Quality Measure Implementation Guide (STU3)
3.0.0 - STU 3
US
Quality Measure Implementation Guide (STU3)
3.0.0 - STU 3
US
This page is part of the Quality Measure STU2 for FHIR R4 Implementation Guide (v3.0.0: STU3) based on FHIR R4. This is the current published version. For a full list of available versions, see the Directory of published versions 
| Active as of 2022-02-22 |
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"url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-directReferenceCode",
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"version" : "http://snomed.info/sct/731000124108/version/201709",
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"valueString" : "define \"SDE Sex\":\n case\n when Patient.gender = 'male' then Code { code: 'M', system: 'http://hl7.org/fhir/v3/AdministrativeGender', display: 'Male' }\n when Patient.gender = 'female' then Code { code: 'F', system: 'http://hl7.org/fhir/v3/AdministrativeGender', display: 'Female' }\n else null\n end"
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"valueString" : "EXM124"
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{
"url" : "name",
"valueString" : "Cervical Cytology Within 3 Years"
},
{
"url" : "statement",
"valueString" : "define \"Cervical Cytology Within 3 Years\":\n\t[Observation: \"Pap Test\"] CervicalCytology\n\t\twhere CervicalCytology.value is not null\n\t\t\tand CervicalCytology.status in { 'final', 'amended', 'corrected', 'preliminary' }\n\t\t and Global.\"Normalize Interval\"(CervicalCytology.effective) ends 3 years or less on or before end of \"Measurement Period\""
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"url" : "statement",
"valueString" : "// and NoCervixBirth.clinicalStatus ~ ToConcept(Global.\"active\") because this is an excluion, all statuses are acceptable\ndefine \"Numerator\":\n\texists \"Cervical Cytology Within 3 Years\"\n\t\tor exists \"HPV Test Within 5 Years for Women Age 30 and Older\""
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"valueString" : "AdultOutpatientEncounters"
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{
"url" : "name",
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"url" : "statement",
"valueString" : "define \"Qualifying Encounters\":\n\t(\n [Encounter: \"Office Visit\"]\n \t\tunion [Encounter: \"Annual Wellness Visit\"]\n \t\tunion [Encounter: \"Preventive Care Services - Established Office Visit, 18 and Up\"]\n \t\tunion [Encounter: \"Preventive Care Services-Initial Office Visit, 18 and Up\"]\n \t\tunion [Encounter: \"Home Healthcare Services\"]\n ) ValidEncounter\n\t\twhere ValidEncounter.period during \"Measurement Period\"\n \t\tand ValidEncounter.status = 'finished'"
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"url" : "libraryName",
"valueString" : "EXM124"
},
{
"url" : "name",
"valueString" : "Initial Population"
},
{
"url" : "statement",
"valueString" : "define \"Initial Population\":\n\tPatient.gender = 'female'\n\t\tand Global.\"CalendarAgeInYearsAt\"(FHIRHelpers.ToDate(Patient.birthDate), start of \"Measurement Period\") in Interval[23, 64]\n\t\tand exists AdultOutpatientEncounters.\"Qualifying Encounters\""
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{
"url" : "name",
"valueString" : "SDE Payer"
},
{
"url" : "statement",
"valueString" : "define \"SDE Payer\":\n [Coverage: type in \"Payer\"] Payer\n return {\n code: Payer.type,\n period: Payer.period\n }"
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"valueInteger" : 9
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"url" : "name",
"valueString" : "SDE Ethnicity"
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"url" : "statement",
"valueString" : "define \"SDE Ethnicity\":\n (flatten (\n Patient.extension Extension\n where Extension.url = 'http://hl7.org/fhir/us/core/StructureDefinition/us-core-ethnicity'\n return Extension.extension\n )) E\n where E.url = 'ombCategory'\n or E.url = 'detailed'\n return E.value as Coding"
},
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"valueString" : "SDE Ethnicity"
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"url" : "statement",
"valueString" : "define \"SDE Ethnicity\":\n SDE.\"SDE Ethnicity\""
},
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"url" : "displaySequence",
"valueInteger" : 11
}
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"url" : "libraryName",
"valueString" : "Hospice"
},
{
"url" : "name",
"valueString" : "Has Hospice"
},
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"url" : "statement",
