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 in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions 
| Active as of 2022-02-22 |
{
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"id" : "BreastCancerScreeningFHIR",
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"lastUpdated" : "2021-01-15T09:56:41.000-07:00",
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"status" : "extensions",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\" xml:lang=\"en\" lang=\"en\">\n <table class=\"grid dict\">\n \n <tr>\n <th scope=\"row\"><b>Id: </b></th>\n <td style=\"padding-left: 4px;\">BreastCancerScreeningFHIR</td>\n </tr>\n \n \n <tr>\n <th scope=\"row\"><b>Url: </b></th>\n <td style=\"padding-left: 4px;\">http://ecqi.healthit.gov/ecqms/Measure/BreastCancerScreeningFHIR</td>\n </tr>\n \n \n <tr>\n <th scope=\"row\"><b>Version: </b></th>\n <td style=\"padding-left: 4px;\">2.0.003</td>\n </tr>\n \n \n <tr>\n <th scope=\"row\"><b>Identifier: </b></th>\n <td style=\"padding-left: 4px;\">\n \n \n <p style=\"margin-bottom: 5px;\">\n <b>value: </b> <span>125</span>\n </p>\n \n </td>\n </tr>\n \n <tr>\n <th scope=\"row\"><b>Identifier: </b></th>\n <td style=\"padding-left: 4px;\">\n \n <p style=\"margin-bottom: 5px;\">\n <b>type: </b> <span></span>\n </p>\n \n \n <p style=\"margin-bottom: 5px;\">\n <b>value: </b> <span>urn:uuid:11873bc9-ca0a-4cf3-b8f2-605a950aac74</span>\n </p>\n \n </td>\n </tr>\n \n <tr>\n <th scope=\"row\"><b>Identifier: </b></th>\n <td style=\"padding-left: 4px;\">\n \n <p style=\"margin-bottom: 5px;\">\n <b>type: </b> <span></span>\n </p>\n \n \n <p style=\"margin-bottom: 5px;\">\n <b>value: </b> <span>urn:uuid:b366f29b-347f-464e-8064-c83842d825c7</span>\n </p>\n \n </td>\n </tr>\n \n <tr>\n <th scope=\"row\"><b>Identifier: </b></th>\n <td style=\"padding-left: 4px;\">\n \n <p style=\"margin-bottom: 5px;\">\n <b>type: </b> <span></span>\n </p>\n \n \n <p style=\"margin-bottom: 5px;\">\n <b>value: </b> <span>BCS-FHIR</span>\n </p>\n \n </td>\n </tr>\n \n \n <tr>\n <th scope=\"row\"><b>Name: </b></th>\n <td style=\"padding-left: 4px;\">BreastCancerScreeningFHIR</td>\n </tr>\n \n \n <tr>\n <th scope=\"row\"><b>Title: </b></th>\n <td style=\"padding-left: 4px;\">Breast Cancer Screening FHIR Measure</td>\n </tr>\n \n \n \n <tr>\n <th scope=\"row\"><b>Status: </b></th>\n <td style=\"padding-left: 4px;\">active</td>\n </tr>\n \n \n <tr>\n <th scope=\"row\"><b>Experimental: </b></th>\n <td style=\"padding-left: 4px;\">false</td>\n </tr>\n \n \n <tr>\n <th scope=\"row\"><b>Scoring: </b></th>\n <td style=\"padding-left: 4px;\">\n \n \n \n <p style=\"margin-bottom: 5px;\">\n <b>system: </b> <span>http://terminology.hl7.org/CodeSystem/measure-scoring</span>\n </p>\n \n \n <p style=\"margin-bottom: 5px;\">\n <b>code: </b> <span>proportion</span>\n </p>\n \n \n <p style=\"margin-bottom: 5px;\">\n <b>display: </b> <span>Proportion</span>\n </p>\n \n \n \n \n </td>\n </tr>\n \n \n <tr>\n <th scope=\"row\"><b>Improvement Notation: </b></th>\n <td style=\"padding-left: 4px;\">\n \n \n \n <p style=\"margin-bottom: 5px;\">\n <b>system: </b> <span>http://terminology.hl7.org/CodeSystem/measure-improvement-notation</span>\n </p>\n \n \n <p style=\"margin-bottom: 5px;\">\n <b>code: </b> <span>increase</span>\n </p>\n \n \n \n \n \n </td>\n </tr>\n \n \n <tr>\n <th scope=\"row\"><b>Type: </b></th>\n <td style=\"padding-left: 4px;\">\n \n \n \n <p style=\"margin-bottom: 5px;\">\n <b>system: </b> <span>http://terminology.hl7.org/CodeSystem/measure-type</span>\n </p>\n \n \n <p style=\"margin-bottom: 5px;\">\n <b>code: </b> <span>process</span>\n </p>\n \n \n \n \n \n </td>\n </tr>\n \n \n \n <tr>\n <th scope=\"row\"><b>Date: </b></th>\n <td style=\"padding-left: 4px;\">2022-02-22T11:37:03-06:00</td>\n </tr>\n \n \n <tr>\n <th scope=\"row\"><b>Publisher: </b></th>\n <td style=\"padding-left: 4px;\">Clinical Quality Information WG</td>\n </tr>\n \n \n <tr>\n <th scope=\"row\"><b>Description: </b></th>\n <td style=\"padding-left: 4px;\">Percentage of women 50-74 years of age who had a mammogram to screen for breast cancer in the 27 months prior to the end of the Measurement Period</td>\n </tr>\n \n \n \n \n \n \n \n \n <tr>\n <th scope=\"row\"><b>Use Context: </b></th>\n <td style=\"padding-left: 4px;\">\n <table class=\"grid-dict\">\n <tr><th><b>code</b></th><th><b>value</b></th></tr>\n \n <tr>\n <td>program</td>\n <td></td>\n </tr>\n \n </table>\n </td>\n </tr>\n \n \n <tr>\n <th scope=\"row\"><b>Jurisdiction: </b></th>\n <td style=\"padding-left: 25px;\">US</td>\n </tr>\n \n \n \n <tr>\n <th scope=\"row\"><b>Purpose: </b></th>\n <td style=\"padding-left: 4px;\">Unknown</td>\n </tr>\n \n \n \n <tr>\n <th scope=\"row\"><b>Copyright: </b></th>\n <td style=\"padding-left: 25px;\">This Physician Performance Measure (Measure) and related data specifications are owned and 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 (e.g., 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) 2012-2019 National Committee for Quality Assurance. All Rights Reserved. \n\nLimited 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\nCPT(R) contained in the Measure specifications is copyright 2004-2019 American Medical Association. LOINC(R) copyright 2004-2019 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2019 International Health Terminology Standards Development Organisation. ICD-10 copyright 2019 World Health Organization. All Rights Reserved.</td>\n </tr>\n \n \n <tr>\n <th scope=\"row\"><b>Disclaimer: </b></th>\n <td style=\"padding-left: 25px;\">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 \nDue to technical limitations, registered trademarks are indicated by (R) or [R] and unregistered trademarks are indicated by (TM) or [TM].</td>\n </tr>\n \n \n <tr>\n <th scope=\"row\"><b>Approval Date: </b></th>\n <td style=\"padding-left: 4px;\">2019-03-08</td>\n </tr>\n \n \n <tr>\n <th scope=\"row\"><b>Last Review Date: </b></th>\n <td style=\"padding-left: 4px;\">2019-03-08</td>\n </tr>\n \n \n <tr>\n <th scope=\"row\"><b>Effective Period: </b></th>\n <td style=\"padding-left: 4px;\">2021-01-01..2021-12-31</td>\n </tr>\n \n \n \n \n \n \n </table>\n</div>"
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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" : "Numerator"
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"url" : "statement",
"valueString" : "define \"Numerator\":\n\t\texists (\n\t\t\t\t[DiagnosticReport: \"Mammography\"] Mammogram\n\t\t\t\t\t\twhere ( Global.\"Normalize Interval\"(Mammogram.effective) ends 27 months or less before day of end of \"Measurement Period\" )\n\t\t\t\t\t\t\t\tand Mammogram.status in { 'final', 'amended', 'corrected', 'appended' }\n\t\t)"
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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" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
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"url" : "libraryName",
"valueString" : "EXM125"
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{
"url" : "name",
"valueString" : "Initial Population"
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{
"url" : "statement",
"valueString" : "define \"Initial Population\":\n\t\tPatient.gender = 'female'\n\t\t\t\tand Global.\"CalendarAgeInYearsAt\"(FHIRHelpers.ToDate(Patient.birthDate), start of \"Measurement Period\") in Interval[51, 74]\n\t\t\t\tand exists AdultOutpatientEncounters.\"Qualifying Encounters\""
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"valueString" : "define \"Denominator\":\n\t\t\"Initial Population\""
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"extension" : [
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"url" : "libraryName",
"valueString" : "Hospice"
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{
"url" : "name",
"valueString" : "Has Hospice"
},
{
"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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],
"url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
},
{
"extension" : [
{
"url" : "libraryName",
"valueString" : "EXM125"
},
{
"url" : "name",
"valueString" : "Unilateral Mastectomy Procedure"
},
{
"url" : "statement",
"valueString" : "define \"Unilateral Mastectomy Procedure\":\n\t\t[Procedure: \"Unilateral Mastectomy\"] UnilateralMastectomyProcedure\n\t\t\t\twhere Global.\"Normalize Interval\"(UnilateralMastectomyProcedure.performed) ends before day of end of \"Measurement Period\"\n\t\t\t\t\t\tand UnilateralMastectomyProcedure.status = 'completed'"
