTime:
        select most_recent effectiveTime from Observation of 'Diastolic blood pressure (observable entity) [SNOMED CT] ' ' Time before current encounter
    >=
    • label: Systolic BP goal_high
    • language: Gello
    • functional_expression: ?SystolicBPGoal.high
• split_constraint: XOR

5. Action: Two consecutive occasions with elevated BP. Dx HTN. Notify MD

• description: Two consecutive occasions with the average BP above goal, therefore notiify MD of new Dx of HTN and add HTN to the problem list.
• subguideline:

  Subguideline ( Hypertension recommendation subguideline )

  • description: This subguideline should be used when the patient's blood pressure is above the goal level and medication recommendations are desired with existing treatment noted.
  • subrecommendations:
    Perform Synch 5 Hypertension Logic
  • execution_type: SYNCHR
• action_spec:

  Notify ( Notify MD of new HTN DX )

  • label: Notify MD of new HTN DX
  • communication_mode:
    Provider inbox communication protocol
  • addressee:
    Primary care physician
  • parameterized_string:
    This patients BP has been elevated on two consecutive encounters, so HTN has been added to the problem list. Consider antihypertensive medicaiton.

  Conclude ()

  • assertion:

    Problem ()

    code is subsumed by Hypertensive disorder, systemic arterial (disorder) [SNOMED CT]

7. Decision: Is the average BP greater than 180/110?

• decision_model:

  Alternative_Choice ()

  • alternative:
    Is the average BP at Stage II level?
  • recommendation_threshhold: 0
  • strict_rule_out:
    • average Diastolic blood pressure (observable entity) [SNOMED CT] Observation During this visit >= 110.0
    • average Systolic blood pressure (observable entity) [SNOMED CT] Observation During this visit >= 180.0

  Alternative_Choice ()

  • alternative:
    Average BP greater than 180/110, so recommend consider antihypertensive medication
  • recommendation_threshhold: 1
  • strict_rule_in:
    • average Diastolic blood pressure (observable entity) [SNOMED CT] Observation During this visit >= 110.0
    • average Systolic blood pressure (observable entity) [SNOMED CT] Observation During this visit >= 180.0
• split_constraint: XOR

9. Action: Average BP greater than 180/110, so recommend consider antihypertensive medication

• subguideline:

  Subguideline ( Hypertension recommendation subguideline )

  • description: This subguideline should be used when the patient's blood pressure is above the goal level and medication recommendations are desired with existing treatment noted.
  • subrecommendations:
    Perform Synch 5 Hypertension Logic
  • execution_type: SYNCHR
• action_spec:

  Notify ( Notify provider BP elevated greater than 180/110 )

  • label: Notify provider BP elevated greater than 180/110
  • communication_mode:
    Provider inbox communication protocol
  • addressee:
    Session_Owner
  • parameterized_string:
    This patients BP is greater than 180/110 mmHg, consider medications and f/u in 1 week.

11. Action: Stage I elevation in BP, recommend 2 mo F/U

• action_spec:

  Notify ( Suggest f/u in 2 months )

  • label: Suggest f/u in 2 months
  • communication_mode:
    Provider inbox communication protocol
  • addressee:
    Session_Owner
  • parameterized_string:
    This patients BP was elevated and a follow-up to recheck the BP should be scheduled within the next 2 months.

13. Action: Stage II elevation in BP recommend 1 mo F/U

• action_spec:

  Notify ( 1 month BP F/U recommendation )

  • label: 1 month BP F/U recommendation
  • communication_mode:
    Provider inbox communication protocol
  • addressee:
    Session_Owner
  • parameterized_string:
    This patients BP was elevated to stage II, therefore a follow-up to recheck the BP should be scheduled within the next 1 month.

15. Decision: Is the average BP at Stage II level?

• decision_model:

  Alternative_Choice ()

  • alternative:
    Stage II elevation in BP recommend 1 mo F/U
  • recommendation_threshhold: 1
  • strict_rule_in:

    Comparison_Criterion ( Add 10 mmHg to diastolic goal )

    average Diastolic blood pressure (observable entity) [SNOMED CT] Observation During this visit >=
    • label: Add 10 mmHg to diastolic goal
    • language: Gello
    • functional_expression: ?DiastolicBPGoal.high.PLUS(PhysicalQuantity.new(10,CodedValue.new("SNOMED CT",259018001)))

    Comparison_Criterion ( Add 20 mmHg to Systolic goal )

    average Systolic blood pressure (observable entity) [SNOMED CT] Observation During this visit >=
    • label: Add 20 mmHg to Systolic goal
    • language: Gello
    • functional_expression: ?SystolicBPGoal.high.PLUS(PhysicalQuantity.new(20,CodedValue.new("SNOMED CT",259018001)))

  Alternative_Choice ()

