PACIO - added extended case history and prescriber/pharmacy change detection (#183)

* added advanced case history and prescriber/pharmacy change detection

* run lint / prettier

* ncpdp endpoint implimentation

* update routing

* add package ndc code tracking for ncpdp messages

* fix ndc logic

* updated models for patient id tracking

* include response type in ncpdp messages

* use saved medication on rems case creation to get ndc code from rxnorm

* don't show patient status until patient enrolled

* rxfill

* proper reason code handling

* singular denial reason

* single denial reason

Author: smalho01

.env

@@ -12,6 +12,7 @@ VSAC_API_KEY = changeMe
 WHITELIST = *
 SERVER_NAME = CodeX REMS Administrator Prototype
 FULL_RESOURCE_IN_APP_CONTEXT = false
+DOCKERED_EHR_CONTAINER_NAME = false
 
 #Frontend Vars
 FRONTEND_PORT=9090

README.md

@@ -118,6 +118,8 @@ Following are a list of modifiable paths:
 | WHITELIST       | `http://localhost, http://localhost:3005`  | List of valid URLs for CORS. Should include any URLs the server accesses for resources.                                     |
 | SERVER_NAME     | `CodeX REMS Administrator Prototype`       | Name of the server that is returned in the card source.                                                                     |
 | FULL_RESOURCE_IN_APP_CONTEXT     | 'false'       | If true, the entire order resource will be included in the appContext, otherwise only a reference will be.                                                                     |
+| DOCKERED_EHR_CONTAINER_NAME     | ''       | String of the EHR container name for local docker networking communication                              |
+
 | FRONTEND_PORT            | `9080`                                             | Port that the frontend  server should run on, change if there are conflicts with port usage.                   |
 | VITE_REALM | `ClientFhirServer` | Keycloak realm for frontend authentication. |
 | VITE_AUTH | `http://localhost:8180` | Keycloak authentication server URL for frontend. |

src/config.ts

@@ -41,7 +41,8 @@ export default {
   fhirServerConfig: {
     auth: {
       // This server's URI
-      resourceServer: env.get('RESOURCE_SERVER').required().asUrlString()
+      resourceServer: env.get('RESOURCE_SERVER').required().asUrlString(),
+      dockered_ehr_container_name: env.get('DOCKERED_EHR_CONTAINER_NAME').asString()
       //
       // if you use this strategy, you need to add the corresponding env vars to docker-compose
       //

src/fhir/models.ts

@@ -5,7 +5,7 @@ export interface Requirement {
   name: string;
   description: string;
   questionnaire: Questionnaire | null;
-  stakeholderType: 'patient' | 'prescriber' | 'pharmacist' | string; // From fhir4.Parameters.parameter.name
+  stakeholderType: 'patient' | 'prescriber' | 'pharmacist' | string;
   createNewCase: boolean;
   resourceId: string;
   requiredToDispense: boolean;
@@ -15,7 +15,8 @@ export interface Requirement {
 export interface Medication extends Document {
   name: string;
   codeSystem: string;
-  code: string;
+  code: string;  // RxNorm code (used for CDS Hooks)
+  ndcCode: string;  // NDC code (used for NCPDP SCRIPT)
   requirements: Requirement[];
 }
 
@@ -30,15 +31,31 @@ export interface MetRequirements extends Document {
   metRequirementId: any;
 }
 
+export interface PrescriptionEvent {
+  medicationRequestReference: string;
+  prescriberId: string;
+  pharmacyId?: string;
+  timestamp: Date;
+  originatingFhirServer?: string;
+  caseStatusAtTime: string;
+}
+
 export interface RemsCase extends Document {
   case_number: string;
+  remsPatientId?: string;
   status: string;
   dispenseStatus: string;
   drugName: string;
   drugCode: string;
+  drugNdcCode?: string;
   patientFirstName: string;
   patientLastName: string;
   patientDOB: string;
+  currentPrescriberId?: string;
+  currentPharmacyId?: string;
+  prescriberHistory: string[];
+  pharmacyHistory: string[];
+  prescriptionEvents: PrescriptionEvent[];
   medicationRequestReference?: string;
   originatingFhirServer?: string;
   metRequirements: Partial<MetRequirements>[];
@@ -48,6 +65,7 @@ const medicationCollectionSchema = new Schema<Medication>({
   name: { type: String },
   codeSystem: { type: String },
   code: { type: String },
+  ndcCode: { type: String },
   requirements: [
     {
       name: { type: String },
@@ -63,6 +81,8 @@ const medicationCollectionSchema = new Schema<Medication>({
 });
 
