#191: Handle Low BP recommendation.

input/cql/HypertensiveEmergency.cql

@@ -10,8 +10,9 @@ context Patient
 define function "BP Within 14 Days"(O Tuple { id String, effective DateTime, systolic Decimal, diastolic Decimal, readingType String }):
   O.effective + 14 days >= Today()
 
+// Two Low BPs are handled through an adverse event creation
 define "In Population":
-  Common."HTN Crisis"
+  Common."HTN Crisis" and not "Two Low BPs"
 
 define "BP Observation Count":
   Count(Common."All BP Observations" O)
@@ -21,20 +22,22 @@ define "Next Most Recent BP Reading":
   else null
 
 define "Two High BPs":
-  "In Population" and "BP Within 14 Days"(Common."Most Recent BP Reading") and 
+  Common."HTN High Crisis" and "BP Within 14 Days"(Common."Most Recent BP Reading") and 
   "BP Within 14 Days"("Next Most Recent BP Reading") and Common."HTN Crisis BP"("Next Most Recent BP Reading")
 
+define "Two Low BPs":
+  Common."HTN Low Crisis" and Common."HTN Low Crisis BP"("Next Most Recent BP Reading")
+
 define "Recommendation":
-  if "Two High BPs" then 'Blank.Summary'
-  else if "In Population" then 'Blank.Summary'
-  else null
+  'Blank.Summary'
 
 define "Rationale Combined Data":
   "Rationale" + '|' + "Suggestions" + '|' + "Selection Behavior" + '|' + "Links"
 
 define "Rationale":
   if "Two High BPs" then 'Your last two BP readings >=180 mmHg systolic and/or >=120 mmHg diastolic) are very high. <strong>If you <a href="/symptoms-911">do not feel well</a>, call 911; otherwise, it is strongly recommended that you now contact your clinic.</strong>'
-  else if "In Population" then 'Remain calm and check your BP again following these <a href="/vitals#instructions">instructions</a> in 5 to 30 minutes. Read more about managing very high blood pressure in the link below.'
+  else if Common."HTN High Crisis" then 'Remain calm and check your BP again following these <a href="/vitals#instructions">instructions</a> in 5 to 30 minutes. Read more about managing very high blood pressure in the link below.'
+  else if Common."HTN Low Crisis" then 'Remain calm and check your BP again following these <a href="/vitals#instructions">instructions</a> in 5 to 30 minutes. Read more about symptoms from low blood pressure in the link below.'
   else null
 
 define "Indicator Status":
@@ -44,14 +47,16 @@ define "Indicator Status":
 
 define "Suggestions":
   if "Two High BPs" then '[{"id": "display-clinic-contact", "label": "", "type": "clinic-contact"}]'
-  else if "In Population" then '[ { "id": "enter-bp-suggestion", "label": "Enter Blood Pressure", "type": "suggestion-link", "actions": [{"label":"Check your BP again (strongly recommended)", "url":"/vitals"}] } ]'
+  else if Common."HTN Crisis" then '[ { "id": "enter-bp-suggestion", "label": "Enter Blood Pressure", "type": "suggestion-link", "actions": [{"label":"Check your BP again (strongly recommended)", "url":"/vitals"}] } ]'
   else null
 
 define "Selection Behavior":
   'at-most-one'
 
 define "Links":
-  '[{"label":"American Heart Association: When to call 911 for high blood pressure", "url":"https://www.heart.org/en/health-topics/high-blood-pressure/understanding-blood-pressure-readings/hypertensive-crisis-when-you-should-call-911-for-high-blood-pressure"}]'
+if "Two High BPs" or Common."HTN High Crisis" then '[{"label":"American Heart Association: When to call 911 for high blood pressure", "url":"https://www.heart.org/en/health-topics/high-blood-pressure/understanding-blood-pressure-readings/hypertensive-crisis-when-you-should-call-911-for-high-blood-pressure"}]'
+else if Common."HTN Low Crisis" then '[{"label":"American Heart Association: When Blood Pressure is too Low", "url":"https://www.heart.org/en/health-topics/high-blood-pressure/the-facts-about-high-blood-pressure/low-blood-pressure-when-blood-pressure-is-too-low"}]'
+else null
 
 define "TEST Most Recent BP Reading":
   Common."Most Recent BP Reading"
@@ -62,3 +67,9 @@ define "TEST Next Most Recent BP Reading":
 define "TEST Two High BPs":
   "Two High BPs"
 
+define "TEST Two Low BPs":
+  "Two Low BPs"
+
+define "TEST One Low BP":
+  Common."HTN Low Crisis"
+

input/cql/OHSUHTNCommon.cql

@@ -90,6 +90,9 @@ define function "HTN Stage 2 BP Systolic Second Test"(list List<Tuple { id Strin
 define function "HTN Crisis BP"(O Tuple { id String, effective DateTime, systolic Decimal, diastolic Decimal, readingType String }):
   O.systolic >= 180 or O.diastolic >= 120
 