  • alternative:
    Stage I elevation in BP, recommend 2 mo F/U
  • recommendation_threshhold: 0
  • strict_rule_out:

    Comparison_Criterion ( Add 10 mmHg to diastolic goal )

    average Diastolic blood pressure (observable entity) [SNOMED CT] Observation During this visit >=
    • label: Add 10 mmHg to diastolic goal
    • language: Gello
    • functional_expression: ?DiastolicBPGoal.high.PLUS(PhysicalQuantity.new(10,CodedValue.new("SNOMED CT",259018001)))

    Comparison_Criterion ( Add 20 mmHg to Systolic goal )

    average Systolic blood pressure (observable entity) [SNOMED CT] Observation During this visit >=
    • label: Add 20 mmHg to Systolic goal
    • language: Gello
    • functional_expression: ?SystolicBPGoal.high.PLUS(PhysicalQuantity.new(20,CodedValue.new("SNOMED CT",259018001)))
• split_constraint: XOR

Recommendation Set (Decision Map): Decision map to set lipid goals

This decision map sets lipid goals to levels appropriate for a diabetic patient, with the precondition of Diabetes Mellitus on the problem list.

1. Decision Context: Start node for setting lipid goals

• description: This lipid goal setting is only done if the patient has DM on the problem list.

3. Action: Set LDL goal

• description: The LDL goal is set to < 100 mg/dL for this diabetic patient.
• action_spec:
  set GoalGoal for 'LDL Tests for SAGE DM [SAGE LOINC]' as 10.0, 100.0 mg/dL (qualifier value) [SNOMED CT]within after NOW

5. Action: Set triglycerides goal

• description: Set triglycerides goal to < 150 mg/dL for this diabetic patient
• action_spec:
  set GoalGoal for 'Triglyceride tests for SAGE DM [SAGE LOINC]' as 10.0, 150.0 mg/dL (qualifier value) [SNOMED CT]within after NOW

7. Action: Set HDL goal

• description: Sets HDL goal to > 40 mg/dL for a male diabetic and > 50 mg/dL for a female diabetic
• action_spec:
  • presence of ObservationObservation where 'Gender finding (finding) [SNOMED CT]' code = 'Male (finding) [SNOMED CT]' set GoalGoal for 'HDL Tests for SAGE DM [SAGE LOINC]' as 40.0, mg/dL (qualifier value) [SNOMED CT]within after NOW
  • presence of ObservationObservation where 'Gender finding (finding) [SNOMED CT]' code = 'Female (finding) [SNOMED CT]' set GoalGoal for 'HDL Tests for SAGE DM [SAGE LOINC]' as 50.0, mg/dL (qualifier value) [SNOMED CT]within after NOW

Recommendation Set (Decision Map): Decision map for lipid checking

This subguideline performs checking for lipid parameters in adult and pediatric patients.

1. Decision Context: Adult patient

• description: Context for adult patients (age >= 19 years)
• precondition:
  • Age >= 19.0 Year (qualifier value) [SNOMED CT] )

3. Decision Context: Pediatric patient

• description: Context for pediatric patients (age < 19 years)
• precondition:
  • Age < 19.0 Year (qualifier value) [SNOMED CT] )

5. Decision: When should adult lipid labs be ordered?

• description: Decide whether lipids should be measured now, or 6 months, 12 months, or 24 months from last measurement.
• decision_model:

  Alternative_Choice ()

  • alternative:
    Order lipid labs now
  • recommendation_threshhold: 1
  • strict_rule_in:
    absence of Observation LDL Tests for SAGE DM [SAGE LOINC]

  Alternative_Choice ()

  • alternative:
    Order lipid labs for 3 months from last labs
  • recommendation_threshhold: 1
  • strict_rule_in:
    ( NOT
    satisfy 'LDL Tests for SAGE DM [SAGE LOINC]' goal
    )
  • strict_rule_out:
    absence of Observation LDL Tests for SAGE DM [SAGE LOINC]

  Alternative_Choice ()

  • alternative:
    Order lipid labs for 6 months from last labs
  • recommendation_threshhold: 2
  • strict_rule_in:
    • presence of Problem Hyperlipidemia (disorder) [SNOMED CT] Now
    • ( AND
      • satisfy 'LDL Tests for SAGE DM [SAGE LOINC]' goal
      • satisfy 'Triglyceride tests for SAGE DM [SAGE LOINC]' goal
      • satisfy 'HDL Tests for SAGE DM [SAGE LOINC]' goal
      )
  • strict_rule_out:
    absence of Observation LDL Tests for SAGE DM [SAGE LOINC]

  Alternative_Choice ()

