Atrius India Core FHIR Implementation Guide
0.1.0 - ci-build

Atrius India Core FHIR Implementation Guide - Local Development build (v0.1.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

Er Chest Pain Pathway

ER chest pain clinical pathway

Clinical decision support pathway for a person presenting to the emergency department with chest pain. This is a clinical-protocol PlanDefinition (not a quality measure): triage → classify etiology → branch-specific management.

See also: CDS clinical reasoning, Frontend contract.

Clinical overview

The pathway follows standard ED chest-pain logic:

  1. Confirm context — active emergency encounter with chest pain as chief complaint.
  2. Initial clinical assessment — focused history, examination, vital signs; obtain 12-lead ECG when ACS is suspected.
  3. Classify etiology (mutually exclusive branches after assessment):
    • Acute coronary syndrome (ACS)
    • Other cardiac — aortic dissection, pericarditis
    • Non-cardiac pulmonary — pneumothorax, pleurisy / pneumonia
    • Other — musculoskeletal chest pain, heartburn / GERD
  4. Branch management — ACS branch includes a full order-set scaffold (ECG, troponin, aspirin, cardiology consult); other branches are stubbed for extension.
ED encounter + chest pain
        │
        ▼
 Initial assessment (history, exam, vitals, ECG if ACS suspected)
        │
        ▼
 Record classification (QuestionnaireResponse — 7-way choice)
        │
        ▼
 Apply pathway branch ──exactly-one──► ...
        │                  ├── Aortic dissection workup
        │                  ├── Pericarditis workup
        │                  ├── Pneumothorax workup
        │                  ├── Pleurisy / pneumonia workup
        │                  ├── Musculoskeletal
        │                  └── Heartburn / GERD
        ▼
 Branch-specific orders (v0.1: ACS detailed; others stubbed)

v0.2: Classification is read from a completed QuestionnaireResponse to Questionnaire/er-chest-pain-classification. If none exists for the active ED encounter, CQL falls back to encounter diagnoses.

Classification questionnaire

Item Value
Questionnaire er-chest-pain-classification v0.2.0
Link id primary-classification
Answer type Single required choice (AtriusInERChestPainClassificationVS)

Answer options (7):

Code Label Pathway branch
acs Acute coronary syndrome ACS order set
aortic-dissection Aortic dissection Other cardiac
pericarditis Pericarditis Other cardiac
pneumothorax Pneumothorax Non-cardiac pulmonary
pleurisy-pneumonia Pleurisy or pneumonia Non-cardiac pulmonary
musculoskeletal Musculoskeletal chest pain Other
heartburn Heartburn or GERD Other

CQL reads the latest completed response linked to the active chest-pain ED encounter (Library/AtriusERChestPainPathway v0.2.0).

Example: QuestionnaireResponse/atrius-in-qr-er-chest-pain-acs-example (ACS selected).

Artifacts

Resource Id Role
Library AtriusERChestPainPathway v0.2.0 In Scope + QR-based classification
Questionnaire er-chest-pain-classification v0.2.0 7-way working classification form
PlanDefinition er-chest-pain-pathway v0.1.0 Workflow + CDS Hooks (encounter-start)
ActivityDefinition er-chest-pain-initial-assessment Assessment step
ActivityDefinition er-chest-pain-acs-* ACS order templates (ECG, troponin, aspirin, consult)
ActivityDefinition er-chest-pain-branch-* Non-ACS branch stubs

Canonical base: https://atrius.in/fhir/r4/atrius-in/

Authoring locations

input/fsh/clinical-reasoning/pathways/er-chest-pain/
  plandefinition.fsh
  activities/
    initial-assessment.fsh
    acs-orders.fsh
    branch-pathways.fsh
input/cql/AtriusERChestPainPathway.cql
input/resources/Library-AtriusERChestPainPathway.json

CDS Hooks

Concept Value
Service id er-chest-pain-pathway
Hook encounter-start
Applicability CQL In Scope
Prefetch Patient, Encounter, Condition, Observation (vitals)

Build and publish

./scripts/link-ig-loader-cql.sh
./scripts/translate-cql.sh
# sushi && ./_build.sh
./scripts/import-atrius-kr-libraries.py --clinical-reasoning
./scripts/cds-er-chest-pain-smoke.sh

Next steps (clinical + technical)

  1. Richer assessment form — add history/exam items before the classification question (still one QR or nested items).
  2. Expand non-ACS branches — add ActivityDefinitions for CT angiography (dissection), chest X-ray (pneumothorax), antibiotics (pneumonia), etc.
  3. Contraindication logic — CQL guards for aspirin, anticoagulation, allergy.
  4. Clinical validation — review with ED/cardiology stakeholders before production CDS deployment.