 medicationCollectionSchema.index({ name: 1 }, { unique: true });
+medicationCollectionSchema.index({ code: 1 });
+medicationCollectionSchema.index({ ndcCode: 1 });
 
 export const medicationCollection = model<Medication>(
   'medicationCollection',
@@ -91,13 +111,29 @@ export const metRequirementsCollection = model<MetRequirements>(
 
 const remsCaseCollectionSchema = new Schema<RemsCase>({
   case_number: { type: String },
+  remsPatientId: { type: String },
   status: { type: String },
   dispenseStatus: { type: String },
   drugName: { type: String },
   patientFirstName: { type: String },
   patientLastName: { type: String },
   patientDOB: { type: String },
-  drugCode: { type: String },
+  drugCode: { type: String }, 
+  drugNdcCode: { type: String },
+  currentPrescriberId: { type: String },
+  currentPharmacyId: { type: String },
+  prescriberHistory: [{ type: String }],
+  pharmacyHistory: [{ type: String }],
+  prescriptionEvents: [
+    {
+      medicationRequestReference: { type: String },
+      prescriberId: { type: String },
+      pharmacyId: { type: String },
+      timestamp: { type: Date },
+      originatingFhirServer: { type: String },
+      caseStatusAtTime: { type: String }
+    }
+  ],
   medicationRequestReference: { type: String },
   originatingFhirServer: { type: String },
   metRequirements: [
@@ -111,4 +147,12 @@ const remsCaseCollectionSchema = new Schema<RemsCase>({
   ]
 });
 
+remsCaseCollectionSchema.index(
+  { patientFirstName: 1, patientLastName: 1, patientDOB: 1, drugNdcCode: 1 }
+);
+
+remsCaseCollectionSchema.index(
+  { patientFirstName: 1, patientLastName: 1, patientDOB: 1, drugCode: 1 }
+);
+
 export const remsCaseCollection = model<RemsCase>('RemsCaseCollection', remsCaseCollectionSchema);

src/fhir/utilities.ts

@@ -127,6 +127,7 @@ export class FhirUtilities {
         name: 'Turalio',
         codeSystem: 'http://www.nlm.nih.gov/research/umls/rxnorm',
         code: '2183126',
+        ndcCode: '65597-407-20',
         requirements: [
           {
             name: 'Patient Enrollment',
@@ -196,6 +197,7 @@ export class FhirUtilities {
         name: 'TIRF',
         codeSystem: 'http://www.nlm.nih.gov/research/umls/rxnorm',
         code: '1237051',
+        ndcCode: '63459-502-30',
         requirements: [
           {
             name: 'Patient Enrollment',
@@ -262,6 +264,7 @@ export class FhirUtilities {
         name: 'Isotretinoin',
         codeSystem: 'http://www.nlm.nih.gov/research/umls/rxnorm',
         code: '6064',
+        ndcCode: '0245-0571-01',
         requirements: [
           {
             name: 'Patient Enrollment',
@@ -305,6 +308,7 @@ export class FhirUtilities {
         name: 'Addyi',
         codeSystem: 'http://www.nlm.nih.gov/research/umls/rxnorm',
         code: '1666386',
+        ndcCode: '58604-214-30',
         requirements: []
       }
     ];

src/hooks/hookResources.ts

@@ -24,7 +24,7 @@ import {
 import axios from 'axios';
 import { ServicePrefetch } from '../rems-cds-hooks/resources/CdsService';
 import { hydrate } from '../rems-cds-hooks/prefetch/PrefetchHydrator';
-import { createNewRemsCaseFromCDSHook } from '../lib/etasu';
+import { createNewRemsCaseFromCDSHook, handleStakeholderChangesAndRecordEvent } from '../lib/etasu';
 
 type HandleCallback = (
   res: any,
@@ -406,11 +406,50 @@ export const handleCardOrder = async (
     drugCode: code
   });
 
