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 |
<Measure xmlns="http://hl7.org/fhir">
<id value="BreastCancerScreeningFHIR"/>
<meta>
<versionId value="2"/>
<lastUpdated value="2021-01-15T09:56:41.000-07:00"/>
<source value="#6C52w7dhFJuyuCDD"/>
<profile
value="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/proportion-measure-cqfm"/>
<profile
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<profile
value="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/publishable-measure-cqfm"/>
</meta>
<language value="en"/>
<text>
<status value="extensions"/>
<div xmlns="http://www.w3.org/1999/xhtml" xml:lang="en" lang="en">
<table class="grid dict">
<tr>
<th scope="row"><b>Id: </b></th>
<td style="padding-left: 4px;">BreastCancerScreeningFHIR</td>
</tr>
<tr>
<th scope="row"><b>Url: </b></th>
<td style="padding-left: 4px;">http://ecqi.healthit.gov/ecqms/Measure/BreastCancerScreeningFHIR</td>
</tr>
<tr>
<th scope="row"><b>Version: </b></th>
<td style="padding-left: 4px;">2.0.003</td>
</tr>
<tr>
<th scope="row"><b>Identifier: </b></th>
<td style="padding-left: 4px;">
<p style="margin-bottom: 5px;">
<b>value: </b> <span>125</span>
</p>
</td>
</tr>
<tr>
<th scope="row"><b>Identifier: </b></th>
<td style="padding-left: 4px;">
<p style="margin-bottom: 5px;">
<b>type: </b> <span></span>
</p>
<p style="margin-bottom: 5px;">
<b>value: </b> <span>urn:uuid:11873bc9-ca0a-4cf3-b8f2-605a950aac74</span>
</p>
</td>
</tr>
<tr>
<th scope="row"><b>Identifier: </b></th>
<td style="padding-left: 4px;">
<p style="margin-bottom: 5px;">
<b>type: </b> <span></span>
</p>
<p style="margin-bottom: 5px;">
<b>value: </b> <span>urn:uuid:b366f29b-347f-464e-8064-c83842d825c7</span>
</p>
</td>
</tr>
<tr>
<th scope="row"><b>Identifier: </b></th>
<td style="padding-left: 4px;">
<p style="margin-bottom: 5px;">
<b>type: </b> <span></span>
</p>
<p style="margin-bottom: 5px;">
<b>value: </b> <span>BCS-FHIR</span>
</p>
</td>
</tr>
<tr>
<th scope="row"><b>Name: </b></th>
<td style="padding-left: 4px;">BreastCancerScreeningFHIR</td>
</tr>
<tr>
<th scope="row"><b>Title: </b></th>
<td style="padding-left: 4px;">Breast Cancer Screening FHIR Measure</td>
</tr>
<tr>
<th scope="row"><b>Status: </b></th>
<td style="padding-left: 4px;">active</td>
</tr>
<tr>
<th scope="row"><b>Experimental: </b></th>
<td style="padding-left: 4px;">false</td>
</tr>
<tr>
<th scope="row"><b>Scoring: </b></th>
<td style="padding-left: 4px;">
<p style="margin-bottom: 5px;">
<b>system: </b> <span>http://terminology.hl7.org/CodeSystem/measure-scoring</span>
</p>
<p style="margin-bottom: 5px;">
<b>code: </b> <span>proportion</span>
</p>
<p style="margin-bottom: 5px;">
<b>display: </b> <span>Proportion</span>
</p>
</td>
</tr>
<tr>
<th scope="row"><b>Improvement Notation: </b></th>
<td style="padding-left: 4px;">
<p style="margin-bottom: 5px;">
<b>system: </b> <span>http://terminology.hl7.org/CodeSystem/measure-improvement-notation</span>
</p>
<p style="margin-bottom: 5px;">
<b>code: </b> <span>increase</span>
</p>
</td>
</tr>
<tr>
<th scope="row"><b>Type: </b></th>
<td style="padding-left: 4px;">
<p style="margin-bottom: 5px;">
<b>system: </b> <span>http://terminology.hl7.org/CodeSystem/measure-type</span>
</p>
<p style="margin-bottom: 5px;">
<b>code: </b> <span>process</span>
</p>
</td>
</tr>
<tr>
<th scope="row"><b>Date: </b></th>
<td style="padding-left: 4px;">2022-02-22T11:37:03-06:00</td>
</tr>
<tr>
<th scope="row"><b>Publisher: </b></th>
<td style="padding-left: 4px;">Clinical Quality Information WG</td>
</tr>
<tr>
<th scope="row"><b>Description: </b></th>
<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>
</tr>
<tr>
<th scope="row"><b>Use Context: </b></th>
<td style="padding-left: 4px;">
<table class="grid-dict">
<tr><th><b>code</b></th><th><b>value</b></th></tr>
<tr>
<td>program</td>
<td></td>
</tr>
</table>
</td>
</tr>
<tr>
<th scope="row"><b>Jurisdiction: </b></th>
<td style="padding-left: 25px;">US</td>
</tr>
<tr>
<th scope="row"><b>Purpose: </b></th>
<td style="padding-left: 4px;">Unknown</td>
</tr>
<tr>
<th scope="row"><b>Copyright: </b></th>
<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.