},
{
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"valueInteger" : 5
}
],
"url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
},
{
"extension" : [
{
"url" : "libraryName",
"valueString" : "EXM125"
},
{
"url" : "name",
"valueString" : "Right Mastectomy"
},
{
"url" : "statement",
"valueString" : "define \"Right Mastectomy\":\n\t\t(\n\t\t\t\t( [Condition: \"Status Post Right Mastectomy\"] C\n where C.clinicalStatus ~ ToConcept(Global.\"active\")\n )\n\t\t\t\tunion (\n\t\t\t\t\t\t[Condition: \"Unilateral Mastectomy, Unspecified Laterality\"] UnilateralMastectomyDiagnosis\n\t\t\t\t\t\t\t\twhere UnilateralMastectomyDiagnosis.bodySite in \"Right\"\n and UnilateralMastectomyDiagnosis.clinicalStatus ~ ToConcept(Global.\"active\")\n\t\t\t\t)\n\t\t) RightMastectomy\n\t\t\t\twhere Global.\"Normalize Interval\"(RightMastectomy.onset) starts before day of end of \"Measurement Period\""
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{
"extension" : [
{
"url" : "libraryName",
"valueString" : "EXM125"
},
{
"url" : "name",
"valueString" : "Left Mastectomy"
},
{
"url" : "statement",
"valueString" : "define \"Left Mastectomy\":\n\t\t(\n\t\t ( [Condition: \"Status Post Left Mastectomy\"] C\n where C.clinicalStatus ~ ToConcept(Global.\"active\")\n )\n\t\t\t\tunion (\n\t\t\t\t\t\t[Condition: \"Unilateral Mastectomy, Unspecified Laterality\"] UnilateralMastectomyDiagnosis\n\t\t\t\t\t\t\t\twhere UnilateralMastectomyDiagnosis.bodySite in \"Left\"\n and UnilateralMastectomyDiagnosis.clinicalStatus ~ ToConcept(Global.\"active\")\n\t\t\t\t)\n\t\t) LeftMastectomy\n\t\t\t\twhere Global.\"Normalize Interval\"(LeftMastectomy.onset) starts before day of end of \"Measurement Period\""
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"extension" : [
{
"url" : "libraryName",
"valueString" : "EXM125"
},
{
"url" : "name",
"valueString" : "History Bilateral Mastectomy"
},
{
"url" : "statement",
"valueString" : "define \"History Bilateral Mastectomy\":\n\t\t[Condition: \"History of bilateral mastectomy\"] BilateralMastectomyHistory\n\t\t\t\twhere Global.\"Normalize Interval\"(BilateralMastectomyHistory.onset) starts before day of end of \"Measurement Period\"\n and BilateralMastectomyHistory.clinicalStatus ~ ToConcept(Global.\"active\")"
},
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"extension" : [
{
"url" : "libraryName",
"valueString" : "EXM125"
},
{
"url" : "name",
"valueString" : "Bilateral Mastectomy Procedure"
},
{
"url" : "statement",
"valueString" : "define \"Bilateral Mastectomy Procedure\":\n\t\t[Procedure: \"Bilateral Mastectomy\"] BilateralMastectomyPerformed\n\t\t\t\twhere Global.\"Normalize Interval\"(BilateralMastectomyPerformed.performed) ends before day of end of \"Measurement Period\"\n\t\t\t\t\t\tand BilateralMastectomyPerformed.status = 'completed'"
},
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"url" : "displaySequence",
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"url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
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{
"extension" : [
{
"url" : "libraryName",
"valueString" : "EXM125"
},
{
"url" : "name",
"valueString" : "Denominator Exclusion"
},
{
"url" : "statement",
"valueString" : "define \"Denominator Exclusion\":\n\t\tHospice.\"Has Hospice\"\n\t\t\t\tor ( Count(\"Unilateral Mastectomy Procedure\") = 2 )\n\t\t\t\tor ( exists \"Right Mastectomy\" and exists \"Left Mastectomy\" )\n\t\t\t\tor exists \"History Bilateral Mastectomy\"\n\t\t\t\tor exists \"Bilateral Mastectomy Procedure\""
},
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"valueInteger" : 10
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"url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
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"system" : "http://terminology.hl7.org/CodeSystem/library-type",
"code" : "module-definition"
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},
"date" : "2022-02-22T10:37:03-07:00",
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"type" : "depends-on",