"valueString" : "define \"Has Hospice\":\n\texists (\n [Encounter: \"Encounter Inpatient\"] DischargeHospice\n\t\t\twhere DischargeHospice.status = 'finished'\n\t\t and (\n\t DischargeHospice.hospitalization.dischargeDisposition ~ \"Discharge to home for hospice care (procedure)\"\n\t\t\t\t or DischargeHospice.hospitalization.dischargeDisposition ~ \"Discharge to healthcare facility for hospice care (procedure)\"\n\t \t)\n\t\t\t\tand DischargeHospice.period ends during \"Measurement Period\"\n\t)\n or exists (\n [ServiceRequest: \"Hospice care ambulatory\"] HospiceOrder\n where HospiceOrder.intent = 'order'\n and HospiceOrder.authoredOn in \"Measurement Period\"\n )\n or exists (\n [Procedure: \"Hospice care ambulatory\"] HospicePerformed\n where HospicePerformed.status = 'completed'\n and Global.\"Normalize Interval\"(HospicePerformed.performed) overlaps \"Measurement Period\"\n )"
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"extension" : [
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"url" : "libraryName",
"valueString" : "EXM124"
},
{
"url" : "name",
"valueString" : "Absence of Cervix"
},
{
"url" : "statement",
"valueString" : "define \"Absence of Cervix\":\n ([Procedure: \"Hysterectomy with No Residual Cervix\"] NoCervixProcedure\n where Global.\"Normalize Interval\"(NoCervixProcedure.performed) ends on or before end of \"Measurement Period\"\n and NoCervixProcedure.status = 'completed'\n )\n union [Condition : \"Congenital absence of cervix (disorder)\"] NoCervixBirth\n\t\twhere Global.\"Normalize Interval\"(NoCervixBirth.onset) starts on or before end of \"Measurement Period\""
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"valueString" : "EXM124"
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"url" : "name",
"valueString" : "Denominator Exclusion"
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"url" : "statement",
"valueString" : "define \"Denominator Exclusion\":\n\tHospice.\"Has Hospice\"\n\t\tor exists \"Absence of Cervix\""
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"valueInteger" : 14
}
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"extension" : [
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"url" : "libraryName",
"valueString" : "SupplementalDataElements"
},
{
"url" : "name",
"valueString" : "SDE Race"
},
{
"url" : "statement",
"valueString" : "define \"SDE Race\":\n (flatten (\n Patient.extension Extension\n where Extension.url = 'http://hl7.org/fhir/us/core/StructureDefinition/us-core-race'\n return Extension.extension\n )) E\n where E.url = 'ombCategory'\n or E.url = 'detailed'\n return E.value as Coding"
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"valueString" : "EXM124"
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{
"url" : "name",
"valueString" : "SDE Race"
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"url" : "statement",
"valueString" : "define \"SDE Race\":\n SDE.\"SDE Race\""
},
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"url" : "displaySequence",
"valueInteger" : 16
}
],
"url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
}
],
"name" : "EffectiveDataRequirements",
"status" : "active",
"type" : {
"coding" : [
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"system" : "http://terminology.hl7.org/CodeSystem/library-type",
"code" : "module-definition"
}
]
},
"date" : "2022-02-22T10:37:03-07:00",
"relatedArtifact" : [
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"type" : "depends-on",
"display" : "Library SDE",
"resource" : "http://hl7.org/fhir/us/cqfmeasures/Library/SupplementalDataElements|2.0.000"
},
{
"type" : "depends-on",
"display" : "Library FHIRHelpers",
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},
{
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"display" : "Library AdultOutpatientEncounters",
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},
{
"type" : "depends-on",
"display" : "Library Hospice",
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},
{
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"display" : "Code system SNOMEDCT:2017-09",
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},
{
"type" : "depends-on",
"display" : "Value set Pap Test",
"resource" : "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.108.12.1017"
},
{
"type" : "depends-on",
"display" : "Value set HPV Test",
"resource" : "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.110.12.1059"
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"type" : "depends-on",