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.
CPT(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>
</tr>
<tr>
<th scope="row"><b>Disclaimer: </b></th>
<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.
Due to technical limitations, registered trademarks are indicated by (R) or [R] and unregistered trademarks are indicated by (TM) or [TM].</td>
</tr>
<tr>
<th scope="row"><b>Approval Date: </b></th>
<td style="padding-left: 4px;">2019-03-08</td>
</tr>
<tr>
<th scope="row"><b>Last Review Date: </b></th>
<td style="padding-left: 4px;">2019-03-08</td>
</tr>
<tr>
<th scope="row"><b>Effective Period: </b></th>
<td style="padding-left: 4px;">2021-01-01..2021-12-31</td>
</tr>
</table>
</div>
</text>
<contained>
<Library>
<id value="effective-data-requirements"/>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-directReferenceCode">
<valueCoding>
<system value="http://snomed.info/sct"/>
<version value="http://snomed.info/sct/731000124108/version/201709"/>
<code value="428361000124107"/>
<display value="Discharge to home for hospice care (procedure)"/>
</valueCoding>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-directReferenceCode">
<valueCoding>
<system value="http://snomed.info/sct"/>
<version value="http://snomed.info/sct/731000124108/version/201709"/>
<code value="428371000124100"/>
<display
value="Discharge to healthcare facility for hospice care (procedure)"/>
</valueCoding>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-directReferenceCode">
<valueCoding>
<system
value="http://terminology.hl7.org/CodeSystem/condition-clinical"/>
<code value="active"/>
</valueCoding>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
<extension url="libraryName">
<valueString value="EXM125"/>
</extension>
<extension url="name">
<valueString value="Numerator"/>
</extension>
<extension url="statement">
<valueString
value="define "Numerator":
exists (
[DiagnosticReport: "Mammography"] Mammogram
where ( Global."Normalize Interval"(Mammogram.effective) ends 27 months or less before day of end of "Measurement Period" )
and Mammogram.status in { 'final', 'amended', 'corrected', 'appended' }
)"/>
</extension>
<extension url="displaySequence">
<valueInteger value="0"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
<extension url="libraryName">
<valueString value="AdultOutpatientEncounters"/>
</extension>
<extension url="name">
<valueString value="Qualifying Encounters"/>
</extension>
<extension url="statement">
<valueString
value="define "Qualifying Encounters":
(
[Encounter: "Office Visit"]
union [Encounter: "Annual Wellness Visit"]
union [Encounter: "Preventive Care Services - Established Office Visit, 18 and Up"]
union [Encounter: "Preventive Care Services-Initial Office Visit, 18 and Up"]
union [Encounter: "Home Healthcare Services"]
) ValidEncounter
where ValidEncounter.period during "Measurement Period"
and ValidEncounter.status = 'finished'"/>
</extension>
<extension url="displaySequence">
<valueInteger value="1"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
<extension url="libraryName">
<valueString value="EXM125"/>
</extension>
<extension url="name">
<valueString value="Initial Population"/>
</extension>
<extension url="statement">
<valueString
value="define "Initial Population":
Patient.gender = 'female'
and Global."CalendarAgeInYearsAt"(FHIRHelpers.ToDate(Patient.birthDate), start of "Measurement Period") in Interval[51, 74]
and exists AdultOutpatientEncounters."Qualifying Encounters""/>
</extension>
<extension url="displaySequence">
<valueInteger value="2"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
<extension url="libraryName">
<valueString value="EXM125"/>
</extension>
<extension url="name">
<valueString value="Denominator"/>
</extension>
<extension url="statement">
<valueString
value="define "Denominator":
"Initial Population""/>
</extension>
<extension url="displaySequence">
<valueInteger value="3"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
<extension url="libraryName">
<valueString value="Hospice"/>
</extension>
<extension url="name">
<valueString value="Has Hospice"/>
</extension>
<extension url="statement">
<valueString
value="define "Has Hospice":
exists (
[Encounter: "Encounter Inpatient"] DischargeHospice
