Table 1.

Examples of Boundaries of ATHENA-Opioid Therapy

Issue	Solution
Lack of expert consensus on specific criteria for judging an opioid trial as failed and thus appropriate to discontinue.	The determination of whether to discontinue an opioid medication was left to clinical judgment and always presented as an option. Detailed instructions on how but not when to discontinue the opioid medication were provided.
CPG was written to guide prescribing for non-cancer pain. Some patients have cancer plus pain from non-cancer-related causes, making it unclear whether the CPG was appropriate to apply.	ATHENA-OT issued a warning when the patient had cancer and indicated that system recommendations may not be appropriate if the patient's pain was caused by the cancer.
Determination of the severity of illness requires clinical assessment during the current visit.	ATHENA-OT issued a warning about potentially concerning diagnoses and recommended that the clinician assess the patient's current status to clarify if opioid dose adjustments were necessary.
In the electronic medical record (VistA), allergies are not distinguished from adverse events.	As a conservative measure, any record of an allergy/adverse event was considered an allergy, and recommendations were generated based on this assumption. This definition was clarified in clinician training sessions.

The table above provides examples of portions of the guideline that were not encoded. For each example, we describe how this boundary of the DSS was indicated in ATHENA-OT.