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},
{
"type" : "depends-on",
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},
{
"type" : "depends-on",
"display" : "Value set Preventive Care Services - Established Office Visit, 18 and Up",
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},
{
"type" : "depends-on",
"display" : "Value set Preventive Care Services-Initial Office Visit, 18 and Up",
"resource" : "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1023"
},
{
"type" : "depends-on",
"display" : "Value set Home Healthcare Services",
"resource" : "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1016"
},
{
"type" : "depends-on",
"display" : "Value set Payer",
"resource" : "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591"
},
{
"type" : "depends-on",
"display" : "Value set Encounter Inpatient",
"resource" : "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.666.5.307"
},
{
"type" : "depends-on",
"display" : "Value set Hospice care ambulatory",
"resource" : "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1108.15"
},
{
"type" : "depends-on",
"display" : "Value set Hysterectomy with No Residual Cervix",
"resource" : "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1014"
}
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{
"name" : "SDE Payer",
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"type" : "Any"
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"name" : "Initial Population",
"use" : "out",
"min" : 0,
"max" : "1",
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{
"name" : "SDE Ethnicity",
"use" : "out",
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"name" : "Denominator Exclusion",
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"name" : "SDE Race",
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"min" : 0,
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},
{
"type" : "Encounter",
"profile" : [
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{
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"path" : "type",
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}
]
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"type"
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"path" : "type",
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}
]
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"path" : "code",
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},
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{
"path" : "code",
"valueSet" : "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1014"
}
]
},
{
"type" : "Condition",
"profile" : [
"http://hl7.org/fhir/StructureDefinition/Condition"
],
"mustSupport" : [
"code",
"onset"
],
"codeFilter" : [
{
"path" : "code",
"code" : [
{
"system" : "http://snomed.info/sct",
"version" : "http://snomed.info/sct/731000124108/version/201709",
"code" : "37687000",
"display" : "Congenital absence of cervix (disorder)"
}
]
}
]
},
{
"type" : "Observation",
"profile" : [
"http://hl7.org/fhir/StructureDefinition/Observation"
],
"mustSupport" : [
"effective",
"code",
"value",
"status"
],
"codeFilter" : [
{
"path" : "code",
"valueSet" : "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.108.12.1017"
}
]
},
{
"type" : "Observation",
"profile" : [
"http://hl7.org/fhir/StructureDefinition/Observation"
],
"mustSupport" : [
"effective",
"code",
"value",
"status"
],
"codeFilter" : [
{
"path" : "code",
"valueSet" : "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.110.12.1059"
}
]
}
]
}
],
"extension" : [
{
"url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-populationBasis",
"valueCode" : "boolean"
},
{
"id" : "effective-data-requirements",
"url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-effectiveDataRequirements",
"valueReference" : {
"reference" : "#effective-data-requirements"
}
}
],
"url" : "http://hl7.org/fhir/us/cqfmeasures/Measure/measure-exm124-FHIR",
"identifier" : [
{
"use" : "official",
"system" : "http://example.org/fhir/cqi/ecqm/Measure/Identifier/cms",
"value" : "124"
},
{
"use" : "official",
"system" : "http://example.org/fhir/cqi/ecqm/Measure/Identifier/mips",
"value" : "309"
}
],
"version" : "9.0.000",
"name" : "EXM124",
"title" : "EXM124 - Cervical Cancer Screening",
"status" : "active",
"experimental" : true,
"date" : "2022-02-22",
"publisher" : "Clinical Quality Information WG",
"contact" : [
{
"telecom" : [
{
"system" : "url",
"value" : "http://www.hl7.org/Special/committees/cqi"
}
]
}
],
