Colorectal Cancer Screening and Management (CRCSM) Clinical Decision Support (CDS) Implementation Guide
0.1.0 - ci-build
Colorectal Cancer Screening and Management (CRCSM) Clinical Decision Support (CDS) Implementation Guide - Local Development build (v0.1.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions
| Draft as of 2025-02-28 |
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<td style="padding-left: 4px;"><a href="PlanDefinition-flow-DecisionToScreen.html">Decision to Screen</a></td>
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<td style="padding-left: 4px;">0.1.0</td>
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<th scope="row"><b>Date: </b></th>
<td style="padding-left: 4px;">2025-02-28</td>
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<th scope="row"><b>Publisher: </b></th>
<td style="padding-left: 4px;">MITRE</td>
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<tr>
<th scope="row"><b>Description: </b></th>
<td style="padding-left: 4px;"><div><p>Evaluates criteria for when to stop screening for colorectal cancer, and determines whether the patient is eligible for average risk screening, increased risk screening, or surveillance, based on the risk factors outlined by USPSTF.</p>
<p>Provides recommendations for screening and surveillance based on the identified risk path and specific risk factors.</p>
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structured
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<td style="padding-left: 4px;"><div><p>(C) 2025 The MITRE Corporation. All Rights Reserved. Approved for Public Release: 24-2711. Distribution Unlimited. Unless otherwise noted, this work is available under an Apache 2.0 license. It was produced by the MITRE Corporation for the Division of Cancer Prevention and Control, Centers for Disease Control and Prevention in accordance with the Statement of Work, contract number 75FCMC18D0047, task order number 75D30123F17931.</p>
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<th scope="row"><b>Approval Date: </b></th>
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<th scope="row"><b>Libraries: </b></th>
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<td><code>Library/DecisionToScreen|1.0.0</code></td>
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<th scope="row"><b>Actions: </b></th>
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<tr>
<td>
<b> Selectively offer screening:</b> The USPSTF recommends that clinicians selectively offer screening for colorectal cancer in adults aged 76 to 85 years.
<br/>
<b>If:</b>
<i>Applicability:</i>
<i>(ExistsSDMContinueScreeningAge)</i>
<br/>
<b>Then:</b> <i>Definition:</i> <code>http://cancerscreeningcds.github.io/crcsm-cds/ActivityDefinition/CommunicateSDMContinueScreening|1.0.0</code><br/>
<i>Dynamic Values:</i><br/>
reasonCode[0].coding[0]: <i>(SDMContinueScreeningAgeReason)</i>
<br/>
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<b> Discuss decision to continue screening:</b> ACS advises that individuals should continue colorectal cancer screening as long as their overall health is good and they have a life expectancy of 10 years or more. Decision to continue screening in cases of limited life expectancy should be based on shared decision-making.
<br/>
<b>If:</b>
<i>Applicability:</i>
<i>(ExistsSDMContinueScreeningLifeExp)</i>
<br/>
<b>Then:</b> <i>Definition:</i> <code>http://cancerscreeningcds.github.io/crcsm-cds/ActivityDefinition/CommunicateSDMContinueScreening|1.0.0</code><br/>
<i>Dynamic Values:</i><br/>
reasonCode[0].coding[0]: <i>(SDMContinueScreeningLifeExpReason)</i>
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<b> Stop screening:</b> Evidence is lacking on benefits and harms of colorectal cancer screening for individuals aged 86 and older. Competing causes of mortality likely preclude survival benefit that would outweigh the harms of screening.
<br/>
<b>If:</b>
<i>Applicability:</i>
<i>(ExistsStopScreeningAge)</i>
<br/>
<b>Then:</b> <i>Definition:</i> <code>http://cancerscreeningcds.github.io/crcsm-cds/ActivityDefinition/CommunicateRecommendationStopScreening|1.0.0</code><br/>
<i>Dynamic Values:</i><br/>
reasonCode[0].coding[0]: <i>(StopScreeningAgeReason)</i>
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<td>
<b> Colorectal cancer surveillance per specialist recommendations:</b> Refer to GI specialist for colorectal cancer (and possibly additional cancers) surveillance recommendations.
