openevidence-reference-architecture

OpenEvidence Reference Architecture

Overview

Production-ready architecture patterns for OpenEvidence clinical AI integrations in healthcare environments.

Prerequisites

• Understanding of layered architecture
• OpenEvidence SDK knowledge
• Healthcare compliance requirements
• TypeScript/Node.js project setup

Project Structure

clinical-evidence-api/
├── src/
│   ├── openevidence/
│   │   ├── client.ts           # Singleton client wrapper
│   │   ├── config.ts           # Environment configuration
│   │   ├── types.ts            # TypeScript types
│   │   ├── errors.ts           # Custom error classes
│   │   ├── cache.ts            # Caching layer
│   │   └── handlers/
│   │       ├── webhooks.ts     # Webhook handlers
│   │       └── events.ts       # Event processing
│   ├── services/
│   │   └── clinical/
│   │       ├── index.ts        # Service facade
│   │       ├── query.ts        # Clinical query service
│   │       ├── deepconsult.ts  # DeepConsult service
│   │       └── drug-info.ts    # Drug information service
│   ├── api/
│   │   ├── routes/
│   │   │   ├── clinical.ts     # Clinical query endpoints
│   │   │   └── webhooks.ts     # Webhook endpoints
│   │   └── middleware/
│   │       ├── auth.ts         # Authentication
│   │       ├── audit.ts        # HIPAA audit logging
│   │       └── rate-limit.ts   # Rate limiting
│   ├── integrations/
│   │   ├── ehr/
│   │   │   ├── fhir.ts         # FHIR integration
│   │   │   ├── epic.ts         # Epic EHR hooks
│   │   │   └── cerner.ts       # Cerner integration
│   │   └── notifications/
│   │       ├── email.ts        # Email notifications
│   │       └── push.ts         # Push notifications
│   ├── compliance/
│   │   ├── hipaa/
│   │   │   ├── audit-log.ts    # HIPAA audit logging
│   │   │   ├── phi-handler.ts  # PHI sanitization
│   │   │   └── encryption.ts   # Data encryption
│   │   └── retention.ts        # Data retention policies
│   └── jobs/
│       ├── cleanup.ts          # Data cleanup job
│       └── reporting.ts        # Usage reporting job
├── tests/
│   ├── unit/
│   │   └── services/
│   ├── integration/
│   │   └── openevidence/
│   └── clinical-validation/
│       └── known-answers/
├── config/
│   ├── default.json
│   ├── development.json
│   ├── staging.json
│   └── production.json
├── docs/
│   ├── architecture.md
│   ├── runbook.md
│   └── api-reference.md
└── scripts/
    ├── migrate.sh
    └── deploy.sh

Layer Architecture

┌─────────────────────────────────────────────────────┐
│                  API Layer                           │
│   (Controllers, Routes, Webhooks, Middleware)        │
├─────────────────────────────────────────────────────┤
│                Service Layer                         │
│    (Business Logic, Orchestration, Validation)       │
├─────────────────────────────────────────────────────┤
│              OpenEvidence Layer                      │
│     (Client, Types, Caching, Error Handling)         │
├─────────────────────────────────────────────────────┤
│             Compliance Layer                         │
│       (HIPAA Audit, PHI Handling, Encryption)        │
├─────────────────────────────────────────────────────┤
│            Integration Layer                         │
│    (EHR/FHIR, Notifications, External Services)      │
├─────────────────────────────────────────────────────┤
│            Infrastructure Layer                      │
│      (Database, Cache, Queue, Monitoring)            │
└─────────────────────────────────────────────────────┘

Key Components

Step 1: Client Wrapper with Caching & Monitoring

// src/openevidence/client.ts
import { OpenEvidenceClient } from '@openevidence/sdk';
import { ClinicalQueryCache } from './cache';
import { MetricsCollector } from '../monitoring/metrics';
import { HIPAAAuditLogger } from '../compliance/hipaa/audit-log';

export interface OpenEvidenceServiceConfig {
  apiKey: string;
  orgId: string;
  baseUrl: string;
  timeout: number;
  cache: ClinicalQueryCache;
  metrics: MetricsCollector;
  auditLogger: HIPAAAuditLogger;
}

export class OpenEvidenceService {
  private client: OpenEvidenceClient;
  private cache: ClinicalQueryCache;
  private metrics: MetricsCollector;
  private auditLogger: HIPAAAuditLogger;

  constructor(config: OpenEvidenceServiceConfig) {
    this.client = new OpenEvidenceClient({
      apiKey: config.apiKey,
      orgId: config.orgId,
      baseUrl: config.baseUrl,
      timeout: config.timeout,
    });
    this.cache = config.cache;
    this.metrics = config.metrics;
    this.auditLogger = config.auditLogger;
  }

  async query(
    request: ClinicalQueryRequest,
    context: RequestContext
  ): Promise<ClinicalQueryResponse> {
    const timer = this.metrics.startTimer('clinical_query');

    try {
      // Check cache
      const cached = await this.cache.get(request.question, request.context);
      if (cached) {
        this.metrics.incrementCounter('cache_hit');
        timer.stop({ cached: 'true' });
        return cached;
      }
      this.metrics.incrementCounter('cache_miss');