+  // If case exists, check for stakeholder changes and record prescription event
+  if (remsCase && drug && fhirServer) {
+    const practitionerReference = request.requester?.reference || '';
+    const pharmacistReference = pharmacy?.id ? `HealthcareService/${pharmacy.id}` : '';
+    const medicationRequestReference = `${request.resourceType}/${request.id}`;
+
+    const prescriberChanged = remsCase.currentPrescriberId !== practitionerReference;
+    const pharmacyChanged =
+      pharmacistReference && remsCase.currentPharmacyId !== pharmacistReference;
+
+    if (prescriberChanged || pharmacyChanged) {
+      try {
+        const updatedCase = await handleStakeholderChangesAndRecordEvent(
+          remsCase,
+          drug,
+          practitionerReference,
+          pharmacistReference,
+          medicationRequestReference,
+          fhirServer
+        );
+        console.log(`Updated case ${updatedCase?.case_number} with stakeholder changes`);
+      } catch (error) {
+        console.error('Failed to handle stakeholder changes:', error);
+      }
+    } else {
+      // Record prescription event even if no stakeholder change
+      remsCase.prescriptionEvents.push({
+        medicationRequestReference: medicationRequestReference,
+        prescriberId: practitionerReference,
+        pharmacyId: pharmacistReference,
+        timestamp: new Date(),
+        originatingFhirServer: fhirServer,
+        caseStatusAtTime: remsCase.status
+      });
+      remsCase.medicationRequestReference = medicationRequestReference;
+      await remsCase.save();
+    }
+  }
+
   // If no REMS case exists and drug has requirements, create case with all requirements unmet
   if (!remsCase && drug && patient && request) {
     const requiresCase = drug.requirements.some(req => req.requiredToDispense);
 
-    if (requiresCase && fhirServer) {     
+    if (requiresCase && fhirServer) {
       try {
         const patientReference = `Patient/${patient.id}`;
         const medicationRequestReference = `${request.resourceType}/${request.id}`;
@@ -527,6 +566,11 @@ const getCardOrEmptyArrayFromRules =
       const notFound = remsCase && !metRequirement;
       const noEtasuToCheckAndRequiredToDispense = !remsCase && requirement.requiredToDispense;
 
+      // Only show forms that are not required to dispense (like patient status) if case is approved
+      if (!requirement.requiredToDispense && remsCase && remsCase.status !== 'Approved') {
+        return false;
+      }
+
       return formNotProcessed || notFound || noEtasuToCheckAndRequiredToDispense;
     };
 
@@ -786,7 +830,7 @@ const containsMatchingMedicationRequest =
 
 const getCardOrEmptyArrayFromCases =
   (entries: BundleEntry[] | undefined) =>
-  async ({ drugCode, drugName, metRequirements }: RemsCase): Promise<Card | never[]> => {
+  async ({ drugCode, drugName, metRequirements, status }: RemsCase): Promise<Card | never[]> => {
     // find the drug in the medicationCollection that matches the REMS case to get the smart links
     const drug = await medicationCollection
       .findOne({
@@ -828,6 +872,11 @@ const getCardOrEmptyArrayFromCases =
       const formNotProcessed = metRequirement && !metRequirement.completed;
       const notFound = !metRequirement;
 
+      // Only show forms that are not required to dispense (like patient status) if case is approved
+      if (!requirement.requiredToDispense && status !== 'Approved') {
+        return false;
+      }
+
       return formNotProcessed || notFound;
     };
 

src/lib/communication.ts

@@ -8,15 +8,14 @@ import { Requirement } from '../fhir/models';
 
 const logger = container.get('application');
 