"description" : "Percentage of women 21-64 years of age who were screened for cervical cancer using either of the following criteria: \n * Women age 21-64 who had cervical cytology performed every 3 years <br.* Women age 30-64 who had cervical cytology/human papillomavirus (HPV) co-testing performed every 5 years ",
"useContext" : [
{
"code" : {
"system" : "http://terminology.hl7.org/CodeSystem/usage-context-type",
"code" : "program"
},
"valueCodeableConcept" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/cqfmeasures/CodeSystem/quality-programs",
"code" : "ep-ec",
"display" : "EP/EC"
}
]
}
}
],
"jurisdiction" : [
{
"coding" : [
{
"system" : "urn:iso:std:iso:3166",
"code" : "US"
}
]
}
],
"purpose" : "Women 23-64 years of age with a visit during the measurement period",
"copyright" : "This Physician Performance Measure (Measure) and related data specifications were developed by the National Committee for Quality Assurance (NCQA). NCQA is not responsible for any use of the Measure. NCQA makes no representations, warranties, or endorsement about the quality of any organization or physician that uses or reports performance measures and NCQA has no liability to anyone who relies on such measures or specifications. NCQA holds a copyright in the Measure. The Measure can be reproduced and distributed, without modification, for noncommercial purposes (eg, use by healthcare providers in connection with their practices) without obtaining approval from NCQA. Commercial use is defined as the sale, licensing, or distribution of the Measure for commercial gain, or incorporation of the Measure into a product or service that is sold, licensed or distributed for commercial gain. All commercial uses or requests for modification must be approved by NCQA and are subject to a license at the discretion of NCQA. (C) 2012-2017 National Committee for Quality Assurance. All Rights Reserved. \n Limited proprietary coding is contained in the Measure specifications for user convenience. Users of proprietary code sets should obtain all necessary licenses from the owners of the code sets. NCQA disclaims all liability for use or accuracy of any third party codes contained in the specifications. \n CPT(R) contained in the Measure specifications is copyright 2004-2017 American Medical Association. LOINC(R) copyright 2004-2017 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R] ) copyright 2004-2017 International Health Terminology Standards Development Organisation. ICD-10 copyright 2017 World Health Organization. All Rights Reserved.",
"approvalDate" : "2016-01-01",
"lastReviewDate" : "2016-09-01",
"effectivePeriod" : {
"start" : "2018-01-01",
"end" : "2018-12-31"
},
"topic" : [
{
"coding" : [
{
"system" : "http://loinc.org",
"code" : "57024-2",
"display" : "Health Quality Measure Document"
}
]
}
],
"library" : [
"http://hl7.org/fhir/us/cqfmeasures/Library/EXM124"
],
"disclaimer" : "The performance Measure is not a clinical guideline and does not establish a standard of medical care, and has not been tested for all potential applications. THE MEASURE AND SPECIFICATIONS ARE PROVIDED \"AS IS\" WITHOUT WARRANTY OF ANY KIND. \n Due to technical limitations, registered trademarks are indicated by (R) or [R] and unregistered trademarks are indicated by (TM) or [TM].",
"scoring" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/measure-scoring",
"code" : "proportion",
"display" : "Proportion"
}
]
},
"type" : [
{
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/measure-type",
"code" : "process"
}
]
}
],
"rationale" : "Breast cancer is one of the most common types of cancers, accounting for 15 percent of all new cancer diagnoses in the U.S. (Howlader et al, 2016). In 2013, over 3 million women were estimated to be living with breast cancer in the U.S. and it is estimated that 12 percent of women will be diagnosed with breast cancer at some point during their lifetime (Howlader et al, 2016). \n While there are other factors that affect a woman's risk of developing breast cancer, advancing age is a primary risk factor. Breast cancer is most frequently diagnosed among women ages 55-64; the median age at diagnosis is 62 years (Howlader et al, 2016). The chance of a woman being diagnosed with breast cancer in a given year increases with age. By age 40, the chances are 1 in 235; by age 50 it becomes 1 in 54; by age 60, it is 1 in 25 (National Business Group on Health, 2011). \n In the U.S., costs associated with a diagnosis of breast cancer range from $451 to $2,520, factoring in continued testing, multiple office visits and procedures. The total costs related to breast cancer add up to nearly $7 billion per year in the U.S., including $2 billion spent on late-stage treatment (National Business Group on Health, 2011). If breast cancer is detected through mammography screening and diagnosed in its earliest stages, treatment may be less expensive (Feig, 2011).",