Patients with a hereditary cancer syndrome require specialized management and colonoscopy surveillance for colorectal cancer (as well as additional surveillance for other cancers). Recommendations on when to start surveillance and surveillance intervals vary according to the syndrome.
<br/>
<b>If:</b>
<i>Applicability:</i>
<i>(ExistsHereditarySyndrome)</i>
<br/>
<i>Applicability:</i>
<i>(ExistsIncreasedRiskExclusionsRecommendations)</i>
<br/>
<b>Then:</b> <i>Definition:</i> <code>http://cancerscreeningcds.github.io/crcsm-cds/ActivityDefinition/ColorectalCancerScreeningServiceRequest|1.0.0</code><br/>
<i>Dynamic Values:</i><br/>
code.coding[0]: <i>(HereditarySyndromeCode)</i>
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reasonCode[0].coding[0]: <i>(HereditarySyndromeReason)</i>
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<b> IBD surveillance per specialist recommendations:</b> Start colonoscopy surveillance 8-10 years after disease onset.
Repeat colonoscopy every 1-5 years based on GI specialist recommendations.
<br/>
<b>If:</b>
<i>Applicability:</i>
<i>(ExistsIBD)</i>
<br/>
<i>Applicability:</i>
<i>(ExistsIncreasedRiskExclusionsRecommendations)</i>
<br/>
<b>Then:</b> <i>Definition:</i> <code>http://cancerscreeningcds.github.io/crcsm-cds/ActivityDefinition/ColorectalCancerScreeningServiceRequest|1.0.0</code><br/>
<i>Dynamic Values:</i><br/>
code.coding[0]: <i>(IBDCode)</i>
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reasonCode[0].coding[0]: <i>(IBDReason)</i>
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<b> Post-colorectal cancer resection surveillance:</b> Patients with a history of colorectal cancer should begin colonoscopy surveillance 1 year pos-resection.
Repeat colonoscopy 3 years after 1st surveillance, and every 5 years thereafter. Post-polypectomy surveillance intervals apply if shorter.
Refer to patient's oncologic treatment team of survivorship care plan for patient-specific guidance.
<br/>
<b>If:</b>
<i>Applicability:</i>
<i>(ExistsHxCRC)</i>
<br/>
<i>Applicability:</i>
<i>(ExistsIncreasedRiskExclusionsRecommendations)</i>
<br/>
<b>Then:</b> <i>Definition:</i> <code>http://cancerscreeningcds.github.io/crcsm-cds/ActivityDefinition/ColorectalCancerScreeningServiceRequest|1.0.0</code><br/>
<i>Dynamic Values:</i><br/>
code.coding[0]: <i>(HxCRCCode)</i>
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reasonCode[0].coding[0]: <i>(HxCRCReason)</i>
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<b> Family history increased risk screening/surveillance:</b> For patients with a single first-degree relative (mother, father, full sibling, child) with colorectal cancer or an advanced polyp(s):
* If relative diagnosed at >= 60 years:
* Start screening at 40 years old. Tests and intervals are as per average risk screening recommendations.
* If relative diagnosed at < 60 years old:
* Start screening 10 years before relative's age at diagnosis or age 40, whichever is earlier. Repeat colonoscopy every 5 years.
* If no significant neoplasia appears by age 60 years, can offer expanding the interval between colonoscopies.
For patients with 2 or more first-degree relatives with colorectal cancer or an advanced polyp:
* Start screening colonoscopy 10 years before the reatives' youngest age at diagnosis or age 40, whichever is earlier. Repeat colonoscopy every 5 years.
Patients with a history of potentially precancerous polyps should follow shortest interval between recommendations above and recommendations based on colonoscopy findings.
<br/>
<b>If:</b>
<i>Applicability:</i>
<i>(ExistsFamilyHx)</i>
<br/>
<i>Applicability:</i>
<i>(ExistsIncreasedRiskExclusionsRecommendations)</i>
<br/>
<b>Then:</b> <i>Definition:</i> <code>http://cancerscreeningcds.github.io/crcsm-cds/ActivityDefinition/ColorectalCancerScreeningServiceRequest|1.0.0</code><br/>
<i>Dynamic Values:</i><br/>
code.coding[0]: <i>(FamilyHxCode)</i>
<br/>
reasonCode[0].coding[0]: <i>(FamilyHxReason)</i>
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<b> Post-polypectomy surveillance:</b> Follow endoscopist-recommended interval.
