Quality Measure Implementation Guide (STU4)
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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: Pneumococcal Vaccination Status for Older Adults

Draft as of 2022-02-22
Id: PVSComponent
Download cql: PVSComponent.cql
Url: Pneumococcal Vaccination Status for Older Adults
Version: 0.0.001
Name: PVSComponent
Title: Pneumococcal Vaccination Status for Older Adults
Status: draft
Experimental: true
Scoring:

Proportion

Improvement Notation:

increase

Type:

process

Date: 2022-02-22 11:37:04-0600
Publisher: Clinical Quality Information WG
Description:

This is an example only.
Jurisdiction: US
Effective Period: 2022-01-01..2022-12-31
Supplemental Data Elements: SDE Ethnicity SDE Payer SDE Race SDE Sex
Libraries:
PVS Component 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
  • Hospice FHIR Library
  • http://snomed.info/sct|http://snomed.info/sct/731000124108/version/201709
  • Pneumococcal Vaccine
  • Pneumococcal Vaccine Administered
  • 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
  • Discharge Services Nursing Facility
  • Nursing Facility Visit
  • Care Services in Long Term Residential Facility
  • Payer
  • Encounter Inpatient
  • Hospice Care Ambulatory
    		•
    Parameters:
    nameuseminmaxtype
    Measurement Period in 0 1 Period
    SDE Sex out 0 1 Coding
    Numerator out 0 1 boolean
    Denominator out 0 1 boolean
    SDE Payer out 0 * Resource
    Initial Population out 0 1 boolean
    SDE Ethnicity out 0 * Coding
    Denominator Exclusions out 0 1 boolean
    SDE Race out 0 * Coding
    DataRequirements:
    TypeMust SupportValueset NameValueset
    Coverage period type Payer Payer
    Patient extension value url
    Encounter period hospitalization hospitalization.dischargeDisposition type status Encounter Inpatient Encounter Inpatient
    Encounter type Office Visit Office Visit
    Encounter type Annual Wellness Visit 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 Home Healthcare Services
    Encounter type Discharge Services - Nursing Facility Discharge Services Nursing Facility
    Encounter type Nursing Facility Visit Nursing Facility Visit
    Encounter type Care Services in Long-Term Residential Facility Care Services in Long Term Residential Facility
    ServiceRequest code authoredOn intent Hospice care ambulatory Hospice Care Ambulatory
    Procedure code performed status Hospice care ambulatory Hospice Care Ambulatory
    Procedure code performed status Pneumococcal Vaccine Administered Pneumococcal Vaccine Administered
    Immunization occurrence vaccineCode status Pneumococcal Vaccine Pneumococcal Vaccine
    Direct Reference Codes:
    displaycodesystem
    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)
    Logic Definitions:
    GroupScoringPopulation CriteriaExpression
    Measure scoring:

    Proportion

    Initial Population 
    define "Initial Population":   Global."CalendarAgeInYearsAt" ( FHIRHelpers.ToDate ( Patient.birthDate ), start of "Measurement Period" ) >= 65       and exists "Qualifying Encounters"
    Denominator 
    define "Denominator":   "Initial Population"
    Denominator Exclusion 
    define "Denominator Exclusions":   Hospice."Has Hospice"
    Numerator 
    define "Numerator":   exists ( [Immunization: "Pneumococcal Vaccine"] PneumococcalVaccine         where PneumococcalVaccine.status = 'completed'           and PneumococcalVaccine.occurrence as dateTime on or before           end of "Measurement Period"     )       or exists ( [Procedure: "Pneumococcal Vaccine Administered"] PneumococcalVaccineGiven           where PneumococcalVaccineGiven.status = 'completed'             and PneumococcalVaccineGiven.performed as Period on or before             end of "Measurement Period"       )
    Library NameName
    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 NameName
    PVSComponent SDE Sex 
    define "SDE Sex":   SDE."SDE Sex"
    Library NameName
    PVSComponent Numerator 
    define "Numerator":   exists ( [Immunization: "Pneumococcal Vaccine"] PneumococcalVaccine         where PneumococcalVaccine.status = 'completed'           and PneumococcalVaccine.occurrence as dateTime on or before           end of "Measurement Period"     )       or exists ( [Procedure: "Pneumococcal Vaccine Administered"] PneumococcalVaccineGiven           where PneumococcalVaccineGiven.status = 'completed'             and PneumococcalVaccineGiven.performed as Period on or before             end of "Measurement Period"       )
    Library NameName
    PVSComponent 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"]       union [Encounter: "Discharge Services - Nursing Facility"]       union [Encounter: "Nursing Facility Visit"]       union [Encounter: "Care Services in Long-Term Residential Facility"] ) ValidEncounter       where ValidEncounter.period during "Measurement Period"         and ValidEncounter.status = 'finished'
    Library NameName
    PVSComponent Initial Population 
    define "Initial Population":   Global."CalendarAgeInYearsAt" ( FHIRHelpers.ToDate ( Patient.birthDate ), start of "Measurement Period" ) >= 65       and exists "Qualifying Encounters"
    Library NameName
    PVSComponent Denominator 
    define "Denominator":   "Initial Population"
    Library NameName
    SupplementalDataElements SDE Payer 
    define "SDE Payer":   [Coverage: type in "Payer"] Payer         return {           code: Payer.type,           period: Payer.period         }
    Library NameName
    PVSComponent SDE Payer 
    define "SDE Payer":   SDE."SDE Payer"
    Library NameName
    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 NameName
    PVSComponent SDE Ethnicity 
    define "SDE Ethnicity":   SDE."SDE Ethnicity"
    Library NameName
    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 NameName
    PVSComponent Denominator Exclusions 
    define "Denominator Exclusions":   Hospice."Has Hospice"
    Library NameName
    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 NameName
    PVSComponent SDE Race 
    define "SDE Race":   SDE."SDE Race"

    Contained resources