+define function "HTN Low Crisis BP"(O Tuple { id String, effective DateTime, systolic Decimal, diastolic Decimal, readingType String }):
+  O.systolic < 90 or O.diastolic < 60
+
 /* Helpers */
 define function WithUnit(list List<Observation>, Unit String):
   list Observations
@@ -450,9 +453,15 @@ define "All BP Observations":
 define "Most Recent BP Reading":
   Last("All BP Observations" O sort by effective)
 
-define "HTN Crisis":
+define "HTN High Crisis":
   "HTN Crisis BP"("Most Recent BP Reading")
 
+define "HTN Low Crisis":
+  "HTN Low Crisis BP"("Most Recent BP Reading")
+
+define "HTN Crisis":
+  "HTN High Crisis" or "HTN Low Crisis"
+
 define "Blood Pressure Observations for Last 2 Years":
   "All BP Observations" BP where BP.effective + 24 months >= Today()
     sort by effective

input/resources/plandefinition/plandefinition-HypertensiveEmergency.json

@@ -10,7 +10,7 @@
   ],
   "version": "0.1",
   "name": "HypertensiveEmergency",
-  "title": "High Blood Pressure Warning",
+  "title": "Blood Pressure Warning",
   "type": {
     "coding": [
       {
@@ -23,8 +23,8 @@
   "status": "draft",
   "date": "2020-02-04T00:00:00-08:00",
   "publisher": "Oregon Health and Science University (OHSU)",
-  "description": "This PlanDefinition detects a recent high blood pressure reading.",
-  "purpose": "The purpose is to identify very high blood pressure and recommend the patient seek treatment.",
+  "description": "This PlanDefinition detects a recent high or low blood pressure reading.",
+  "purpose": "The purpose is to identify very high or low blood pressure and recommend the patient seek treatment.",
   "usage": "This is to be used in conjunction with a patient-facing FHIR application.",
   "jurisdiction": [
     {
@@ -49,7 +49,7 @@
   "action": [
     {
       "title": "Recommendation",
-      "description": "Recommendation for patient with a recent very high blood pressure",
+      "description": "Recommendation for patient with a recent high or low blood pressure",
       "trigger": [{
         "type": "named-event",
         "name":"patient-view"
@@ -58,7 +58,7 @@
         {
           "kind": "applicability",
           "expression": {
-            "description": "Determine if patient had a recent very high blood pressure",
+            "description": "Determine if patient had a recent high or low blood pressure",
             "language": "text/cql.identifier",
             "expression": "In Population"
           }

input/tests/plandefinition/HypertensiveEmergency/HE-SingleLowBP/Condition/condition-HE-SingleLowBP-1.json

@@ -0,0 +1,52 @@
+{
+  "resourceType": "Condition",
+  "id": "condition-HE-SingleLowBP-1",
+  "note": [
+    {
+      "text": "Indicates Preexisting Diagnosis of Hypertension"
+    }
+  ],
+  "category": [
+    {
+      "coding": [
+        {
+          "system": "http://terminology.hl7.org/CodeSystem/condition-category",
+          "code": "problem-list-item",
+          "display": "Problem List Item"
+        }
+      ],
+      "text": "Problem List Item"
+    }
+  ],
+  "clinicalStatus": {
+    "coding": [
+      {
+        "system": "http://terminology.hl7.org/CodeSystem/condition-clinical",
+        "code": "active"
+      }
+    ]
+  },
+  "verificationStatus": {
+    "coding": [
+      {
+        "system": "http://terminology.hl7.org/CodeSystem/condition-ver-status",
+        "code": "confirmed"
+      }
+    ]
+  },
+  "code": {
+    "coding": [
+      {
+        "system": "http://snomed.info/sct",
+        "code": "59621000",
+        "display": "Hypertension"
+      }
+    ],
+    "text": "Hypertension"
+  },
+  "subject": {
+    "reference": "Patient/HE-SingleLowBP"
+  },
+  "onsetDateTime": "2017-01-23T15:16:21-05:00",
+  "recordedDate": "2017-01-23T15:16:21-05:00"
+}

input/tests/plandefinition/HypertensiveEmergency/HE-SingleLowBP/Encounter/encounter-HE-SingleLowBP-1.json

