feat: méthode TIM experte CPAM + moteur de règles étendu
CPAM — Méthode TIM (mémoire en défense) : - Réécriture CPAM_ARGUMENTATION avec raisonnement 5 passes TIM (contexte admin → motif réel → confrontation bio → hiérarchie → validation défensive) - _BIO_THRESHOLDS (19 entrées) + _build_bio_confrontation() pour confrontation biologie/diagnostic avec seuils chiffrés et verdicts - _format_response() dual format : nouveau TIM (moyens numérotés, tableau bio, codes non défendables, conclusion dispositive) + rétrocompat legacy - CPAM_ADVERSARIAL mis à jour pour vérifier honnêteté intellectuelle - Tests adaptés + 12 nouveaux tests (bio confrontation, format TIM) Moteur de règles : - Nouvelles règles YAML : demographic, diagnostic_conflicts, procedure_diagnosis, temporal, parcours - Bio extraction FAISS (synonymes vectoriels) - Veto engine enrichi (citations, Trackare skip, règles démographiques) - Decision engine : _apply_bio_rules_gen() + matchers analytiques Co-Authored-By: Claude Opus 4.6 <noreply@anthropic.com>
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dom
@@ -161,7 +161,6 @@ def _threshold_high(cfg: dict, test: str, age_band: str, doc_hi: float | None) -
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def _is_sodium_test(test: str) -> bool:
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t = (test or "").lower().strip()
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# 'na' est trop générique: on privilégie sodium/natrémie
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if "sodium" in t or "natr" in t:
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return True
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return bool(re.fullmatch(r"na\+?", t))
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@@ -174,6 +173,131 @@ def _is_potassium_test(test: str) -> bool:
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return bool(re.fullmatch(r"k\+?", t))
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def _get_bio_matcher(analyte: str):
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"""Retourne une fonction de matching pour l'analyte demandé."""
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a = analyte.lower()
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if a == "sodium": return _is_sodium_test
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if a == "potassium": return _is_potassium_test
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if a == "hemoglobin": return lambda t: "hemoglob" in t.lower() or "hb" in t.lower().split()
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if a == "platelets": return lambda t: "plaquette" in t.lower() or "platelet" in t.lower()
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if a == "creatinine": return lambda t: "creatinine" in t.lower()
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if a == "glucose": return lambda t: "glucose" in t.lower() or "glycemie" in t.lower()
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if a == "hba1c": return lambda t: "hba1c" in t.lower()
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if a == "tsh": return lambda t: "tsh" in t.lower()
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# Fallback: simple inclusion
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return lambda t: a in t.lower()
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def _apply_bio_rules_gen(dossier: DossierMedical, cfg_ranges: dict) -> None:
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"""Applique les règles de validation biologique définies dans config/bio_rules.yaml."""
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bio_cfg = load_bio_rules() or {}
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rules = (bio_cfg.get("rules") or {}) if isinstance(bio_cfg, dict) else {}
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missing_cfg = (bio_cfg.get("missing_evidence") or {}) if isinstance(bio_cfg, dict) else {}
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age_band = _age_band(dossier, cfg_ranges)
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def _push_need_info_veto(where: str, message: str) -> None:
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if dossier.veto_report is None: return
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vr = dossier.veto_report
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veto = str(missing_cfg.get("veto") or "VETO-17")
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if not rule_enabled(veto): return
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severity = str(missing_cfg.get("severity") or "LOW")
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penalty = int(missing_cfg.get("score_penalty") or 0)
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if any((it.veto == veto and it.where == where and (it.message or "") == message) for it in (vr.issues or [])):
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return
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vr.issues.append(VetoIssue(veto=veto, severity=severity, where=where, message=message))
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if (vr.verdict or "") == "PASS": vr.verdict = "NEED_INFO"
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if penalty: vr.score_contestabilite = max(0, int(vr.score_contestabilite or 0) - penalty)
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for rule_id, r in rules.items():
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if not r.get("enabled", True):
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continue
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analyte = r.get("analyte")
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if not analyte: continue
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codes = set(r.get("codes") or [])
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matcher = _get_bio_matcher(analyte)
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values, lo_doc, hi_doc = _bio_values(dossier, matcher)
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t_type = r.get("threshold_type", "low") # 'low' pour hypo/anémie, 'high' pour hyper/insuffisance
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# 1) PREUVE MANQUANTE
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if not values and bool(missing_cfg.get("enabled", False)):
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for i, das in enumerate(dossier.diagnostics_associes or []):
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if (das.cim10_suggestion or "") not in codes: continue
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if das.cim10_decision and (das.cim10_decision.action or "") in ("RULED_OUT", "REMOVE"): continue
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rule_key = f"RULE-{rule_id.upper()}-MISSING"
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if not rule_enabled(rule_key): continue
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reason = f"Preuve manquante: {analyte} non extrait — impossible de valider {das.cim10_suggestion} de façon défendable."