<br/>
<b>If:</b>
<i>Applicability:</i>
<i>(ExistsHxPolyps)</i>
<br/>
<i>Applicability:</i>
<i>(ExistsIncreasedRiskExclusionsRecommendations)</i>
<br/>
<b>Then:</b> <i>Definition:</i> <code>http://cancerscreeningcds.github.io/crcsm-cds/ActivityDefinition/ColorectalCancerScreeningServiceRequest|1.0.0</code><br/>
<i>Dynamic Values:</i><br/>
code.coding[0]: <i>(HxPolypsCode)</i>
<br/>
reasonCode[0].coding[0]: <i>(HxPolypsReason)</i>
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<b> Start screening at 45 years old:</b> Patients at average risk for colorectal cancer should start screening at 45 years old.
<br/>
<b>If:</b>
<i>Applicability:</i>
<i>(ExistsUSPSTFAvgRiskStartAt45)</i>
<br/>
<i>Applicability:</i>
<i>(ExistsUSPSTFAverageRiskRecommendations)</i>
<br/>
<b>Then:</b> <i>Definition:</i> <code>http://cancerscreeningcds.github.io/crcsm-cds/ActivityDefinition/ColorectalCancerScreeningServiceRequest|1.0.0</code><br/>
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<b> Start screening Now:</b> Start screening now. Patients at average risk for colorectal cancer should start screening at 45 years old.
Screening strategies and intervals recommended for average risk patients include:
* Colonoscopy every 10 years
* High-sensitivity gFOBT or FIT every year
* sDNA-FIT every 1 to 3 years
* CT colonography every 5 years
* Flexible sigmoidoscopy every 5 years
* Flexible sigmoidoscopy every 10 years + FIT every year
<br/>
<b>If:</b>
<i>Applicability:</i>
<i>(ExistsUSPSTFAvgRiskStartNow)</i>
<br/>
<i>Applicability:</i>
<i>(ExistsUSPSTFAverageRiskRecommendations)</i>
<br/>
<b>Then:</b> <i>Definition:</i> <code>http://cancerscreeningcds.github.io/crcsm-cds/ActivityDefinition/ColorectalCancerScreeningServiceRequest|1.0.0</code><br/>
<i>Dynamic Values:</i><br/>
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<b> Continue routine screening:</b> Continue routine screening.
Screening strategies and intervals recommended for average risk patients include:
* Colonoscopy every 10 years
* High-sensitivity gFOBT or FIT every year
* sDNA-FIT every 1 to 3 years
* CT colonography every 5 years
* Flexible sigmoidoscopy every 5 years
* Flexible sigmoidoscopy every 10 years + FIT every year
<br/>
<b>If:</b>
<i>Applicability:</i>
<i>(ExistsUSPSTFAvgRiskNextDue)</i>
<br/>
<i>Applicability:</i>
<i>(ExistsUSPSTFAverageRiskRecommendations)</i>
<br/>
<b>Then:</b> <i>Definition:</i> <code>http://cancerscreeningcds.github.io/crcsm-cds/ActivityDefinition/ColorectalCancerScreeningServiceRequest|1.0.0</code><br/>
<i>Dynamic Values:</i><br/>
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value="Gupta, S., et al. (2020). Recommendations for Follow-Up After Colonoscopy and Polypectomy: A Consensus Update by the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology, 158(4), 1131–1153.e5. https://doi.org/10.1053/j.gastro.2019.10.026"/>
</documentation>
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<kind value="applicability"/>
<expression>
<language value="text/cql-identifier"/>
<expression value="ExistsHxCRC"/>
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<condition>
<kind value="applicability"/>
<expression>
<language value="text/cql-identifier"/>
<expression value="ExistsIncreasedRiskExclusionsRecommendations"/>
</expression>
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<expression value="HxCRCCode"/>
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<expression value="HxCRCReason"/>
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<action id="FamilyHistoryIncreasedRisk">
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<description
value="For patients with a single first-degree relative (mother, father, full sibling, child) with colorectal cancer or an advanced polyp(s):
* If relative diagnosed at >= 60 years:
* Start screening at 40 years old. Tests and intervals are as per average risk screening recommendations.