"display" : "Library Global",
"resource" : "http://hl7.org/fhir/us/cqfmeasures/Library/MATGlobalCommonFunctions|5.0.000"
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{
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},
{
"type" : "depends-on",
"display" : "Library AdultOutpatientEncounters",
"resource" : "http://hl7.org/fhir/us/cqfmeasures/Library/AdultOutpatientEncounters|2.0.000"
},
{
"type" : "depends-on",
"display" : "Library Hospice",
"resource" : "http://hl7.org/fhir/us/cqfmeasures/Library/Hospice|2.0.000"
},
{
"type" : "depends-on",
"display" : "Code system SNOMEDCT:2017-09",
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{
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"display" : "Code system ConditionClinicalStatusCodes",
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{
"type" : "depends-on",
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},
{
"type" : "depends-on",
"display" : "Value set Office Visit",
"resource" : "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1001"
},
{
"type" : "depends-on",
"display" : "Value set Annual Wellness Visit",
"resource" : "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.526.3.1240"
},
{
"type" : "depends-on",
"display" : "Value set Preventive Care Services - Established Office Visit, 18 and Up",
"resource" : "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1025"
},
{
"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",
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},
{
"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 Unilateral Mastectomy",
"resource" : "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1020"
},
{
"type" : "depends-on",
"display" : "Value set Status Post Right Mastectomy",
"resource" : "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1070"
},
{
"type" : "depends-on",
"display" : "Value set Unilateral Mastectomy, Unspecified Laterality",
"resource" : "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1071"
},
{
"type" : "depends-on",
"display" : "Value set Right",
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},
{
"type" : "depends-on",
"display" : "Value set Status Post Left Mastectomy",
"resource" : "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1069"
},
{
"type" : "depends-on",
"display" : "Value set Left",
"resource" : "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.122.12.1036"
},
{
"type" : "depends-on",
"display" : "Value set History of bilateral mastectomy",
"resource" : "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1068"
},
{
"type" : "depends-on",
"display" : "Value set Bilateral Mastectomy",
"resource" : "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1005"
}
],
"parameter" : [
{
"name" : "Measurement Period",
"use" : "in",
"min" : 0,
"max" : "1",
"type" : "Period"
},
{
"name" : "Numerator",
"use" : "out",
"min" : 0,
"max" : "1",
"type" : "boolean"
},
{
"name" : "Denominator",
"use" : "out",
"min" : 0,
"max" : "1",
"type" : "boolean"
},
{
"name" : "Initial Population",
"use" : "out",
"min" : 0,
"max" : "1",
"type" : "boolean"
},
{
"name" : "Denominator Exclusion",
"use" : "out",
"min" : 0,
"max" : "1",
"type" : "boolean"
}
],
"dataRequirement" : [
{
"type" : "Encounter",
"profile" : [
"http://hl7.org/fhir/StructureDefinition/Encounter"
],
"mustSupport" : [
"type"
],
"codeFilter" : [
{
"path" : "type",
"valueSet" : "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1001"
}
]
},
{
"type" : "Encounter",
"profile" : [
"http://hl7.org/fhir/StructureDefinition/Encounter"
],
"mustSupport" : [
"type"
],
"codeFilter" : [
{
"path" : "type",
"valueSet" : "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.526.3.1240"
}
]
},
{
"type" : "Encounter",
"profile" : [
"http://hl7.org/fhir/StructureDefinition/Encounter"
],
"mustSupport" : [
"type"
],
"codeFilter" : [
{
"path" : "type",
"valueSet" : "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1025"
}
]
},
{
"type" : "Encounter",
"profile" : [
"http://hl7.org/fhir/StructureDefinition/Encounter"
],
"mustSupport" : [
"type"
],
"codeFilter" : [
{
"path" : "type",
"valueSet" : "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1023"
}
]
},
{
"type" : "Encounter",
"profile" : [
