Common CQL Artifacts for FHIR (US-Based)
1.0.0 - Informative 1

Common CQL Artifacts for FHIR (US-Based) - Downloaded Version null See the Directory of published versions

## Overall Patterns

Page standards status: Informative

### Element Considerations

Whether logic in general should make use of the various elements of a resource (or profile of a resource) depends on measure or rule intent. However, there are some general guidelines that should be followed to ensure correct expression and evaluation of CQL.

#### Element Cardinality

To begin with, all elements in FHIR resources and profiles have a cardinality that determines whether and how many values may appear in that element. Cardinality is expressed as a range, typically from `0` or `1` to `1` or `*`. A cardinality of `0..1` means the element is optional. A cardinality of `1..1` means the element is required. A cardinality of `0..*` means the element may appear any number of times, and a cardinality of `1..*` means the element must appear at least once, but may appear multiple times. Although other cardinalities are possible, those described above are the most common.

NOTE: Cardinality determines whether and how many values may appear for a given element, but the fact that an element is specified as required (e.g. 1..1) does not mean that expressions using that profile must use that element.

#### Must Support Elements

In addition, elements in FHIR resources and profiles may be marked must support, meaning that implementations are required to provide values for the element if they are present in the system. To ensure expression logic can be evaluated correctly, expressions should only make use of elements that are marked must support (or otherwise have a reasonable expectation of being present). For a complete discussion of this aspect, refer to the MustSupport Flag topic in the US Core Implementation Guide.

#### Modifier Elements

And finally, elements in FHIR resources and profiles may be marked as modifier elements, meaning that the value of the element may change the overall meaning of the resource. For example, the `clinicalStatus` element of a `Condition` is a modifier element because the value determines whether the `Condition` overall represents the presence or absence of a condition. As a result, for each modifier element, authors must carefully consider whether each possible value would impact the intent of the expression.

##### Modifier Extensions

In addition to modifier elements, extensions in FHIR may be modifier extensions, and any FHIR resource that has modifier extensions that are not understood cannot be processed. Applications may consider performing this check as part of the overall environment, or the CQL logic may be used to ensure that either no modifier extensions are specified, or that only expected modifier extensions are present using the `checkModifiers()` function.

### ImplicitRules

A key modifier element that must be considered for any FHIR resource is `implicitRules`. If this element is specified, it must be respected and understood. Applications may consider performing this check as part of the overall environment, or the CQL logic may be used to ensure that either no implicit rules are specified, or that the implicitRules are expected:

    define fluent function checkImplicitRules(resource Resource, knownImplicitRules String):
      Message(
        resource,
        resource.imiplicitRules !~ knownImplicitRules,
        'implicit-rules-check',
        'Error',
        'Implicit rules check failed for resource ' + resource.resourceType + '\' + resource.id
      )

### Accessing Data

To summarize, cardinality determines whether data will be present at all, must support determines whether the element can reasonably be expected to be present, and modifier elements must always be considered to determine the impact of possible values of the element on the result of the expression.

With these element considerations in mind, there are some general patterns for accessing data within CQL using the Retrieve expression:

    define "All Allergies and Intolerances":
      [USCore."AllergyIntolerance"]

This retrieve expression consists only of the name of the profiled resource being requested, and will result in all AllergyIntolerance resources that conform to the profile being retrieved.

Because the `clinicalStatus` and `verificationStatus` elements of the AllergyIntolerance resource are modifier elements, they should be considered whenever accessing and using these types of resources.

The `USCoreCommon` library provides fluent functions for checking these status elements:

    define "Active Confirmed Allergies and Intolerances":
      "All Allergies and Intolerances".allergyActive().allergyConfirmed()

> NOTE: For discussion on how to manage search parameters with terminology, see the Terminology Considerations discussion in the Architectural Guidance topic.

> NOTE: For discussion on how to manage optional search parameters, see the Performant Data Access discussion in the Architectural Guidance topic.

### Context Questions

The following topics discuss issues related to types of questions that will be common to multiple questionnaires, and may potentially already be known from context.

Note that the ExamplePatientAndCoverage questionnaire is an illustration of how some of this information might be determined if it is not already known from context, leaving these types of context questions out of the rest of the examples as would normally be expected in an electronic prior authorization flow.

#### SubscriberId/MemberId

The Coverage resource includes a `subscriberId` element; however, this is expected to be the Subscriber ID associated with the already established Member ID (individual). That is to say Subscriber ID is the plan-level identifier for an individual that has the plan, whereas Member ID is specific to the individual beneficiaries of the plan.

Note that some plans do not establish individual Member IDs and instead use a combination of SubscriberId and individual identifying information.

#### Billing/Servicing Provider

For data elements related to determining and identifying billing/servicing provider in the prior-authorization use case, there are several possibilities:

1. Known ahead of time (and part of the ServiceRequest, so doesn't make sense to ask)
2. Not known, but will be specified by a separate process (such as order dispatch)
3. Servicing isn't part of the process

This information is generally reflected in two categories of orders:

- Directed order - provider has to be on the order
- Undirected order - provider may or may not be on the order, requesting organization may need to specify at some point, but may not care. If provider doesn't care and payer does, having it in the questionnaire potentially gives the payer an opportunity for the in/out of network check to be performed, as well as for the payer to participate in the decision of who the servicing/billing provider is

When needed and possible, this information should be framed as "Pick one of these in network providers near you", rather than the more paper-based approach of gathering provider demographics such as name, address, and phone number.

#### Questions related to the Service being Authorized

Authorization for lab tests is sometimes determined based on category (e.g. preventative, treatment, elective). If appropriate, this information could be represented in a "reason" element, but this may not necessarily be coded in a way that is useful for the payer. As such, this may be a useful data element to work towards providing standardized categorization, with the categories specified in USCore Observation Category Codes as a starting point.

#### Urgency

Almost all prior authorization forms contain a question about the urgency of the request. Different forms have different ways of expressing the same logic. E.g., the Humana Uniform Pharmacy Prior Authorization Request Form uses check boxes with the strings "Urgent" and "Non-Urgent". The form Geisinger Medical Benefit Outpatient Drug Authorization Form contains a categorization as "Urgent" more in a boolean logic with a required rationale if the request is labelled as "Urgent".

However, this characterization of the urgency of the request is part of the request resource, such as `MedicationRequest.priority`, and so in general would be provided to the payer as part of the prior-authorization request, and would not be requested by the payer. As such, this element, if present at all, would likely be readonly in the prior-authorization use case.