where DischargeHospice.status = 'finished'
and (
DischargeHospice.hospitalization.dischargeDisposition ~ "Discharge to home for hospice care (procedure)"
or DischargeHospice.hospitalization.dischargeDisposition ~ "Discharge to healthcare facility for hospice care (procedure)"
)
and DischargeHospice.period ends during "Measurement Period"
)
or exists (
[ServiceRequest: "Hospice care ambulatory"] HospiceOrder
where HospiceOrder.intent = 'order'
and HospiceOrder.authoredOn in "Measurement Period"
)
or exists (
[Procedure: "Hospice care ambulatory"] HospicePerformed
where HospicePerformed.status = 'completed'
and Global."Normalize Interval"(HospicePerformed.performed) overlaps "Measurement Period"
)"/>
</extension>
<extension url="displaySequence">
<valueInteger value="4"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
<extension url="libraryName">
<valueString value="EXM125"/>
</extension>
<extension url="name">
<valueString value="Unilateral Mastectomy Procedure"/>
</extension>
<extension url="statement">
<valueString
value="define "Unilateral Mastectomy Procedure":
[Procedure: "Unilateral Mastectomy"] UnilateralMastectomyProcedure
where Global."Normalize Interval"(UnilateralMastectomyProcedure.performed) ends before day of end of "Measurement Period"
and UnilateralMastectomyProcedure.status = 'completed'"/>
</extension>
<extension url="displaySequence">
<valueInteger value="5"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
<extension url="libraryName">
<valueString value="EXM125"/>
</extension>
<extension url="name">
<valueString value="Right Mastectomy"/>
</extension>
<extension url="statement">
<valueString
value="define "Right Mastectomy":
(
( [Condition: "Status Post Right Mastectomy"] C
where C.clinicalStatus ~ ToConcept(Global."active")
)
union (
[Condition: "Unilateral Mastectomy, Unspecified Laterality"] UnilateralMastectomyDiagnosis
where UnilateralMastectomyDiagnosis.bodySite in "Right"
and UnilateralMastectomyDiagnosis.clinicalStatus ~ ToConcept(Global."active")
)
) RightMastectomy
where Global."Normalize Interval"(RightMastectomy.onset) starts before day of end of "Measurement Period""/>
</extension>
<extension url="displaySequence">
<valueInteger value="6"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
<extension url="libraryName">
<valueString value="EXM125"/>
</extension>
<extension url="name">
<valueString value="Left Mastectomy"/>
</extension>
<extension url="statement">
<valueString
value="define "Left Mastectomy":
(
( [Condition: "Status Post Left Mastectomy"] C
where C.clinicalStatus ~ ToConcept(Global."active")
)
union (
[Condition: "Unilateral Mastectomy, Unspecified Laterality"] UnilateralMastectomyDiagnosis
where UnilateralMastectomyDiagnosis.bodySite in "Left"
and UnilateralMastectomyDiagnosis.clinicalStatus ~ ToConcept(Global."active")
)
) LeftMastectomy
where Global."Normalize Interval"(LeftMastectomy.onset) starts before day of end of "Measurement Period""/>
</extension>
<extension url="displaySequence">
<valueInteger value="7"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
<extension url="libraryName">
<valueString value="EXM125"/>
</extension>
<extension url="name">
<valueString value="History Bilateral Mastectomy"/>
</extension>
<extension url="statement">
<valueString
value="define "History Bilateral Mastectomy":
[Condition: "History of bilateral mastectomy"] BilateralMastectomyHistory
where Global."Normalize Interval"(BilateralMastectomyHistory.onset) starts before day of end of "Measurement Period"
and BilateralMastectomyHistory.clinicalStatus ~ ToConcept(Global."active")"/>
</extension>
<extension url="displaySequence">
<valueInteger value="8"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
<extension url="libraryName">
<valueString value="EXM125"/>
</extension>
<extension url="name">
<valueString value="Bilateral Mastectomy Procedure"/>
</extension>
<extension url="statement">
<valueString
value="define "Bilateral Mastectomy Procedure":
[Procedure: "Bilateral Mastectomy"] BilateralMastectomyPerformed
where Global."Normalize Interval"(BilateralMastectomyPerformed.performed) ends before day of end of "Measurement Period"
and BilateralMastectomyPerformed.status = 'completed'"/>
</extension>