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das.status = "needs_info"
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das.cim10_final = None
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das.cim10_decision = CodeDecision(
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action="NEED_INFO",
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final_code=None,
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downgraded_from=das.cim10_suggestion,
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reason=reason,
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needs_info=[f"Valeur(s) de {analyte} + date(s) ?", "Normes du laboratoire si disponibles ?"],
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applied_rules=[rule_key],
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)
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_push_need_info_veto(f"diagnostics_associes[{i}]", f"{das.cim10_suggestion} suggéré mais aucune preuve de {analyte} n'a été extraite.")
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# 2) CONTRADICTION (RULED_OUT)
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if values:
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is_conflict = False
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found_val = 0.0
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threshold = 0.0
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if t_type == "low":
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# Pour un diagnostic de type "Bas" (hypo, anémie), on écarte si la valeur est >= seuil bas normal
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threshold = _threshold(cfg_ranges, analyte, age_band, lo_doc)
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if min(values) >= threshold:
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is_conflict = True
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found_val = min(values)
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else:
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# Pour un diagnostic de type "Haut" (hyper, insuff), on écarte si la valeur est <= seuil haut normal
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threshold = _threshold_high(cfg_ranges, analyte, age_band, hi_doc)
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if max(values) <= threshold:
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is_conflict = True
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found_val = max(values)
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# Cas particulier : seuil fixe dans le YAML (ex: HbA1c > 9)
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if r.get("threshold_value") is not None:
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fixed_t = float(r["threshold_value"])
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if t_type == "high" and max(values) < fixed_t:
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is_conflict = True
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found_val = max(values)
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threshold = fixed_t
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elif t_type == "low" and min(values) > fixed_t:
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is_conflict = True
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found_val = min(values)
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threshold = fixed_t
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if is_conflict:
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rule_key = f"RULE-{rule_id.upper()}-NORMAL"
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if not rule_enabled(rule_key): continue
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op = "≥" if t_type == "low" else "≤"
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reason = f"Contradiction biologique: {analyte}={found_val} ({op}{threshold}, valeur normale) — {r.get('message', 'diagnostic non retenu')}."
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for das in dossier.diagnostics_associes or []:
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if (das.cim10_suggestion or "") not in codes: continue
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das.status = "ruled_out"
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das.ruled_out_reason = reason
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das.cim10_final = None
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das.cim10_decision = CodeDecision(
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action="RULED_OUT",
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final_code=None,
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downgraded_from=das.cim10_suggestion,
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reason=reason,
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needs_info=[
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f"Valeurs de {analyte} sur d'autres dates (trend) ?",
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f"Mention explicite de {das.cim10_suggestion} confirmée malgré valeurs normales ?",
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],
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applied_rules=[rule_key],
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)
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def _bio_values(
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dossier: DossierMedical,
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matcher,
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@@ -369,6 +493,30 @@ def apply_decisions(dossier: DossierMedical) -> None:
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for das in dossier.diagnostics_associes or []:
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_set_default_final(das)
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# --- Règle: nettoyage hiérarchique (VETO-22bis) ---
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# Si un code spécifique (ex: K81.0) est présent, on retire le code générique (K81.9)
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all_final_codes = set()
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if dossier.diagnostic_principal and dossier.diagnostic_principal.cim10_final:
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all_final_codes.add(dossier.diagnostic_principal.cim10_final)
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for das in dossier.diagnostics_associes or []:
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if das.cim10_final:
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all_final_codes.add(das.cim10_final)
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for das in dossier.diagnostics_associes or []:
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if das.cim10_final and das.cim10_final.endswith(".9"):
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cat3 = das.cim10_final[:3]
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# Chercher s'il existe un autre code plus spécifique dans la même catégorie
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if any(c.startswith(cat3) and c != das.cim10_final for c in all_final_codes):
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das.status = "removed"
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das.cim10_decision = CodeDecision(
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action="REMOVE",
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final_code=None,
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downgraded_from=das.cim10_final,
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reason=f"Code générique {das.cim10_final} retiré car un code plus spécifique de la catégorie {cat3} est présent.",
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applied_rules=["RULE-HIERARCHY-CLEANUP"],
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)
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das.cim10_final = None
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# --- Règle: D50 sans preuve martiale -> downgrade D64.9 + needs_info ---
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if rule_enabled("RULE-D50-NEEDS-IRON"):
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for das in dossier.diagnostics_associes or []:
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@@ -427,186 +575,9 @@ def apply_decisions(dossier: DossierMedical) -> None:
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applied_rules=["RULE-D69.6-PLT-NORMAL"],
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)
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# --- Pack "bio": contradictions simples Na/K -> ruled_out (piloté par config/bio_rules.yaml)
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# Objectif: réduire VETO-09 en écartant les diagnostics "hyper/hypo" quand la valeur est clairement normale.
