/**
 * Clinician Decision Support System
 *
 * Provides clinical decision support features:
 * - Treatment recommendations with explanations
 * - Override management and documentation
 * - Tumor board integration
 * - Evidence summaries
 * - Risk-benefit visualization
 * - Alert acknowledgment workflows
 *
 * Designed to augment (not replace) clinical judgment.
 */
import { EventEmitter } from 'events';
export interface ClinicalRecommendation {
    id: string;
    patientId: string;
    generatedAt: Date;
    validUntil: Date;
    primaryRecommendation: {
        regimen: string;
        drugs: {
            name: string;
            dose: string;
            schedule: string;
            route: string;
        }[];
        setting: 'neoadjuvant' | 'adjuvant' | 'first-line' | 'second-line' | 'third-line-plus' | 'maintenance';
        confidenceScore: number;
    };
    alternativeOptions: {
        regimen: string;
        drugs: string[];
        confidenceScore: number;
        comparisonToPrimary: string;
    }[];
    supportingEvidence: {
        type: 'clinical-trial' | 'guideline' | 'real-world' | 'expert-consensus';
        source: string;
        description: string;
        strength: 'strong' | 'moderate' | 'limited';
        url?: string;
    }[];
    biomarkerRationale: {
        biomarker: string;
        status: string;
        impact: string;
        evidenceLevel: string;
    }[];
    predictions: {
        responseRate: {
            value: number;
            ci95: [number, number];
        };
        medianPFS: {
            value: number;
            ci95: [number, number];
            unit: 'months';
        };
        medianOS: {
            value: number;
            ci95: [number, number];
            unit: 'months';
        };
        grade3PlusToxicity: {
            value: number;
            topRisks: string[];
        };
        qualityOfLife: {
            score: number;
            considerations: string[];
        };
    };
    clinicalConsiderations: {
        category: 'efficacy' | 'safety' | 'practical' | 'cost';
        consideration: string;
        importance: 'critical' | 'important' | 'notable';
    }[];
    monitoringPlan: {
        item: string;
        frequency: string;
        rationale: string;
    }[];
    clinicalTrialOptions?: {
        nctId: string;
        title: string;
        phase: string;
        matchingBiomarkers: string[];
        distance?: number;
    }[];
    status: 'active' | 'accepted' | 'modified' | 'rejected' | 'expired';
    reviewedBy?: string;
    reviewedAt?: Date;
}
export interface ClinicianOverride {
    id: string;
    recommendationId: string;
    patientId: string;
    clinicianId: string;
    clinicianName: string;
    clinicianRole: string;
    timestamp: Date;
    overrideType: 'full' | 'partial' | 'modification';
    originalRecommendation: {
        regimen: string;
        drugs: string[];
    };
    selectedTreatment: {
        regimen: string;
        drugs: string[];
        doses?: string[];
    };
    reason: {
        category: OverrideCategory;
        freeText: string;
        clinicalJustification: string;
    };
    riskAcknowledgment?: {
        acknowledgedRisks: string[];
        mitigationPlan?: string;
        signature: string;
        timestamp: Date;
    };
    supervisorApproval?: {
        required: boolean;
        supervisorId?: string;
        supervisorName?: string;
        approved?: boolean;
        approvalTimestamp?: Date;
        comments?: string;
    };
    auditStatus: 'pending-review' | 'reviewed' | 'flagged';
}
export type OverrideCategory = 'patient-preference' | 'comorbidity' | 'prior-treatment' | 'access-availability' | 'clinical-trial' | 'contraindication' | 'organ-function' | 'performance-status' | 'cost-coverage' | 'clinical-judgment' | 'other';
export interface TumorBoardCase {
    id: string;
    patientId: string;
    scheduledDate: Date;
    status: 'scheduled' | 'presented' | 'completed' | 'deferred';
    presenter: {
        id: string;
        name: string;
        role: string;
        department: string;
    };
    attendees: {
        id: string;
        name: string;
        specialty: string;
        present: boolean;
    }[];
    caseSummary: {
        diagnosis: string;
        stage: string;
        relevantHistory: string;
        currentStatus: string;
        questionForBoard: string;
    };
    systemRecommendation?: ClinicalRecommendation;
    boardDecision?: {
        recommendation: string;
        rationale: string;
        votingResult?: {
            agree: number;
            disagree: number;
            abstain: number;
        };
        dissenting_opinions?: string[];
        followUpPlan: string;
        recordedBy: string;
        timestamp: Date;
    };
    actions?: {