<extension url="displaySequence">
<valueInteger value="9"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
<extension url="libraryName">
<valueString value="EXM125"/>
</extension>
<extension url="name">
<valueString value="Denominator Exclusion"/>
</extension>
<extension url="statement">
<valueString
value="define "Denominator Exclusion":
Hospice."Has Hospice"
or ( Count("Unilateral Mastectomy Procedure") = 2 )
or ( exists "Right Mastectomy" and exists "Left Mastectomy" )
or exists "History Bilateral Mastectomy"
or exists "Bilateral Mastectomy Procedure""/>
</extension>
<extension url="displaySequence">
<valueInteger value="10"/>
</extension>
</extension>
<name value="EffectiveDataRequirements"/>
<status value="active"/>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/library-type"/>
<code value="module-definition"/>
</coding>
</type>
<date value="2022-02-22T10:37:03-07:00"/>
<relatedArtifact>
<type value="depends-on"/>
<display value="Library Global"/>
<resource
value="http://hl7.org/fhir/us/cqfmeasures/Library/MATGlobalCommonFunctions|5.0.000"/>
</relatedArtifact>
<relatedArtifact>
<type value="depends-on"/>
<display value="Library FHIRHelpers"/>
<resource
value="http://fhir.org/guides/cqf/common/Library/FHIRHelpers|4.0.1"/>
</relatedArtifact>
<relatedArtifact>
<type value="depends-on"/>
<display value="Library AdultOutpatientEncounters"/>
<resource
value="http://hl7.org/fhir/us/cqfmeasures/Library/AdultOutpatientEncounters|2.0.000"/>
</relatedArtifact>
<relatedArtifact>
<type value="depends-on"/>
<display value="Library Hospice"/>
<resource
value="http://hl7.org/fhir/us/cqfmeasures/Library/Hospice|2.0.000"/>
</relatedArtifact>
<relatedArtifact>
<type value="depends-on"/>
<display value="Code system SNOMEDCT:2017-09"/>
<resource
value="http://snomed.info/sct|http://snomed.info/sct/731000124108/version/201709"/>
</relatedArtifact>
<relatedArtifact>
<type value="depends-on"/>
<display value="Code system ConditionClinicalStatusCodes"/>
<resource
value="http://terminology.hl7.org/CodeSystem/condition-clinical"/>
</relatedArtifact>
<relatedArtifact>
<type value="depends-on"/>
<display value="Value set Mammography"/>
<resource
value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.108.12.1018"/>
</relatedArtifact>
<relatedArtifact>
<type value="depends-on"/>
<display value="Value set Office Visit"/>
<resource
value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1001"/>
</relatedArtifact>
<relatedArtifact>
<type value="depends-on"/>
<display value="Value set Annual Wellness Visit"/>
<resource
value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.526.3.1240"/>
</relatedArtifact>
<relatedArtifact>
<type value="depends-on"/>
<display
value="Value set Preventive Care Services - Established Office Visit, 18 and Up"/>
<resource
value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1025"/>
</relatedArtifact>
<relatedArtifact>
<type value="depends-on"/>
<display
value="Value set Preventive Care Services-Initial Office Visit, 18 and Up"/>
<resource
value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1023"/>
</relatedArtifact>
<relatedArtifact>
<type value="depends-on"/>
<display value="Value set Home Healthcare Services"/>
<resource
value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1016"/>
</relatedArtifact>
<relatedArtifact>
<type value="depends-on"/>
<display value="Value set Encounter Inpatient"/>
<resource
value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.666.5.307"/>
</relatedArtifact>
<relatedArtifact>
<type value="depends-on"/>
<display value="Value set Hospice care ambulatory"/>
<resource
value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1108.15"/>
</relatedArtifact>
<relatedArtifact>
<type value="depends-on"/>
<display value="Value set Unilateral Mastectomy"/>
<resource
value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1020"/>
</relatedArtifact>
<relatedArtifact>
<type value="depends-on"/>
<display value="Value set Status Post Right Mastectomy"/>
<resource
value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1070"/>
</relatedArtifact>
<relatedArtifact>
<type value="depends-on"/>
<display value="Value set Unilateral Mastectomy, Unspecified Laterality"/>
<resource
value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1071"/>