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bio_cfg = load_bio_rules() or {}
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rules = (bio_cfg.get("rules") or {}) if isinstance(bio_cfg, dict) else {}
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missing_cfg = (bio_cfg.get("missing_evidence") or {}) if isinstance(bio_cfg, dict) else {}
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def _push_need_info_veto(where: str, message: str) -> None:
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"""Ajoute un VETO non-bloquant quand la preuve biologique est manquante."""
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if dossier.veto_report is None:
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return
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vr = dossier.veto_report
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veto = str(missing_cfg.get("veto") or "VETO-17")
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# Désactivation globale par YAML (config/rules)
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if not rule_enabled(veto):
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return
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severity = str(missing_cfg.get("severity") or "LOW")
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penalty = int(missing_cfg.get("score_penalty") or 0)
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# Anti-doublon
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if any((it.veto == veto and it.where == where and (it.message or "") == message) for it in (vr.issues or [])):
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return
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vr.issues.append(VetoIssue(veto=veto, severity=severity, where=where, message=message))
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if (vr.verdict or "") == "PASS":
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vr.verdict = "NEED_INFO"
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if penalty:
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vr.score_contestabilite = max(0, int(vr.score_contestabilite or 0) - penalty)
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# Sodium (hyponatrémie)
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r = rules.get("hyponatremia") or {}
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if r.get("enabled", True):
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codes = set(r.get("codes") or ["E87.1"])
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na_values, na_lo_doc, _na_hi_doc = _bio_values(dossier, _is_sodium_test)
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if (not na_values) and bool(missing_cfg.get("enabled", False)) and rule_enabled("RULE-E87.1-MISSING-NA"):
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for i, das in enumerate(dossier.diagnostics_associes or []):
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if (das.cim10_suggestion or "") not in codes:
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continue
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if das.cim10_decision and (das.cim10_decision.action or "") in ("RULED_OUT", "REMOVE"):
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continue
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reason = "Preuve manquante: natrémie (sodium) non extraite — impossible de valider E87.1 de façon défendable."
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where = f"diagnostics_associes[{i}]"
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das.status = "needs_info"
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das.cim10_final = None
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das.cim10_decision = CodeDecision(
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action="NEED_INFO",
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final_code=None,
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downgraded_from=das.cim10_suggestion,
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reason=reason,
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needs_info=[
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"Valeur(s) de sodium (natrémie) + date(s) ?",
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"Normes du laboratoire si disponibles ?",
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],
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applied_rules=["RULE-E87.1-MISSING-NA"],
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)
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_push_need_info_veto(where, "E87.1 suggérée mais aucune natrémie (Na) n'a été extraite des résultats biologiques.")
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if na_values and rule_enabled("RULE-E87.1-NA-NORMAL"):
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na_threshold = _threshold(cfg_ranges, "sodium", age_band, na_lo_doc)
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# Ne ruled_out que si AUCUNE valeur n'est sous la borne basse normale.
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if min(na_values) >= na_threshold:
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na_val = min(na_values)
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for das in dossier.diagnostics_associes or []:
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if (das.cim10_suggestion or "") not in codes:
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continue
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das.status = "ruled_out"
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das.ruled_out_reason = (
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f"Contradiction biologique: sodium={na_val} (≥{na_threshold}, valeur normale) "
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"— hyponatrémie non retenue sans preuve explicite."
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)
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das.cim10_final = None
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das.cim10_decision = CodeDecision(
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action="RULED_OUT",
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final_code=None,
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downgraded_from=das.cim10_suggestion,
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reason=das.ruled_out_reason,
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needs_info=[
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"Valeurs de natrémie sur d'autres dates (trend) ?",
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"Mention explicite d'hyponatrémie confirmée malgré valeurs normales ?",
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"Contexte (perfusions, diurétiques, SIADH, etc.) documenté ?",
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],
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applied_rules=["RULE-E87.1-NA-NORMAL"],
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)
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# Potassium (hyper/hypo)
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k_values, k_lo_doc, k_hi_doc = _bio_values(dossier, _is_potassium_test)
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if (not k_values) and bool(missing_cfg.get("enabled", False)):
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# Valeur de kaliémie manquante : on refuse de valider E87.5/E87.6 sans preuve.
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codes_hyper = set((rules.get("hyperkalemia") or {}).get("codes") or ["E87.5"])
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codes_hypo = set((rules.get("hypokalemia") or {}).get("codes") or ["E87.6"])
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codes = codes_hyper.union(codes_hypo)
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for i, das in enumerate(dossier.diagnostics_associes or []):
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if (das.cim10_suggestion or "") not in codes:
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continue
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if das.cim10_decision and (das.cim10_decision.action or "") in ("RULED_OUT", "REMOVE"):
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continue
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code = das.cim10_suggestion or ""
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rule_id = f"RULE-{code}-MISSING-K"
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if not rule_enabled(rule_id):
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continue
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reason = f"Preuve manquante: kaliémie (potassium) non extraite — impossible de valider {code} de façon défendable."