        action: string;
        assignedTo: string;
        dueDate?: Date;
        completed: boolean;
    }[];
}
export interface AlertAcknowledgment {
    alertId: string;
    alertType: string;
    severity: 'critical' | 'high' | 'moderate' | 'low';
    acknowledgedBy: string;
    acknowledgedAt: Date;
    action: 'proceed' | 'modify' | 'cancel' | 'defer';
    reason?: string;
    signature: string;
}
export declare class ClinicalDecisionSupportService extends EventEmitter {
    private recommendations;
    private overrides;
    private tumorBoardCases;
    private alertAcknowledgments;
    constructor();
    /**
     * Generate a clinical recommendation
     */
    generateRecommendation(params: {
        patientId: string;
        cancerType: string;
        stage: string;
        biomarkers: {
            name: string;
            value: string | number;
            status?: string;
        }[];
        genomicAlterations: {
            gene: string;
            alteration: string;
        }[];
        priorTherapies?: string[];
        performanceStatus?: number;
        comorbidities?: string[];
        patientPreferences?: string[];
    }): Promise<ClinicalRecommendation>;
    /**
     * Get recommendation by ID
     */
    getRecommendation(recommendationId: string): ClinicalRecommendation | undefined;
    /**
     * Get recommendations for a patient
     */
    getPatientRecommendations(patientId: string): ClinicalRecommendation[];
    /**
     * Accept a recommendation
     */
    acceptRecommendation(recommendationId: string, clinicianId: string, clinicianName: string): Promise<void>;
    /**
     * Record an override
     */
    recordOverride(override: Omit<ClinicianOverride, 'id' | 'timestamp' | 'auditStatus'>): Promise<string>;
    /**
     * Check if supervisor approval is required
     */
    private requiresSupervisorApproval;
    /**
     * Approve an override
     */
    approveOverride(overrideId: string, supervisorId: string, supervisorName: string, approved: boolean, comments?: string): Promise<void>;
    /**
     * Get overrides for a patient
     */
    getPatientOverrides(patientId: string): ClinicianOverride[];
    /**
     * Get pending approvals for a supervisor
     */
    getPendingApprovals(): ClinicianOverride[];
    /**
     * Create a tumor board case
     */
    createTumorBoardCase(caseData: Omit<TumorBoardCase, 'id' | 'status' | 'boardDecision' | 'actions'>): Promise<string>;
    /**
     * Record tumor board decision
     */
    recordTumorBoardDecision(caseId: string, decision: TumorBoardCase['boardDecision']): Promise<void>;
    /**
     * Acknowledge an alert
     */
    acknowledgeAlert(acknowledgment: Omit<AlertAcknowledgment, 'acknowledgedAt'>): Promise<void>;
    /**
     * Generate explanation for a recommendation
     */
    generateExplanation(recommendation: ClinicalRecommendation): {
        summary: string;
        detailedRationale: string[];
        keyFactors: {
            factor: string;
            impact: 'positive' | 'negative' | 'neutral';
            weight: number;
        }[];
        uncertainties: string[];
        alternativeConsiderations: string[];
    };
    /**
     * Generate risk-benefit analysis
     */
    generateRiskBenefitAnalysis(recommendation: ClinicalRecommendation): {
        benefits: {
            benefit: string;
            magnitude: 'high' | 'moderate' | 'low';
            confidence: number;
        }[];
        risks: {
            risk: string;
            probability: number;
            severity: 'severe' | 'moderate' | 'mild';
            manageable: boolean;
        }[];
        overallAssessment: string;
        numberNeededToTreat?: number;
        numberNeededToHarm?: number;
    };
    private determinePrimaryRecommendation;
    private determineAlternatives;
    private gatherEvidence;
    private generateBiomarkerRationale;
    private getBiomarkerImpact;
    private getBiomarkerEvidenceLevel;
    private generatePredictions;
    private identifyConsiderations;
    private generateMonitoringPlan;
    private determineImpact;
    private determineWeight;
    private generateOverallAssessment;
    /**
     * Export decision data for quality review
     */
    exportDecisionData(startDate: Date, endDate: Date): {
        recommendations: ClinicalRecommendation[];
        overrides: ClinicianOverride[];
        tumorBoardCases: TumorBoardCase[];
        summary: {
            totalRecommendations: number;
            acceptanceRate: number;
            overrideRate: number;
            commonOverrideReasons: {
                reason: OverrideCategory;
                count: number;
            }[];
        };
    };
}
export default ClinicalDecisionSupportService;
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