* If relative diagnosed at < 60 years old:
* Start screening 10 years before relative's age at diagnosis or age 40, whichever is earlier. Repeat colonoscopy every 5 years.
* If no significant neoplasia appears by age 60 years, can offer expanding the interval between colonoscopies.
For patients with 2 or more first-degree relatives with colorectal cancer or an advanced polyp:
* Start screening colonoscopy 10 years before the reatives' youngest age at diagnosis or age 40, whichever is earlier. Repeat colonoscopy every 5 years.
Patients with a history of potentially precancerous polyps should follow shortest interval between recommendations above and recommendations based on colonoscopy findings."/>
<documentation>
<type value="citation"/>
<label value="USMSTF (2017)"/>
<display
value="Colorectal Cancer Screening: Recommendations for Physicians and Patients From the U.S. Multi-Society Task Force on Colorectal Cancer"/>
<citation
value="Rex, D. K., et al. (2017). Colorectal Cancer Screening: Recommendations for Physicians and Patients From the U.S. Multi-Society Task Force on Colorectal Cancer. Gastroenterology, 153(1), 307-323. https://doi.org/10.1053/j.gastro.2017.05.013"/>
</documentation>
<documentation>
<type value="citation"/>
<label value="ACG Average Risk (2021)"/>
<display
value="ACG Clinical Guidelines: Colorectal Cancer Screening 2021"/>
<citation
value="Shaukat, A., et al. (2021). ACG Clinical Guidelines: Colorectal Cancer Screening 2021. American Journal of Gastroenterology, 116(3), 458-479. https://doi.org/10.14309/ajg.0000000000001122"/>
</documentation>
<documentation>
<type value="citation"/>
<label
value="USMSTF Follow-Up After Colonoscopy and Polypectomy (2020)"/>
<display
value="Recommendations for Follow-Up After Colonoscopy and Polypectomy: A Consensus Update by the US Multi-Society Task Force on Colorectal Cancer"/>
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</documentation>
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<kind value="applicability"/>
<expression>
<language value="text/cql-identifier"/>
<expression value="ExistsFamilyHx"/>
</expression>
</condition>
<condition>
<kind value="applicability"/>
<expression>
<language value="text/cql-identifier"/>
<expression value="ExistsIncreasedRiskExclusionsRecommendations"/>
</expression>
</condition>
<definitionCanonical
value="http://cancerscreeningcds.github.io/crcsm-cds/ActivityDefinition/ColorectalCancerScreeningServiceRequest|1.0.0"/>
<dynamicValue>
<path value="code.coding[0]"/>
<expression>
<language value="text/cql-identifier"/>
<expression value="FamilyHxCode"/>
</expression>
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<dynamicValue>
<path value="reasonCode[0].coding[0]"/>
<expression>
<language value="text/cql-identifier"/>
<expression value="FamilyHxReason"/>
</expression>
</dynamicValue>
</action>
<action id="HistoryPolypsIncreasedRisk">
<title value="Post-polypectomy surveillance"/>
<description value="Follow endoscopist-recommended interval. "/>
<documentation>
<type value="citation"/>
<label
value="USMSTF Follow-Up After Colonoscopy and Polypectomy (2020)"/>
<display
value="Recommendations for Follow-Up After Colonoscopy and Polypectomy: A Consensus Update by the US Multi-Society Task Force on Colorectal Cancer"/>
<citation
value="Gupta, S., et al. (2020). Recommendations for Follow-Up After Colonoscopy and Polypectomy: A Consensus Update by the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology, 158(4), 1131–1153.e5. https://doi.org/10.1053/j.gastro.2019.10.026"/>