@@ -0,0 +1,28 @@
+{
+  "resourceType": "Encounter",
+  "id": "encounter-HE-SingleLowBP-1",
+  "status": "finished",
+  "class": {
+    "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode",
+    "code": "AMB"
+  },
+  "type": [
+    {
+      "coding": [
+        {
+          "system": "http://snomed.info/sct",
+          "code": "162673000",
+          "display": "General examination of patient (procedure)"
+        }
+      ],
+      "text": "General examination of patient (procedure)"
+    }
+  ],
+  "subject": {
+    "reference": "Patient/HE-SingleLowBP"
+  },
+  "period": {
+    "start": "2023-01-22T00:00:00-04:00",
+    "end": "2023-01-22T23:59:59-04:00"
+  }
+}

input/tests/plandefinition/HypertensiveEmergency/HE-SingleLowBP/Encounter/encounter-HE-SingleLowBP-2.json

@@ -0,0 +1,28 @@
+{
+  "resourceType": "Encounter",
+  "id": "encounter-HE-SingleLowBP-2",
+  "status": "finished",
+  "class": {
+    "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode",
+    "code": "AMB"
+  },
+  "type": [
+    {
+      "coding": [
+        {
+          "system": "http://snomed.info/sct",
+          "code": "162673000",
+          "display": "General examination of patient (procedure)"
+        }
+      ],
+      "text": "General examination of patient (procedure)"
+    }
+  ],
+  "subject": {
+    "reference": "Patient/HE-SingleLowBP"
+  },
+  "period": {
+    "start": "2023-02-22T00:00:00-04:00",
+    "end": "2023-02-22T23:59:59-04:00"
+  }
+}

input/tests/plandefinition/HypertensiveEmergency/HE-SingleLowBP/Encounter/encounter-HE-SingleLowBP-3.json

@@ -0,0 +1,28 @@
+{
+  "resourceType": "Encounter",
+  "id": "encounter-HE-SingleLowBP-3",
+  "status": "finished",
+  "class": {
+    "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode",
+    "code": "AMB"
+  },
+  "type": [
+    {
+      "coding": [
+        {
+          "system": "http://snomed.info/sct",
+          "code": "162673000",
+          "display": "General examination of patient (procedure)"
+        }
+      ],
+      "text": "General examination of patient (procedure)"
+    }
+  ],
+  "subject": {
+    "reference": "Patient/HE-SingleLowBP"
+  },
+  "period": {
+    "start": "2023-03-22T00:00:00-04:00",
+    "end": "2023-03-22T23:59:59-04:00"
+  }
+}

input/tests/plandefinition/HypertensiveEmergency/HE-SingleLowBP/Encounter/encounter-HE-SingleLowBP-4.json

@@ -0,0 +1,28 @@
+{
+  "resourceType": "Encounter",
+  "id": "encounter-HE-SingleLowBP-4",
+  "status": "finished",
+  "class": {
+    "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode",
+    "code": "AMB"
+  },
+  "type": [
+    {
+      "coding": [
+        {
+          "system": "http://snomed.info/sct",
+          "code": "162673000",
+          "display": "General examination of patient (procedure)"
+        }
+      ],
+      "text": "General examination of patient (procedure)"
+    }
+  ],
+  "subject": {
+    "reference": "Patient/HE-SingleLowBP"
+  },
+  "period": {
+    "start": "2023-04-22T00:00:00-04:00",
+    "end": "2023-04-22T23:59:59-04:00"
+  }
+}

input/tests/plandefinition/HypertensiveEmergency/HE-SingleLowBP/Goal/goal-HE-SingleLowBP-1.json

@@ -0,0 +1,61 @@
+{
+  "resourceType": "Goal",
+  "id": "goal-HE-SingleLowBP-1",
+  "lifecycleStatus": "active",
+  "achievementStatus": {
+    "coding": [
+      {
+        "system": "http://terminology.hl7.org/CodeSystem/goal-achievement",
+        "version": "4.0.1",
+        "code": "in-progress",
+        "display": "In Progress"
+      }
+    ]
+  },
+  "statusDate": "2023-07-08",
+"startDate": "2023-07-08",
+  "description": {
+    "text": "Goal of 135/85"
+  },
+  "subject": {
+    "reference": "Patient/HE-SingleLowBP"
+  },
+  "target": [
+    {
+      "measure": {
+        "coding": [
+          {
+            "system": "http://loinc.org",
+            "version": "2.68",
+            "code": "8480-6",
+            "display": "Systolic blood pressure"
+          }
+        ]
+      },
+      "detailQuantity": {
+        "value": 135,
+        "unit": "mmHg",
+        "system": "http://unitsofmeasure.org",
+        "code": "mm[Hg]"
+      }
+    },
+    {
+      "measure": {
+        "coding": [
+          {
+            "system": "http://loinc.org",
+            "version": "2.68",
+            "code": "8462-4",
+            "display": "Diastolic blood pressure"
+          }
+        ]
+      },
+      "detailQuantity": {
+        "value": 85,
+        "unit": "mmHg",
+        "system": "http://unitsofmeasure.org",
+        "code": "mm[Hg]"
+      }
+    }
+  ]
+}