-
 export async function sendCommunicationToEHR(
   remsCase: any,
   medication: any,
   outstandingRequirements: any[]
 ): Promise<void> {
   try {
     logger.info(`Creating Communication for case ${remsCase.case_number}`);
-    
+
     // Create patient object from REMS case
     const patient: Patient = {
       resourceType: 'Patient',
@@ -60,9 +59,10 @@ export async function sendCommunicationToEHR(
     // Create Tasks for each outstanding requirement
     const tasks: Task[] = [];
     for (const outstandingReq of outstandingRequirements) {
-      const requirement = outstandingReq.requirement || 
+      const requirement =
+        outstandingReq.requirement ||
         medication.requirements.find((r: Requirement) => r.name === outstandingReq.name);
-      
+
       if (requirement && requirement.appContext) {
         const questionnaireUrl = requirement.appContext;
         const task = createQuestionnaireCompletionTask(
@@ -80,7 +80,7 @@ export async function sendCommunicationToEHR(
     const communication: Communication = {
       resourceType: 'Communication',
       id: `comm-${uid()}`,
-      status: 'completed', 
+      status: 'completed',
       category: [
         {
           coding: [
@@ -92,7 +92,7 @@ export async function sendCommunicationToEHR(
           ]
         }
       ],
-      priority: 'urgent', 
+      priority: 'urgent',
       subject: {
         reference: `Patient/${patient.id}`,
         display: `${remsCase.patientFirstName} ${remsCase.patientLastName}`
@@ -107,7 +107,7 @@ export async function sendCommunicationToEHR(
         ],
         text: 'Outstanding REMS Requirements for Medication Dispensing'
       },
-      sent: new Date().toISOString(), 
+      sent: new Date().toISOString(),
       recipient: [
         {
           reference: medicationRequest.requester?.reference || ''
@@ -119,8 +119,9 @@ export async function sendCommunicationToEHR(
       },
       payload: [
         {
-          contentString: `Medication dispensing authorization DENIED for ${remsCase.drugName}.\n\n` +
-            `The following REMS requirements must be completed:\n\n` +
+          contentString:
+            `Medication dispensing authorization DENIED for ${remsCase.drugName}.\n\n` +
+            'The following REMS requirements must be completed:\n\n' +
             outstandingRequirements
               .map((req, idx) => `${idx + 1}. ${req.name} (${req.stakeholder})`)
               .join('\n') +
@@ -142,17 +143,24 @@ export async function sendCommunicationToEHR(
     };
 
     // Determine EHR endpoint: use originatingFhirServer if available, otherwise default
-    const ehrEndpoint = remsCase.originatingFhirServer || 
-      config.fhirServerConfig?.auth?.resourceServer;
+    let ehrEndpoint =
+      remsCase.originatingFhirServer || config.fhirServerConfig?.auth?.resourceServer;
 
     if (!ehrEndpoint) {
       logger.warn('No EHR endpoint configured, Communication not sent');
       return;
     }
 
+    if (config.fhirServerConfig.auth.dockered_ehr_container_name) {
+      const originalEhrEndpoint = ehrEndpoint;
+      ehrEndpoint = originalEhrEndpoint.replace(/localhost/g, config.fhirServerConfig.auth.dockered_ehr_container_name)
+            .replace(/127\.0\.0\.1/g, config.fhirServerConfig.auth.dockered_ehr_container_name);
+      logger.info(`Running locally in Docker, converting EHR url from ${originalEhrEndpoint} to ${ehrEndpoint}`);
+    }
+
     // Send Communication to EHR
     logger.info(`Sending Communication to EHR: ${ehrEndpoint}`);
-    
+
     const response = await axios.post(`${ehrEndpoint}/Communication`, communication, {
       headers: {
         'Content-Type': 'application/fhir+json'
@@ -164,9 +172,8 @@ export async function sendCommunicationToEHR(
     } else {
       logger.warn(`Unexpected response status from EHR: ${response.status}`);
     }
-    
   } catch (error: any) {
     logger.error(`Failed to send Communication to EHR: ${error.message}`);
-    throw error; 
+    throw error;
   }
-}
+}