      // Query API
      const response = await this.client.query(request);

      // Cache response
      await this.cache.set(request.question, request.context, response);

      // Audit log (without PHI)
      await this.auditLogger.logQuery(context.userId, context.userRole, response.id, true);

      timer.stop({ cached: 'false' });
      return response;
    } catch (error: any) {
      this.metrics.incrementCounter('query_error', { error: error.code });
      await this.auditLogger.logQuery(context.userId, context.userRole, null, false);
      timer.stop({ error: 'true' });
      throw error;
    }
  }

  async deepConsult(
    request: DeepConsultRequest,
    context: RequestContext
  ): Promise<string> {
    // Return consultId for async tracking
    const consultId = await this.client.deepConsult.create(request);
    await this.auditLogger.logDeepConsult(context.userId, context.userRole, consultId, true);
    return consultId;
  }

  async health(): Promise<HealthStatus> {
    try {
      const start = Date.now();
      await this.client.health.check();
      return {
        status: 'healthy',
        latencyMs: Date.now() - start,
      };
    } catch (error: any) {
      return { status: 'unhealthy', error: error.message };
    }
  }
}

Step 2: Service Facade

// src/services/clinical/index.ts
import { OpenEvidenceService } from '../../openevidence/client';
import { PHIHandler } from '../../compliance/hipaa/phi-handler';

export class ClinicalEvidenceService {
  constructor(
    private openEvidence: OpenEvidenceService,
    private phiHandler: PHIHandler
  ) {}

  async queryClinicalEvidence(
    question: string,
    patientContext: PatientContext | undefined,
    context: RequestContext
  ): Promise<FormattedClinicalAnswer> {
    // 1. Sanitize input (remove PHI)
    const sanitizedRequest = this.phiHandler.sanitizeQuery(question, patientContext);

    // 2. Query OpenEvidence
    const response = await this.openEvidence.query(sanitizedRequest, context);

    // 3. Format response for clinical use
    return this.formatClinicalAnswer(response);
  }

  async requestDeepConsult(
    question: string,
    options: DeepConsultOptions,
    context: RequestContext
  ): Promise<{ consultId: string; estimatedTime: number }> {
    const sanitizedQuestion = this.phiHandler.sanitizeText(question);

    const consultId = await this.openEvidence.deepConsult({
      question: sanitizedQuestion,
      context: {
        specialty: options.specialty,
        researchFocus: options.researchFocus,
        timeframe: options.timeframe,
      },
    }, context);

    return {
      consultId,
      estimatedTime: 180, // 3 minutes typical
    };
  }

  async checkDrugInteraction(
    drugs: string[],
    context: RequestContext
  ): Promise<DrugInteractionResult> {
    const question = `What are the drug interactions between ${drugs.join(' and ')}?`;

    const response = await this.openEvidence.query({
      question,
      context: {
        specialty: 'pharmacology',
        urgency: 'urgent',
      },
    }, context);

    return this.parseDrugInteractionResponse(response);
  }

  private formatClinicalAnswer(response: ClinicalQueryResponse): FormattedClinicalAnswer {
    return {
      summary: response.answer.split('.')[0] + '.',
      detailedAnswer: response.answer,
      citations: response.citations.map(c => ({
        source: c.source,
        title: c.title,
        year: c.year,
      })),
      confidence: {
        score: response.confidence,
        level: response.confidence > 0.9 ? 'high' : response.confidence > 0.7 ? 'moderate' : 'low',
      },
      disclaimer: 'For clinical decision support only. Verify with current guidelines.',
    };
  }

  private parseDrugInteractionResponse(response: ClinicalQueryResponse): DrugInteractionResult {
    // Parse response to structured format
    const answerLower = response.answer.toLowerCase();

    return {
      hasInteraction: !answerLower.includes('no significant interaction'),
      severity: this.determineSeverity(answerLower),
      details: response.answer,
      citations: response.citations,
    };
  }

  private determineSeverity(text: string): 'major' | 'moderate' | 'minor' | 'none' {
    if (text.includes('contraindicated') || text.includes('major')) return 'major';
    if (text.includes('moderate') || text.includes('caution')) return 'moderate';
    if (text.includes('minor')) return 'minor';
    return 'none';
  }
}

Step 3: EHR Integration Layer

// src/integrations/ehr/fhir.ts
import { ClinicalEvidenceService } from '../../services/clinical';