"clinicalRecommendationStatement" : "The U.S. Preventive Services Task Force (USPSTF) recommends biennial screening mammography for women aged 50-74 years (B recommendation). \n The decision to start screening mammography in women prior to age 50 years should be an individual one. Women who place a higher value on the potential benefit than the potential harms may choose to begin biennial screening between the ages of 40 and 49 years (C recommendation). (USPSTF, 2016) \n The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening mammography in women aged 75 years or older (I statement). (USPSTF, 2016) \n The USPSTF concludes that the current evidence is insufficient to assess the benefits and harms of digital breast tomosynthesis (DBT) as a primary screening method for breast cancer (I Statement). (USPSTF, 2016) \n The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of adjunctive screening for breast cancer using breast ultrasonography, magnetic resonance imaging, DBT, or other methods in women identified to have dense breasts on an otherwise negative screening mammogram (I statement). (USPSTF, 2016)",
"improvementNotation" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/measure-improvement-notation",
"code" : "increase",
"display" : "Increased score indicates improvement"
}
]
},
"guidance" : "To ensure the measure is only looking for a cervical cytology test only after a woman turns 21 years of age, the youngest age in the initial population is 23. \n Patient self-report for procedures as well as diagnostic studies should be recorded in 'Procedure, Performed' template or 'Diagnostic Study, Performed' template in QRDA-1. \n Include only cytology and HPV \"co-testing\"; in co-testing, both cytology and HPV tests are performed (i.e., the samples are collected and both tests are ordered, regardless of the cytology result) on the same date of service. Do not include reflex testing. In addition, if the medical record indicates the HPV test was performed only after determining the cytology result, this is considered reflex testing and does not meet criteria for the measure.",
"group" : [
{
"population" : [
{
"code" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/measure-population",
"code" : "initial-population",
"display" : "Initial Population"
}
]
},
"criteria" : {
"language" : "text/cql-identifier",
"expression" : "Initial Population"
}
},
{
"code" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/measure-population",
"code" : "numerator",
"display" : "Numerator"
}
]
},
"criteria" : {
"language" : "text/cql-identifier",
"expression" : "Numerator"
}
},
{
"code" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/measure-population",
"code" : "denominator",
"display" : "Denominator"
}
]
},
"criteria" : {
"language" : "text/cql-identifier",
"expression" : "Denominator"
}
},
{
"code" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/measure-population",
"code" : "denominator-exclusion",
"display" : "Denominator Exclusion"
}
]
},
"criteria" : {
"language" : "text/cql-identifier",
"expression" : "Denominator Exclusion"
}
}
]
}
],
"supplementalData" : [
{
"usage" : [
{
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/measure-data-usage",
"code" : "supplemental-data"
}
]
}
],
"criteria" : {
"language" : "text/cql-identifier",
"expression" : "SDE Ethnicity"
}
},
{
"usage" : [
{
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/measure-data-usage",
"code" : "supplemental-data"
}
]
}
],
"criteria" : {
"language" : "text/cql-identifier",
"expression" : "SDE Payer"
}
},
{
"usage" : [
{
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/measure-data-usage",
"code" : "supplemental-data"
}
]
}
],
"criteria" : {
"language" : "text/cql-identifier",
"expression" : "SDE Race"
}
},
{
"usage" : [
{
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/measure-data-usage",
"code" : "supplemental-data"
}
]
}
],
"criteria" : {
"language" : "text/cql-identifier",
"expression" : "SDE Sex"
}
}
]
}
IG © 2019+ Clinical Quality Information WG. Package hl7.fhir.us.cqfmeasures#3.0.0 based on FHIR 4.0.1. Generated 2022-04-28
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