HL7.FHIR.US.CQFMEASURES\EXM125 - Breast Cancer Screening

This page is part of the Quality Measure STU2 for FHIR R4 Implementation Guide (v4.0.0: STU4 (v4.0.0)) 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

Example Measure: EXM125 - Breast Cancer Screening

Active as of 2022-02-22

Id: EXM125-FHIR

Download cql: EXM125-FHIR.cql

Url: EXM125 - Breast Cancer Screening

Version: 8.0.000

Identifier:

value: 125

Identifier:

value: 112

Name: EXM125

Title: EXM125 - Breast Cancer Screening

Status: active

Experimental: true

Scoring:

Proportion

Improvement Notation:

Increased score indicates improvement

Type:

process

Date: 2022-02-22

Publisher: Clinical Quality Information WG

Description:

Percentage of women 50-74 years of age who had a mammogram to screen for breast cancer

Use Context:

code

value

program

Jurisdiction: US

Topic: 57024-2

Purpose:

Women 51-74 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). The Measure is copyrighted but 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 must be approved by NCQA and are subject to a license at the discretion of 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. (C) 2012-2017 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 CPT or other codes contained in the specifications. CPT(R) contained in the Measure specifications is copyright 2004-2016 American Medical Association. LOINC(R) copyright 2004-2016 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2016 International Health Terminology Standards Development Organisation. ICD-10 copyright 2016 World Health Organization. All Rights Reserved. The American Hospital Association holds a copyright to the National Uniform Billing Committee (NUBC) codes contained in the measure specifications. The NUBC codes in the specifications are included with the permission of the AHA. The NUBC codes contained in the specifications may be used by health plans and other health care delivery organizations for the purpose of calculating and reporting Measure results or using Measure results for their internal quality improvement purposes. All other uses of the NUBC codes require a license from the AHA. Anyone desiring to use the NUBC codes in a commercial product to generate Measure results, or for any other commercial use, must obtain a commercial use license directly from the AHA. To inquire about licensing, contact ub04@healthforum.com.

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.

Approval Date: 2016-01-01

Last Review Date: 2016-09-01

Effective Period: 2018-01-01..2018-12-31

Supplemental Data Elements: SDE Ethnicity SDE Payer SDE Race SDE Sex

Libraries:

EXM125 - Breast Cancer Screening Library

Related Artifact Dependencies: Supplemental Data Elements Library

http://fhir.org/guides/cqf/common/Library/FHIRHelpers|4.0.1

MAT Global Common Functions FHIR Library

Adult Outpatient Encounters Common Library

Hospice FHIR Library

http://snomed.info/sct|http://snomed.info/sct/731000124108/version/201709

Condition Clinical Status Codes

Mammography

Office Visit

Annual Wellness Visit

Preventive Care Services Established Office Visit, 18 and Up

Preventive Care Services Initial Office Visit, 18 and Up

Home Healthcare Services

Payer

Encounter Inpatient

Hospice Care Ambulatory

Unilateral Mastectomy

Status Post Right Mastectomy

Unilateral Mastectomy, Unspecified Laterality

Right

Status Post Left Mastectomy

Left

History of bilateral mastectomy

Bilateral Mastectomy

Parameters:

name

use

min

max

type

Measurement Period

Period

SDE Sex

out

Coding

Numerator

out

boolean

Denominator

out

boolean

SDE Payer

out

Resource

Initial Population

out

boolean

SDE Ethnicity

out

Coding

Denominator Exclusion

out

boolean

SDE Race

out

Coding

DataRequirements:

Type

Must Support

Valueset Name

Valueset

Coverage

period type

Payer

Patient

extension value url

Condition

code clinicalStatus

Status Post Right Mastectomy

Condition

code clinicalStatus

Status Post Left Mastectomy

Condition

bodySite code clinicalStatus

Unilateral Mastectomy, Unspecified Laterality

Condition

code clinicalStatus onset

History of bilateral mastectomy

Procedure

code performed status

Bilateral Mastectomy

Procedure

code performed status

Unilateral Mastectomy

Procedure

code performed status

Hospice care ambulatory

Hospice Care Ambulatory

Encounter

type

Office Visit

Encounter

type

Annual Wellness Visit

Encounter

type

Preventive Care Services - Established Office Visit, 18 and Up

Preventive Care Services Established Office Visit, 18 and Up

Encounter

type

Preventive Care Services-Initial Office Visit, 18 and Up

Preventive Care Services Initial Office Visit, 18 and Up

Encounter

type

Home Healthcare Services

Encounter

period hospitalization hospitalization.dischargeDisposition type status

Encounter Inpatient

ServiceRequest

code authoredOn intent

Hospice care ambulatory

Hospice Care Ambulatory

DiagnosticReport

effective code status

Mammography

Direct Reference Codes:

display

code

system

Discharge to home for hospice care (procedure)

428361000124107

SNOMED CT (all versions)

Discharge to healthcare facility for hospice care (procedure)

428371000124100

SNOMED CT (all versions)

active

Condition Clinical Status Codes

Logic Definitions:

Group Scoring Population Criteria Expression

Measure scoring:

Proportion

Initial Population

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"

Numerator

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' }
		)

Denominator

define "Denominator":
		"Initial Population"

Denominator Exclusion

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"

Library Name Name

SupplementalDataElements SDE Sex

define "SDE Sex":
  case
      when Patient.gender = 'male' then Code { code: 'M', system: 'http://hl7.org/fhir/v3/AdministrativeGender', display: 'Male' }
      when Patient.gender = 'female' then Code { code: 'F', system: 'http://hl7.org/fhir/v3/AdministrativeGender', display: 'Female' }
      else null
    end

Library Name Name

EXM125-FHIR SDE Sex

define "SDE Sex":
  SDE."SDE Sex"

Library Name Name

EXM125-FHIR Numerator

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' }
		)

Library Name Name

AdultOutpatientEncounters Qualifying Encounters

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'

Library Name Name

EXM125-FHIR Initial Population

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"

Library Name Name

EXM125-FHIR Denominator

define "Denominator":
		"Initial Population"

Library Name Name

SupplementalDataElements SDE Payer

define "SDE Payer":
  [Coverage: type in "Payer"] Payer
        return {
          code: Payer.type,
          period: Payer.period
        }

Library Name Name

EXM125-FHIR SDE Payer

define "SDE Payer":
  SDE."SDE Payer"

Library Name Name

SupplementalDataElements SDE Ethnicity

define "SDE Ethnicity":
  (flatten (
      Patient.extension Extension
        where Extension.url = 'http://hl7.org/fhir/us/core/StructureDefinition/us-core-ethnicity'
          return Extension.extension
    )) E
      where E.url = 'ombCategory'
        or E.url = 'detailed'
      return E.value as Coding

Library Name Name

EXM125-FHIR SDE Ethnicity

define "SDE Ethnicity":
  SDE."SDE Ethnicity"

Library Name Name

Hospice Has Hospice

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"
    )

Library Name Name

EXM125-FHIR Unilateral Mastectomy Procedure

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'

Library Name Name

EXM125-FHIR Right Mastectomy

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"

Library Name Name

EXM125-FHIR Left Mastectomy

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"

Library Name Name

EXM125-FHIR History Bilateral Mastectomy

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")

Library Name Name

EXM125-FHIR Bilateral Mastectomy Procedure

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'

Library Name Name

EXM125-FHIR Denominator Exclusion

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"

Library Name Name

SupplementalDataElements SDE Race

define "SDE Race":
  (flatten (
      Patient.extension Extension
        where Extension.url = 'http://hl7.org/fhir/us/core/StructureDefinition/us-core-race'
          return Extension.extension
    )) E
      where E.url = 'ombCategory'
        or E.url = 'detailed'
      return E.value as Coding

Library Name Name

EXM125-FHIR SDE Race

define "SDE Race":
  SDE."SDE Race"

Contained resources

EffectiveDataRequirements