</documentation>
<condition>
<kind value="applicability"/>
<expression>
<language value="text/cql-identifier"/>
<expression value="ExistsHxPolyps"/>
</expression>
</condition>
<condition>
<kind value="applicability"/>
<expression>
<language value="text/cql-identifier"/>
<expression value="ExistsIncreasedRiskExclusionsRecommendations"/>
</expression>
</condition>
<definitionCanonical
value="http://cancerscreeningcds.github.io/crcsm-cds/ActivityDefinition/ColorectalCancerScreeningServiceRequest|1.0.0"/>
<dynamicValue>
<path value="code.coding[0]"/>
<expression>
<language value="text/cql-identifier"/>
<expression value="HxPolypsCode"/>
</expression>
</dynamicValue>
<dynamicValue>
<path value="reasonCode[0].coding[0]"/>
<expression>
<language value="text/cql-identifier"/>
<expression value="HxPolypsReason"/>
</expression>
</dynamicValue>
</action>
<action id="StartScreeningAt45YearsOld">
<title value="Start screening at 45 years old"/>
<description
value="Patients at average risk for colorectal cancer should start screening at 45 years old."/>
<documentation>
<type value="citation"/>
<label value="USPSTF (2021)"/>
<display
value="Screening for Colorectal Cancer: US Preventive Services Task Force Recommendation Statement"/>
<citation
value="US Preventive Services Task Force. Screening for Colorectal Cancer: US Preventive Services Task Force Recommendation Statement. JAMA. Published online May 18, 2021."/>
<url
value="https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/colorectal-cancer-screening"/>
<document>
<url
value="https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/colorectal-cancer-screening"/>
</document>
</documentation>
<condition>
<kind value="applicability"/>
<expression>
<language value="text/cql-identifier"/>
<expression value="ExistsUSPSTFAvgRiskStartAt45"/>
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</condition>
<condition>
<kind value="applicability"/>
<expression>
<language value="text/cql-identifier"/>
<expression value="ExistsUSPSTFAverageRiskRecommendations"/>
</expression>
</condition>
<definitionCanonical
value="http://cancerscreeningcds.github.io/crcsm-cds/ActivityDefinition/ColorectalCancerScreeningServiceRequest|1.0.0"/>
<dynamicValue>
<path value="%action.code[0].coding[0]"/>
<expression>
<language value="text/cql-identifier"/>
<expression value="USPSTFAvgRiskCode"/>
</expression>
</dynamicValue>
<dynamicValue>
<path value="%action.timingTiming"/>
<expression>
<language value="text/cql-identifier"/>
<expression value="USPSTFAvgRiskTiming"/>
</expression>
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<dynamicValue>
<path value="code.coding[0]"/>
<expression>
<language value="text/cql-identifier"/>
<expression value="USPSTFAvgRiskCode"/>
</expression>
</dynamicValue>
<dynamicValue>
<path value="reasonCode[0].coding[0]"/>
<expression>
<language value="text/cql-identifier"/>
<expression value="USPSTFAvgRiskReason"/>
</expression>
</dynamicValue>
<dynamicValue>
<path value="occurrenceDateTime"/>
<expression>
<language value="text/cql-identifier"/>
<expression value="USPSTFAvgRiskTimingEvent"/>
</expression>
</dynamicValue>
</action>
<action id="StartScreening">
<title value="Start screening Now"/>
<description
value="Start screening now. Patients at average risk for colorectal cancer should start screening at 45 years old.