"http://hl7.org/fhir/StructureDefinition/Encounter"
],
"mustSupport" : [
"type"
],
"codeFilter" : [
{
"path" : "type",
"valueSet" : "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1016"
}
]
},
{
"type" : "Encounter",
"profile" : [
"http://hl7.org/fhir/StructureDefinition/Encounter"
],
"mustSupport" : [
"period",
"hospitalization",
"hospitalization.dischargeDisposition",
"type",
"status"
],
"codeFilter" : [
{
"path" : "type",
"valueSet" : "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.666.5.307"
}
]
},
{
"type" : "Procedure",
"profile" : [
"http://hl7.org/fhir/StructureDefinition/Procedure"
],
"mustSupport" : [
"code",
"performed",
"status"
],
"codeFilter" : [
{
"path" : "code",
"valueSet" : "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1020"
}
]
},
{
"type" : "Procedure",
"profile" : [
"http://hl7.org/fhir/StructureDefinition/Procedure"
],
"mustSupport" : [
"code",
"performed",
"status"
],
"codeFilter" : [
{
"path" : "code",
"valueSet" : "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1108.15"
}
]
},
{
"type" : "Procedure",
"profile" : [
"http://hl7.org/fhir/StructureDefinition/Procedure"
],
"mustSupport" : [
"code",
"performed",
"status"
],
"codeFilter" : [
{
"path" : "code",
"valueSet" : "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1005"
}
]
},
{
"type" : "ServiceRequest",
"profile" : [
"http://hl7.org/fhir/StructureDefinition/ServiceRequest"
],
"mustSupport" : [
"code",
"authoredOn",
"intent"
],
"codeFilter" : [
{
"path" : "code",
"valueSet" : "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1108.15"
}
]
},
{
"type" : "Condition",
"profile" : [
"http://hl7.org/fhir/StructureDefinition/Condition"
],
"mustSupport" : [
"code",
"clinicalStatus"
],
"codeFilter" : [
{
"path" : "code",
"valueSet" : "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1070"
}
]
},
{
"type" : "Condition",
"profile" : [
"http://hl7.org/fhir/StructureDefinition/Condition"
],
"mustSupport" : [
"code",
"clinicalStatus"
],
"codeFilter" : [
{
"path" : "code",
"valueSet" : "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1069"
}
]
},
{
"type" : "Condition",
"profile" : [
"http://hl7.org/fhir/StructureDefinition/Condition"
],
"mustSupport" : [
"bodySite",
"code",
"clinicalStatus"
],
"codeFilter" : [
{
"path" : "code",
"valueSet" : "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1071"
}
]
},
{
"type" : "Condition",
"profile" : [
"http://hl7.org/fhir/StructureDefinition/Condition"
],
"mustSupport" : [
"code",
"clinicalStatus",
"onset"
],
"codeFilter" : [
{
"path" : "code",
"valueSet" : "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1068"
}
]
},
{
"type" : "Patient",
"profile" : [
"http://hl7.org/fhir/StructureDefinition/Patient"
]
},
{
"type" : "DiagnosticReport",
"profile" : [
"http://hl7.org/fhir/StructureDefinition/DiagnosticReport"
],
"mustSupport" : [
"effective",
"code",
"status"
],
"codeFilter" : [
{
"path" : "code",
"valueSet" : "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.108.12.1018"
}
]
}
]
}
],
"extension" : [
{
"url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-populationBasis",
"valueCode" : "boolean"
},
{
"url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-softwaresystem",
"valueReference" : {
"reference" : "Device/software-system-example"
}
},
{
"id" : "effective-data-requirements",
"url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-effectiveDataRequirements",
"valueReference" : {
"reference" : "#effective-data-requirements"
}
}
],
"url" : "http://ecqi.healthit.gov/ecqms/Measure/BreastCancerScreeningFHIR",
"identifier" : [
{
"use" : "official",
"system" : "http://example.org/fhir/cqi/ecqm/Measure/Identifier/exm",
"value" : "125"
},
{
"use" : "official",
"type" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/cqfmeasures/CodeSystem/identifier-type",
"code" : "version-independent"
}
]
},
"system" : "urn:ietf:rfc:3986",
"value" : "urn:uuid:11873bc9-ca0a-4cf3-b8f2-605a950aac74"
},
{
"use" : "official",
"type" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/cqfmeasures/CodeSystem/identifier-type",
"code" : "version-specific"
}
]
},
"system" : "urn:ietf:rfc:3986",
"value" : "urn:uuid:b366f29b-347f-464e-8064-c83842d825c7"
},
{
"use" : "usual",