</relatedArtifact>
<relatedArtifact>
<type value="depends-on"/>
<display value="Value set Right"/>
<resource
value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.122.12.1035"/>
</relatedArtifact>
<relatedArtifact>
<type value="depends-on"/>
<display value="Value set Status Post Left Mastectomy"/>
<resource
value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1069"/>
</relatedArtifact>
<relatedArtifact>
<type value="depends-on"/>
<display value="Value set Left"/>
<resource
value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.122.12.1036"/>
</relatedArtifact>
<relatedArtifact>
<type value="depends-on"/>
<display value="Value set History of bilateral mastectomy"/>
<resource
value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1068"/>
</relatedArtifact>
<relatedArtifact>
<type value="depends-on"/>
<display value="Value set Bilateral Mastectomy"/>
<resource
value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1005"/>
</relatedArtifact>
<parameter>
<name value="Measurement Period"/>
<use value="in"/>
<min value="0"/>
<max value="1"/>
<type value="Period"/>
</parameter>
<parameter>
<name value="Numerator"/>
<use value="out"/>
<min value="0"/>
<max value="1"/>
<type value="boolean"/>
</parameter>
<parameter>
<name value="Denominator"/>
<use value="out"/>
<min value="0"/>
<max value="1"/>
<type value="boolean"/>
</parameter>
<parameter>
<name value="Initial Population"/>
<use value="out"/>
<min value="0"/>
<max value="1"/>
<type value="boolean"/>
</parameter>
<parameter>
<name value="Denominator Exclusion"/>
<use value="out"/>
<min value="0"/>
<max value="1"/>
<type value="boolean"/>
</parameter>
<dataRequirement>
<type value="Encounter"/>
<profile value="http://hl7.org/fhir/StructureDefinition/Encounter"/>
<mustSupport value="type"/>
<codeFilter>
<path value="type"/>
<valueSet
value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1001"/>
</codeFilter>
</dataRequirement>
<dataRequirement>
<type value="Encounter"/>
<profile value="http://hl7.org/fhir/StructureDefinition/Encounter"/>
<mustSupport value="type"/>
<codeFilter>
<path value="type"/>
<valueSet
value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.526.3.1240"/>
</codeFilter>
</dataRequirement>
<dataRequirement>
<type value="Encounter"/>
<profile value="http://hl7.org/fhir/StructureDefinition/Encounter"/>
<mustSupport value="type"/>
<codeFilter>
<path value="type"/>
<valueSet
value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1025"/>
</codeFilter>
</dataRequirement>
<dataRequirement>
<type value="Encounter"/>
<profile value="http://hl7.org/fhir/StructureDefinition/Encounter"/>
<mustSupport value="type"/>
<codeFilter>
<path value="type"/>
<valueSet
value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1023"/>
</codeFilter>
</dataRequirement>
<dataRequirement>
<type value="Encounter"/>
<profile value="http://hl7.org/fhir/StructureDefinition/Encounter"/>
<mustSupport value="type"/>
<codeFilter>
<path value="type"/>
<valueSet
value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1016"/>
</codeFilter>
</dataRequirement>
<dataRequirement>
<type value="Encounter"/>
<profile value="http://hl7.org/fhir/StructureDefinition/Encounter"/>
<mustSupport value="period"/>
<mustSupport value="hospitalization"/>
<mustSupport value="hospitalization.dischargeDisposition"/>
<mustSupport value="type"/>
<mustSupport value="status"/>
<codeFilter>
<path value="type"/>
<valueSet
value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.666.5.307"/>
</codeFilter>
</dataRequirement>
<dataRequirement>
<type value="Procedure"/>
<profile value="http://hl7.org/fhir/StructureDefinition/Procedure"/>
<mustSupport value="code"/>
<mustSupport value="performed"/>
<mustSupport value="status"/>
<codeFilter>
<path value="code"/>
<valueSet
value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1020"/>
</codeFilter>
</dataRequirement>
<dataRequirement>
<type value="Procedure"/>
<profile value="http://hl7.org/fhir/StructureDefinition/Procedure"/>
<mustSupport value="code"/>
<mustSupport value="performed"/>
<mustSupport value="status"/>
<codeFilter>
<path value="code"/>
<valueSet
value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1108.15"/>
</codeFilter>
</dataRequirement>