// HL7 FHIR CDS Hooks implementation
interface CDSHooksRequest {
  hook: string;
  hookInstance: string;
  context: {
    patientId: string;
    encounterId?: string;
    medications?: FHIRMedication[];
    conditions?: FHIRCondition[];
  };
  prefetch?: {
    patient?: FHIRPatient;
    medications?: FHIRBundle<FHIRMedication>;
  };
}

interface CDSHooksResponse {
  cards: CDSCard[];
}

export class FHIRIntegration {
  constructor(private clinicalService: ClinicalEvidenceService) {}

  async handleCDSHook(request: CDSHooksRequest): Promise<CDSHooksResponse> {
    switch (request.hook) {
      case 'medication-prescribe':
        return this.handleMedicationPrescribe(request);
      case 'order-sign':
        return this.handleOrderSign(request);
      default:
        return { cards: [] };
    }
  }

  private async handleMedicationPrescribe(
    request: CDSHooksRequest
  ): Promise<CDSHooksResponse> {
    const medications = request.context.medications?.map(
      m => m.medicationCodeableConcept?.text
    ).filter(Boolean) as string[];

    if (medications.length < 2) {
      return { cards: [] };
    }

    // Check for drug interactions
    const interaction = await this.clinicalService.checkDrugInteraction(
      medications,
      { userId: 'system', userRole: 'cds-hook' }
    );

    if (!interaction.hasInteraction) {
      return { cards: [] };
    }

    return {
      cards: [{
        uuid: crypto.randomUUID(),
        summary: `Drug Interaction Alert: ${medications.join(', ')}`,
        detail: interaction.details,
        indicator: interaction.severity === 'major' ? 'critical' : 'warning',
        source: {
          label: 'OpenEvidence Clinical Decision Support',
          url: 'https://openevidence.com',
        },
        suggestions: interaction.severity === 'major' ? [{
          label: 'Review alternatives',
          uuid: crypto.randomUUID(),
        }] : undefined,
      }],
    };
  }

  private async handleOrderSign(request: CDSHooksRequest): Promise<CDSHooksResponse> {
    // Similar implementation for order signing
    return { cards: [] };
  }
}

Data Flow Diagram

User/EHR Request
       │
       ▼
┌─────────────────┐
│   API Gateway   │
│  (Auth, Rate)   │
└────────┬────────┘
         │
         ▼
┌─────────────────┐    ┌─────────────────┐
│  PHI Sanitizer  │───▶│   HIPAA Audit   │
└────────┬────────┘    └─────────────────┘
         │
         ▼
┌─────────────────┐    ┌─────────────────┐
│  Clinical       │───▶│   Cache Layer   │
│  Query Service  │    │   (Redis)       │
└────────┬────────┘    └────────┬────────┘
         │                      │
         ▼ (cache miss)         │
┌─────────────────┐             │
│  OpenEvidence   │◄────────────┘
│  API Client     │   (cache hit)
└────────┬────────┘
         │
         ▼
┌─────────────────┐
│  OpenEvidence   │
│  Cloud API      │
└─────────────────┘

Configuration Management

// src/config/index.ts
import convict from 'convict';

const config = convict({
  env: {
    doc: 'Application environment',
    format: ['development', 'staging', 'production'],
    default: 'development',
    env: 'NODE_ENV',
  },
  openevidence: {
    apiKey: {
      doc: 'OpenEvidence API key',
      format: String,
      default: '',
      env: 'OPENEVIDENCE_API_KEY',
      sensitive: true,
    },
    orgId: {
      doc: 'OpenEvidence organization ID',
      format: String,
      default: '',
      env: 'OPENEVIDENCE_ORG_ID',
    },
    baseUrl: {
      doc: 'OpenEvidence API base URL',
      format: 'url',
      default: 'https://api.openevidence.com',
      env: 'OPENEVIDENCE_BASE_URL',
    },
    timeout: {
      doc: 'Request timeout in milliseconds',
      format: 'int',
      default: 30000,
      env: 'OPENEVIDENCE_TIMEOUT',
    },
  },
  cache: {
    enabled: {
      doc: 'Enable caching',
      format: Boolean,
      default: true,
    },
    ttlSeconds: {
      doc: 'Default cache TTL',
      format: 'int',
      default: 3600,
    },
  },
  hipaa: {
    auditLogRetentionDays: {
      doc: 'HIPAA audit log retention',
      format: 'int',
      default: 2190, // 6 years
    },
  },
});

config.loadFile(`./config/${config.get('env')}.json`);
config.validate({ allowed: 'strict' });

export default config;

Output

• Layered architecture with separation of concerns
• HIPAA-compliant data handling
• EHR integration ready
• Comprehensive caching
• Health checks and monitoring

Architecture Checklist

• Layered architecture implemented
• PHI sanitization in place
• HIPAA audit logging
• Caching strategy configured
• EHR integration patterns
• Health checks implemented
• Configuration management
• Error boundaries at each layer

Resources

• HL7 FHIR
• CDS Hooks
• SMART on FHIR

Flagship Skills

For multi-environment setup, see openevidence-multi-env-setup.