Add DetectedIssue resource as an option in FHIR Bundle order-sign/context/draftOrders

[GitJamis]

[rkboyce]

There is a need in the use case for potential drug-drug interaction CDS to be able to submit a DetectedIssue resource.

A workflow diagram showing the context for this need is shown in Figure 5 in the draft PDDI CDS IG. Note in that figure the ordering of PDDI CDS starting from order-select:

1. CDS service returns a card array with a DetectedIssue

2. Clinician makes a decision based on the action options in the card

3. The action is saved to DetectedIssue.mitigation.action

4. A copy of the DetectedIssue with the mitigation.action value would be sent to the CDS service in an order-sign hook

5. The mitigation.action value is used in logic in the CDS service to provide more precise and specific alerts.

One option is to put the DetectedIssue instance in the order-sign draftOrders bundle. We discussed this on a PDDI workgroup call and some of us (including myself) don't think that would be the best place for it. The main reason is that draftOrders holds items that are requests in FHIR workflow and placing DetectedIssue there seems to me to be conceptually and programmaticallly more difficult to work with.

Alternatively, adding an optional field to the order-sign hook that can hold one or more DetectedIssue resources might be a simpler solution.