"type" : {
"coding" : [
{
"system" : "http://hl7.org/fhir/us/cqfmeasures/CodeSystem/identifier-type",
"code" : "short-name"
}
]
},
"value" : "BCS-FHIR"
}
],
"version" : "2.0.003",
"name" : "BreastCancerScreeningFHIR",
"title" : "Breast Cancer Screening FHIR Measure",
"status" : "active",
"experimental" : false,
"date" : "2022-02-22T11:37:03-06:00",
"publisher" : "Clinical Quality Information WG",
"contact" : [
{
"telecom" : [
{
"system" : "url",
"value" : "http://www.hl7.org/Special/committees/cqi"
}
]
}
],
"description" : "Percentage of women 50-74 years of age who had a mammogram to screen for breast cancer in the 27 months prior to the end of the Measurement Period",
"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" : "Unknown",
"copyright" : "This Physician Performance Measure (Measure) and related data specifications are owned and 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 (e.g., 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) 2012-2019 National Committee for Quality Assurance. All Rights Reserved. \n\nLimited 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\nCPT(R) contained in the Measure specifications is copyright 2004-2019 American Medical Association. LOINC(R) copyright 2004-2019 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2019 International Health Terminology Standards Development Organisation. ICD-10 copyright 2019 World Health Organization. All Rights Reserved.",
"approvalDate" : "2019-03-08",
"lastReviewDate" : "2019-03-08",
"effectivePeriod" : {
"start" : "2021-01-01",
"end" : "2021-12-31"
},
"library" : [
"http://hl7.org/fhir/us/cqfmeasures/Library/EXM125"
],
"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 \nDue 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. (Noone et al, 2018). In 2015, 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 (Noone et al, 2018). \n\nWhile 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 (Noone et al, 2018).\n\nThe chance of a woman being diagnosed with breast cancer in a given year increases with age. By age 40, the chances are 1 in 68; by age 50 it becomes 1 in 43; by age 60, it is 1 in 29 (American Cancer Society, 2017).",
"clinicalRecommendationStatement" : "The U.S. Preventive Services Task Force (USPSTF) recommends biennial screening mammography for women aged 50-74 years (B recommendation). \n\nThe 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\nThe 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\nThe 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\nThe 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"
}
]
},
"guidance" : "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\nThis measure evaluates primary screening. Do not count biopsies, breast ultrasounds, or MRIs because they are not appropriate methods for primary breast cancer screening.\n\nThis eCQM is a patient-based measure.",
"group" : [
{
"id" : "group-1",
"population" : [
{
"id" : "3D2DD734-0712-484A-BE23-B1D2FF96D83A",
"code" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/measure-population",
"code" : "initial-population",
"display" : "Initial Population"
}
]
},
"criteria" : {
"language" : "text/cql-identifier",
"expression" : "Initial Population"
}
},
{
"id" : "C4B18753-73BC-4D48-801E-82AB55A70139",
"code" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/measure-population",
"code" : "denominator",
"display" : "Denominator"
}
]
},
"criteria" : {
"language" : "text/cql-identifier",
"expression" : "Denominator"
}
},
{
"id" : "7C770CA2-5177-4C5F-A976-7F57EC9BC311",
"code" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/measure-population",
"code" : "denominator-exclusion",
"display" : "Denominator Exclusion"
}
]
},
"criteria" : {
"language" : "text/cql-identifier",
"expression" : "Denominator Exclusion"
}
},
{
"id" : "57BC5171-93A7-4D9B-AA42-18A344C8623B",
"code" : {
"coding" : [
{
"system" : "http://terminology.hl7.org/CodeSystem/measure-population",
"code" : "numerator",
"display" : "Numerator"
}
]
},
"criteria" : {
"language" : "text/cql-identifier",
"expression" : "Numerator"
}
}
]
}
]
}
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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