<dataRequirement>
<type value="Procedure"/>
<profile value="http://hl7.org/fhir/StructureDefinition/Procedure"/>
<mustSupport value="code"/>
<mustSupport value="performed"/>
<mustSupport value="status"/>
<codeFilter>
<path value="code"/>
<valueSet
value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1005"/>
</codeFilter>
</dataRequirement>
<dataRequirement>
<type value="ServiceRequest"/>
<profile value="http://hl7.org/fhir/StructureDefinition/ServiceRequest"/>
<mustSupport value="code"/>
<mustSupport value="authoredOn"/>
<mustSupport value="intent"/>
<codeFilter>
<path value="code"/>
<valueSet
value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1108.15"/>
</codeFilter>
</dataRequirement>
<dataRequirement>
<type value="Condition"/>
<profile value="http://hl7.org/fhir/StructureDefinition/Condition"/>
<mustSupport value="code"/>
<mustSupport value="clinicalStatus"/>
<codeFilter>
<path value="code"/>
<valueSet
value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1070"/>
</codeFilter>
</dataRequirement>
<dataRequirement>
<type value="Condition"/>
<profile value="http://hl7.org/fhir/StructureDefinition/Condition"/>
<mustSupport value="code"/>
<mustSupport value="clinicalStatus"/>
<codeFilter>
<path value="code"/>
<valueSet
value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1069"/>
</codeFilter>
</dataRequirement>
<dataRequirement>
<type value="Condition"/>
<profile value="http://hl7.org/fhir/StructureDefinition/Condition"/>
<mustSupport value="bodySite"/>
<mustSupport value="code"/>
<mustSupport value="clinicalStatus"/>
<codeFilter>
<path value="code"/>
<valueSet
value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1071"/>
</codeFilter>
</dataRequirement>
<dataRequirement>
<type value="Condition"/>
<profile value="http://hl7.org/fhir/StructureDefinition/Condition"/>
<mustSupport value="code"/>
<mustSupport value="clinicalStatus"/>
<mustSupport value="onset"/>
<codeFilter>
<path value="code"/>
<valueSet
value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1068"/>
</codeFilter>
</dataRequirement>
<dataRequirement>
<type value="Patient"/>
<profile value="http://hl7.org/fhir/StructureDefinition/Patient"/>
</dataRequirement>
<dataRequirement>
<type value="DiagnosticReport"/>
<profile
value="http://hl7.org/fhir/StructureDefinition/DiagnosticReport"/>
<mustSupport value="effective"/>
<mustSupport value="code"/>
<mustSupport value="status"/>
<codeFilter>
<path value="code"/>
<valueSet
value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.108.12.1018"/>
</codeFilter>
</dataRequirement>
</Library>
</contained>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-populationBasis">
<valueCode value="boolean"/>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-softwaresystem">
<valueReference>
<reference value="Device/software-system-example"/>
</valueReference>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-effectiveDataRequirements" id="effective-data-requirements">
<valueReference>
<reference value="#effective-data-requirements"/>
</valueReference>
</extension>
<url value="http://ecqi.healthit.gov/ecqms/Measure/BreastCancerScreeningFHIR"/>
<identifier>
<use value="official"/>
<system value="http://example.org/fhir/cqi/ecqm/Measure/Identifier/exm"/>
<value value="125"/>
</identifier>
<identifier>
<use value="official"/>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/cqfmeasures/CodeSystem/identifier-type"/>
<code value="version-independent"/>
</coding>
</type>
<system value="urn:ietf:rfc:3986"/>
<value value="urn:uuid:11873bc9-ca0a-4cf3-b8f2-605a950aac74"/>
</identifier>
<identifier>
<use value="official"/>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/cqfmeasures/CodeSystem/identifier-type"/>
<code value="version-specific"/>
</coding>
</type>
<system value="urn:ietf:rfc:3986"/>
<value value="urn:uuid:b366f29b-347f-464e-8064-c83842d825c7"/>
</identifier>
<identifier>
<use value="usual"/>
<type>
<coding>
<system
value="http://hl7.org/fhir/us/cqfmeasures/CodeSystem/identifier-type"/>
<code value="short-name"/>
</coding>
</type>
<value value="BCS-FHIR"/>
</identifier>
<version value="2.0.003"/>
<name value="BreastCancerScreeningFHIR"/>
<title value="Breast Cancer Screening FHIR Measure"/>
<status value="active"/>
<experimental value="false"/>