Screening strategies and intervals recommended for average risk patients include:
* Colonoscopy every 10 years
* High-sensitivity gFOBT or FIT every year
* sDNA-FIT every 1 to 3 years
* CT colonography every 5 years
* Flexible sigmoidoscopy every 5 years
* Flexible sigmoidoscopy every 10 years + FIT every year"/>
<documentation>
<type value="citation"/>
<label value="USPSTF (2021)"/>
<display
value="Screening for Colorectal Cancer: US Preventive Services Task Force Recommendation Statement"/>
<citation
value="US Preventive Services Task Force. Screening for Colorectal Cancer: US Preventive Services Task Force Recommendation Statement. JAMA. Published online May 18, 2021."/>
<url
value="https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/colorectal-cancer-screening"/>
<document>
<url
value="https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/colorectal-cancer-screening"/>
</document>
</documentation>
<condition>
<kind value="applicability"/>
<expression>
<language value="text/cql-identifier"/>
<expression value="ExistsUSPSTFAvgRiskStartNow"/>
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</condition>
<condition>
<kind value="applicability"/>
<expression>
<language value="text/cql-identifier"/>
<expression value="ExistsUSPSTFAverageRiskRecommendations"/>
</expression>
</condition>
<definitionCanonical
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<dynamicValue>
<path value="%action.code[0].coding[0]"/>
<expression>
<language value="text/cql-identifier"/>
<expression value="USPSTFAvgRiskCode"/>
</expression>
</dynamicValue>
<dynamicValue>
<path value="%action.timingTiming"/>
<expression>
<language value="text/cql-identifier"/>
<expression value="USPSTFAvgRiskTiming"/>
</expression>
</dynamicValue>
<dynamicValue>
<path value="code.coding[0]"/>
<expression>
<language value="text/cql-identifier"/>
<expression value="USPSTFAvgRiskCode"/>
</expression>
</dynamicValue>
<dynamicValue>
<path value="reasonCode[0].coding[0]"/>
<expression>
<language value="text/cql-identifier"/>
<expression value="USPSTFAvgRiskReason"/>
</expression>
</dynamicValue>
<dynamicValue>
<path value="occurrenceDateTime"/>
<expression>
<language value="text/cql-identifier"/>
<expression value="USPSTFAvgRiskTimingEvent"/>
</expression>
</dynamicValue>
</action>
<action id="ContinueRoutineScreening">
<title value="Continue routine screening"/>
<description
value="Continue routine screening.
Screening strategies and intervals recommended for average risk patients include:
* Colonoscopy every 10 years
* High-sensitivity gFOBT or FIT every year
* sDNA-FIT every 1 to 3 years
* CT colonography every 5 years
* Flexible sigmoidoscopy every 5 years
* Flexible sigmoidoscopy every 10 years + FIT every year"/>
<documentation>
<type value="citation"/>
<label value="USPSTF (2021)"/>
<display
value="Screening for Colorectal Cancer: US Preventive Services Task Force Recommendation Statement"/>
<citation
value="US Preventive Services Task Force. Screening for Colorectal Cancer: US Preventive Services Task Force Recommendation Statement. JAMA. Published online May 18, 2021."/>
<url
value="https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/colorectal-cancer-screening"/>
<document>
<url
value="https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/colorectal-cancer-screening"/>
</document>
</documentation>
<condition>
<kind value="applicability"/>
<expression>
<language value="text/cql-identifier"/>
<expression value="ExistsUSPSTFAvgRiskNextDue"/>
</expression>
</condition>
<condition>
<kind value="applicability"/>
<expression>
<language value="text/cql-identifier"/>
<expression value="ExistsUSPSTFAverageRiskRecommendations"/>
</expression>
</condition>
<definitionCanonical
value="http://cancerscreeningcds.github.io/crcsm-cds/ActivityDefinition/ColorectalCancerScreeningServiceRequest|1.0.0"/>
<dynamicValue>
<path value="%action.code[0].coding[0]"/>
<expression>
<language value="text/cql-identifier"/>
<expression value="USPSTFAvgRiskCode"/>
</expression>
</dynamicValue>
<dynamicValue>
<path value="%action.timingTiming"/>
<expression>
<language value="text/cql-identifier"/>
<expression value="USPSTFAvgRiskTiming"/>
</expression>
</dynamicValue>
<dynamicValue>
<path value="code.coding[0]"/>
<expression>
<language value="text/cql-identifier"/>
<expression value="USPSTFAvgRiskCode"/>
</expression>
</dynamicValue>
<dynamicValue>
<path value="reasonCode[0].coding[0]"/>
<expression>
<language value="text/cql-identifier"/>
<expression value="USPSTFAvgRiskReason"/>
</expression>
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<dynamicValue>
<path value="occurrenceDateTime"/>
<expression>
<language value="text/cql-identifier"/>
<expression value="USPSTFAvgRiskTimingEvent"/>
</expression>
</dynamicValue>
</action>
</PlanDefinition>