  • alternative:
    Order lipid labs 12 months from last labs
  • recommendation_threshhold: 3
  • strict_rule_in:
    • absence of Problem Hyperlipidemia (disorder) [SNOMED CT] Now
    • satisfy 'LDL Tests for SAGE DM [SAGE LOINC]' goal
    • ( OR
      • ( NOT
        satisfy 'Triglyceride tests for SAGE DM [SAGE LOINC]' goal
        )
      • ( NOT
        satisfy 'HDL Tests for SAGE DM [SAGE LOINC]' goal
        )
      )
  • strict_rule_out:
    absence of Observation LDL Tests for SAGE DM [SAGE LOINC]

  Alternative_Choice ()

  • alternative:
    Order lipid labs 24 months from last labs
  • recommendation_threshhold: 2
  • strict_rule_in:
    • absence of Problem Hyperlipidemia (disorder) [SNOMED CT] Now
    • ( AND
      • satisfy 'LDL Tests for SAGE DM [SAGE LOINC]' goal
      • satisfy 'Triglyceride tests for SAGE DM [SAGE LOINC]' goal
      • satisfy 'HDL Tests for SAGE DM [SAGE LOINC]' goal
      )
  • strict_rule_out:
    absence of Observation LDL Tests for SAGE DM [SAGE LOINC]
• split_constraint: XOR

7. Action: Order lipid labs now

• description: A complete set of lipid labs has never been ordered for this patient, so order them now.
• action_spec:

  Conclusion ()

  • assertion:
    Observation of 'Timing of next LDL test 'Due' Now

  Order ( Order lipid profile )

  code is subsumed by Fasting lipid profile (procedure) [SNOMED CT]
  • effectiveTime:
    Now
  • vmr_class:
    VMROrder

9. Action: Order lipid labs for 6 months from last labs

• description: If any lipid values are out of goal range, and the patient is known to be hyperlipidemic, order lipid labs for six months after the last time they were ordered, or now, whichever is later.
• action_spec:

  Conclusion ()

  • assertion:
    Observation of 'Timing of next LDL test 'Due' Max of ?NOW and 6 months from time of last LDL test

  Recommend_VMROrder ()

  • order:
    VMR Order where code is subsumed by Fasting lipid profile (procedure) [SNOMED CT]
    • effectiveTime:
      Max of ?NOW and 6 months from time of last LDL test

11. Action: Order lipid labs 12 months from last labs

• description: Since the patient is not hyperlipidemic but LDL is between 90 mg/mL and goal, the next lipid panel is done in 12 months.
• action_spec:

  Action_Set ( Order set for lipid panel in 12 months )

  • action_spec:

    Conclusion ()

    • assertion:
      Observation of 'Timing of next LDL test 'Due' Max of ?NOW or 12 months from time of last LDL test

    Recommend_VMROrder ()

    • order:
      VMR Order where code is subsumed by Fasting lipid profile (procedure) [SNOMED CT]
      • effectiveTime:
        Max of ?NOW or 12 months from time of last LDL test

13. Action: Order lipid labs 24 months from last labs

• description: LDL is below 90 mg/dL, and hyperlipidemia is not on the problem list, so the next lipid labs may be done in 2 years.
• action_spec:

  Conclusion ()

  • assertion:
    Observation of 'Timing of next LDL test 'Due' Max of ?NOW or 2 years from time of last LDL test

  Recommend_VMROrder ()

  • order:
    VMR Order where code is subsumed by Fasting lipid profile (procedure) [SNOMED CT]
    • effectiveTime:
      Max of ?NOW or 2 years from time of last LDL test

15. Decision: When should pediatric lipid labs be ordered?

• description: If patient has never had lipid labs, order them if blood glucose is under control. If pt has hyperlipidemia, timing is same as adult. If no lipid problems, labs are obtained every 5 years.
• decision_model:

  Alternative_Choice ()

  • alternative:
    Order lipid panel now
  • recommendation_threshhold: 2
  • strict_rule_in:
    • most_recent GLUCOSE:MCNC:PT:BLD:QN: [LOINC] Observation < 100.0 mg/dL (qualifier value) [SNOMED CT]
    • absence of Observation LDL Tests for SAGE DM [SAGE LOINC]

  Alternative_Choice ()

  • alternative:
    Order lipid panel 6 months from last labs
  • recommendation_threshhold: 1
  • strict_rule_in:
    • ( NOT
      satisfy 'LDL Tests for SAGE DM [SAGE LOINC]' goal
      )
    • ( NOT
      satisfy 'Triglyceride tests for SAGE DM [SAGE LOINC]' goal
      )
    • ( NOT
      satisfy 'HDL Tests for SAGE DM [SAGE LOINC]' goal
      )
  • strict_rule_out:
    absence of Observation LDL Tests for SAGE DM [SAGE LOINC]

  Alternative_Choice ()