<date value="2022-02-22T11:37:03-06:00"/>
<publisher value="Clinical Quality Information WG"/>
<contact>
<telecom>
<system value="url"/>
<value value="http://www.hl7.org/Special/committees/cqi"/>
</telecom>
</contact>
<description
value="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 value="http://terminology.hl7.org/CodeSystem/usage-context-type"/>
<code value="program"/>
</code>
<valueCodeableConcept>
<coding>
<system
value="http://hl7.org/fhir/us/cqfmeasures/CodeSystem/quality-programs"/>
<code value="ep-ec"/>
<display value="EP/EC"/>
</coding>
</valueCodeableConcept>
</useContext>
<jurisdiction>
<coding>
<system value="urn:iso:std:iso:3166"/>
<code value="US"/>
</coding>
</jurisdiction>
<purpose value="Unknown"/>
<copyright
value="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.
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.
CPT(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 value="2019-03-08"/>
<lastReviewDate value="2019-03-08"/>
<effectivePeriod>
<start value="2021-01-01"/>
<end value="2021-12-31"/>
</effectivePeriod>
<library value="http://hl7.org/fhir/us/cqfmeasures/Library/EXM125"/>
<disclaimer
value="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.
Due to technical limitations, registered trademarks are indicated by (R) or [R] and unregistered trademarks are indicated by (TM) or [TM]."/>
<scoring>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/measure-scoring"/>
<code value="proportion"/>
<display value="Proportion"/>
</coding>
</scoring>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/measure-type"/>
<code value="process"/>
</coding>
</type>
<rationale
value="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).
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 (Noone et al, 2018).
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 68; by age 50 it becomes 1 in 43; by age 60, it is 1 in 29 (American Cancer Society, 2017)."/>
<clinicalRecommendationStatement
value="The U.S. Preventive Services Task Force (USPSTF) recommends biennial screening mammography for women aged 50-74 years (B recommendation).
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)
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)
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)
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
value="http://terminology.hl7.org/CodeSystem/measure-improvement-notation"/>
<code value="increase"/>
</coding>
</improvementNotation>
<guidance
value="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.
This measure evaluates primary screening. Do not count biopsies, breast ultrasounds, or MRIs because they are not appropriate methods for primary breast cancer screening.
This eCQM is a patient-based measure."/>
<group id="group-1">
<population id="3D2DD734-0712-484A-BE23-B1D2FF96D83A">
<code>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/measure-population"/>
<code value="initial-population"/>
<display value="Initial Population"/>
</coding>
</code>
<criteria>
<language value="text/cql-identifier"/>
<expression value="Initial Population"/>
</criteria>
</population>
<population id="C4B18753-73BC-4D48-801E-82AB55A70139">
<code>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/measure-population"/>
<code value="denominator"/>
<display value="Denominator"/>
</coding>
</code>
<criteria>
<language value="text/cql-identifier"/>
<expression value="Denominator"/>
</criteria>
</population>
<population id="7C770CA2-5177-4C5F-A976-7F57EC9BC311">
<code>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/measure-population"/>
<code value="denominator-exclusion"/>
<display value="Denominator Exclusion"/>
</coding>
</code>
<criteria>
<language value="text/cql-identifier"/>
<expression value="Denominator Exclusion"/>
</criteria>
</population>
<population id="57BC5171-93A7-4D9B-AA42-18A344C8623B">
<code>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/measure-population"/>
<code value="numerator"/>
<display value="Numerator"/>
</coding>
</code>
<criteria>
<language value="text/cql-identifier"/>
<expression value="Numerator"/>
</criteria>
</population>
</group>
</Measure>
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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