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where = f"diagnostics_associes[{i}]"
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das.status = "needs_info"
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das.cim10_final = None
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das.cim10_decision = CodeDecision(
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action="NEED_INFO",
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final_code=None,
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downgraded_from=code,
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reason=reason,
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needs_info=[
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"Valeur(s) de potassium (kaliémie) + date(s) ?",
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"Normes du laboratoire si disponibles ?",
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],
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applied_rules=[f"RULE-{code}-MISSING-K"],
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)
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_push_need_info_veto(where, f"{code} suggéré mais aucune kaliémie (K) n'a été extraite des résultats biologiques.")
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if k_values:
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# Hyperkaliémie
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r = rules.get("hyperkalemia") or {}
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if r.get("enabled", True) and rule_enabled("RULE-E87.5-K-NORMAL"):
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codes = set(r.get("codes") or ["E87.5"])
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k_high = _threshold_high(cfg_ranges, "potassium", age_band, k_hi_doc)
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# Ruled_out si AUCUNE valeur ne dépasse la borne haute normale.
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if max(k_values) <= k_high:
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k_val = max(k_values)
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for das in dossier.diagnostics_associes or []:
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if (das.cim10_suggestion or "") not in codes:
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continue
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das.status = "ruled_out"
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das.ruled_out_reason = (
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f"Contradiction biologique: potassium={k_val} (≤{k_high}, valeur normale) "
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"— hyperkaliémie non retenue sans preuve explicite."
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)
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das.cim10_final = None
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das.cim10_decision = CodeDecision(
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action="RULED_OUT",
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final_code=None,
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downgraded_from=das.cim10_suggestion,
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reason=das.ruled_out_reason,
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needs_info=[
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"Valeurs de kaliémie sur d'autres dates (trend) ?",
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"Mention explicite d'hyperkaliémie confirmée malgré valeurs normales ?",
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"Contexte (IRA, IEC/ARA2, spironolactone, hémolyse) documenté ?",
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],
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applied_rules=["RULE-E87.5-K-NORMAL"],
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)
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# Hypokaliémie
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r = rules.get("hypokalemia") or {}
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if r.get("enabled", True) and rule_enabled("RULE-E87.6-K-NORMAL"):
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codes = set(r.get("codes") or ["E87.6"])
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k_low = _threshold(cfg_ranges, "potassium_low", age_band, k_lo_doc)
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# Ruled_out si AUCUNE valeur n'est sous la borne basse normale.
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if min(k_values) >= k_low:
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k_val = min(k_values)
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for das in dossier.diagnostics_associes or []:
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if (das.cim10_suggestion or "") not in codes:
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continue
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das.status = "ruled_out"
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das.ruled_out_reason = (
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f"Contradiction biologique: potassium={k_val} (≥{k_low}, valeur normale) "
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"— hypokaliémie non retenue sans preuve explicite."
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)
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das.cim10_final = None
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das.cim10_decision = CodeDecision(
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action="RULED_OUT",
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final_code=None,
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downgraded_from=das.cim10_suggestion,
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reason=das.ruled_out_reason,
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needs_info=[
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"Valeurs de kaliémie sur d'autres dates (trend) ?",
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"Mention explicite d'hypokaliémie confirmée malgré valeurs normales ?",
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"Contexte (diurétiques, diarrhées, pertes rénales) documenté ?",
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],
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||||
applied_rules=["RULE-E87.6-K-NORMAL"],
|
||||
)
|
||||
# --- Pack "bio": contradictions pilotées par config/bio_rules.yaml
|
||||
cfg_ranges = load_reference_ranges()
|
||||
_apply_bio_rules_gen(dossier, cfg_ranges)
|
||||
|
||||
# --- Règle: promotion DAS→DP quand aucun DP n'a été extrait ---
|
||||
if rule_enabled("RULE-DAS-TO-DP"):
|
||||
@@ -638,6 +609,10 @@ def apply_decisions(dossier: DossierMedical) -> None:
|
||||
),
|
||||
)
|
||||
dossier.diagnostics_associes.remove(best)
|
||||
# Traçabilité : alerte DIM lisible pour audit
|
||||
dossier.alertes_codage.append(
|
||||
f"RULE-DAS-TO-DP: DP absent → DAS {best.cim10_final} ({best.texte}) promu en DP"
|
||||
)
|
||||
logger.warning(
|
||||
"PROMOTE_DP: DAS %s (%s) promu en DP — aucun DP extrait",
|
||||
best.cim10_final, best.texte,
|
||||
|
||||
Reference in New Issue
Block a user