  • alternative:
    Order lipid panel 12 months from last labs
  • recommendation_threshhold: 1
  • strict_rule_in:
    ( AND
    • satisfy 'LDL Tests for SAGE DM [SAGE LOINC]' goal
    • presence of Family history of (contextual qualifier) (context-dependent category) [SNOMED CT]Observation Hyperlipidemia (disorder) [SNOMED CT]
    • ( NOT
      presence of Problem Hyperlipidemia (disorder) [SNOMED CT] Now
      )
    )
  • strict_rule_out:
    absence of Observation LDL Tests for SAGE DM [SAGE LOINC]

  Alternative_Choice ()

  • alternative:
    Order lipid panel 5 years from last labs
  • recommendation_threshhold: 3
  • strict_rule_in:
    • satisfy 'LDL Tests for SAGE DM [SAGE LOINC]' goal
    • ( NOT
      presence of Problem Hyperlipidemia (disorder) [SNOMED CT] Now
      )
    • absence of Family history of (contextual qualifier) (context-dependent category) [SNOMED CT]Observation Hyperlipidemia (disorder) [SNOMED CT]
  • strict_rule_out:
    absence of Observation LDL Tests for SAGE DM [SAGE LOINC]
• split_constraint: XOR

17. Action: Order lipid panel now

• description: Order lipid panel now
• action_spec:

  Order ( Order Fasting Lipid Panel Now )

  code is subsumed by Fasting lipid profile (procedure) [SNOMED CT]
  • effectiveTime:
    Now
  • vmr_class:
    VMROrder

  Conclusion ()

  • assertion:
    Observation of 'Timing of next LDL test 'Due' Now

19. Action: Order lipid panel 6 months from last labs

• description: If any lipid values are out of goal range, order them for six months after the last time they were ordered, or now, whichever is later.
• action_spec:

  Order ( Order Lipid Profile 6 months from last measurement )

  code is subsumed by Fasting lipid profile (procedure) [SNOMED CT]
  • effectiveTime:
    Max of ?NOW and 6 months from time of last LDL test
  • vmr_class:
    VMROrder

  Conclusion ()

  • assertion:
    Observation of 'Timing of next LDL test 'Due' Max of ?NOW and 6 months from time of last LDL test

21. Action: Order lipid panel 12 months from last labs

• description: Lipid values are within goal in a hyperlipidemic patient or one with a family history of hyperlipidemia, so order next labs in 12 months.
• action_spec:

  Order ( Order Lipid Profile 12 months from last lab )

  code is subsumed by Fasting lipid profile (procedure) [SNOMED CT]
  • effectiveTime:
    Max of ?NOW or 12 months from time of last LDL test
  • vmr_class:
    VMROrder

23. Action: Order lipid panel 5 years from last labs

• description: Lipid values are within goal for a pediatric patient without hyperlipidemia or a family history of hyperlipidemia. Order next labs in 5 years.
• action_spec:

  Order ( Order Lipid Profile 5 years from last lab )

  code is subsumed by Fasting lipid profile (procedure) [SNOMED CT]
  • effectiveTime:
    Max of ?NOW or 5 years from time of last LDL test
  • vmr_class:
    VMROrder

  Conclusion ()

  • assertion:
    Observation of 'Timing of next LDL test 'Due' Max of ?NOW or 5 years from time of last LDL test

25. Action: Order lipid labs for 3 months from last labs

• description: If lipid values are out of goal range, order the next set 3 months from last lipid labs.
• action_spec:

  Conclusion ()

  • assertion:
    Observation of 'Timing of next LDL test 'Due' Max of ?NOW and 3 months from time of last LDL test

  Recommend_VMROrder ()

  • order:
    VMR Order where code is subsumed by Fasting lipid profile (procedure) [SNOMED CT]
    • effectiveTime:
      Max of ?NOW and 3 months from time of last LDL test

Evidence Statements

Order Set: Hypertension -- Stage I -- no current antihypertensive therapy

Order Set: Hypertension -- Stage II -- no current antihypertensive therapy

Order Set: Hypertension -- Stage I -- currently on antihypertensive therapy

Order Set: Hypertension -- Stage II -- currently on antihypertensive therapy

Order Collection: Potassium-sparing diuretic

Order Collection: Combined alpha-beta blocker

Order Collection: Aldosterone antagonist

Order Collection: Non-dihydropyridine Ca channel blocker

Order Collection: Alpha-2 agonist

Order Collection: Dihydropyridine Ca channel blocker

Order Collection: Loop diuretic

Order Collection: Vasodilator

Order Collection: Thiazide

Order Collection: Angiotensin II Antagonist

Order Collection: Cardioselective beta blocker

Order Collection: Alpha-1 blocker

Order Collection: ACE Inhibitor

Order Collection: Beta blocker

Variable: NOW

Variable: DAY

Variable: Date of birth

Variable: Patient weight variable

Variable: Patient height variable

Variable: Age

Variable: Today (mid-night to midnight)