Generated Narrative: Library library-exm108-example

Data Requirements

Contents

text/cql

/*
This example is a work in progress and should not be considered a final specification
or recommendation for guidance. This example will help guide and direct the process
of finding conventions and usage patterns that meet the needs of the various stakeholders
in the measure development community.

@author: TJC
Based on CMS108v8 2020 reporting year. QDM to QI-4
Venous Thromboembolism Prophylaxis
*/
library EXM108 version '8.2.000'

using FHIR version '4.0.1'

include FHIRHelpers version '4.0.1' called FHIRHelpers
include MATGlobalCommonFunctions version '5.0.000' called Global
include SupplementalDataElements version '2.0.000' called SDE
include VTEICU version '5.0.000' called VTEICU
include TJCOverall version '4.0.000' called TJC

codesystem "SNOMEDCT": 'http://snomed.info/sct'
codesystem "LOINC": 'http://loinc.org'
// NOTE: R4 code system URLs changed to be based on terminology.hl7.org...
codesystem "RequestIntent": 'http://terminology.hl7.org/CodeSystem/request-intent'
//NOTE: Created for ActPriority for Encounter.category which is codeableConcept
codesystem "ActPriority": 'http://terminology.hl7.org/ValueSet/v3-ActPriority'

valueset "Device Application": 'http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1110.48'
valueset "Atrial Fibrillation/Flutter": 'http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.202'
valueset "Comfort Measures": 'http://cts.nlm.nih.gov/fhir/ValueSet/1.3.6.1.4.1.33895.1.3.0.45'
valueset "Direct Thrombin Inhibitor": 'http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.205'
valueset "Emergency Department Visit": 'http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.292'
valueset "General or Neuraxial Anesthesia": 'http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.666.5.1743'
valueset "General Surgery": 'http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.255'
valueset "Glycoprotein IIb/IIIa Inhibitors": 'http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1045.41'
valueset "Graduated compression stockings (GCS)": 'http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.256'
valueset "Gynecological Surgery": 'http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.257'
valueset "Hemorrhagic Stroke": 'http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.212'
valueset "Hip Fracture Surgery": 'http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.258'
valueset "Hip Replacement Surgery": 'http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.259'
valueset "Injectable Factor Xa Inhibitor for VTE Prophylaxis": 'http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.211'
valueset "INR": 'http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.213'
valueset "Intermittent pneumatic compression devices (IPC)": 'http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.214'
valueset "Intracranial Neurosurgery": 'http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.260'
valueset "Intravenous route": 'http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.222'
valueset "Ischemic Stroke": 'http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.247'
valueset "Knee Replacement Surgery": 'http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.261'
valueset "Low Dose Unfractionated Heparin for VTE Prophylaxis": 'http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1045.39'
valueset "Low Molecular Weight Heparin for VTE Prophylaxis": 'http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.219'
valueset "Low Risk": 'http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.400'
valueset "Medical Reason": 'http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.473'
valueset "Mental Health Diagnoses": 'http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.105.12.1004'
valueset "Obstetrics": 'http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.263'
valueset "Obstetrics VTE": 'http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.264'
valueset "Oral Factor Xa Inhibitor for VTE Prophylaxis or VTE Treatment": 'http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.134'
valueset "Patient Refusal": 'http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.93'
valueset "Subcutaneous route": 'http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.223'
valueset "Unfractionated Heparin": 'http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.218'
valueset "Urological Surgery": 'http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.272'
valueset "Venous foot pumps (VFP)": 'http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.230'
valueset "Venous Thromboembolism": 'http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.279'
valueset "Warfarin": 'http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.232'
valueset "Intensive Care Unit": 'http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1110.23'

code "Risk for venous thromboembolism": '72136-5' from "LOINC" display 'Risk for venous thromboembolism'

context Patient

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

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

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

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

define "Initial Population":
  "Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions"

// Note: added FHIRHelpers.ToDate() in R4
define "Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions":
    ( Global."Inpatient Encounter" InpatientEncounter
    		with ["Patient"] BirthDate
    			such that Global."CalendarAgeInYearsAt"(FHIRHelpers.ToDate(BirthDate.birthDate), start of InpatientEncounter.period) >= 18
    )
    intersect "Admission Without VTE or Obstetrical Conditions"

  define "Admission Without VTE or Obstetrical Conditions":
	  	Global."Inpatient Encounter" InpatientEncounter
		    where not (exists (Global.EncounterDiagnosis(InpatientEncounter)) EncounterDiagnosis
              where (EncounterDiagnosis.code in "Obstetrics"
								or EncounterDiagnosis.code in "Venous Thromboembolism"
								or EncounterDiagnosis.code in "Obstetrics VTE"
			         )
        )

define "Denominator":
      "Initial Population"

define "Denominator Exclusion":
    "Encounter Less Than 2 Days"
     union "Encounter With ICU Location Stay 1 Day or More"
     union "Encounter With Principal Diagnosis of Mental Disorder or Stroke"
     union "Encounter With Principal Procedure of SCIP VTE Selected Surgery"
     union "Encounter With Intervention Comfort Measures From Day of Start of Hospitalization To Day After Admission"
     union "Encounter With Intervention Comfort Measures on Day of or Day After Procedure"

define "Encounter Less Than 2 Days":
  "Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter
  	where Global."LengthInDays"(QualifyingEncounter.period)< 2

define "Encounter With ICU Location Stay 1 Day or More":
  "Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter
    where exists ( QualifyingEncounter.location Location
    		where Global.GetLocation(Location.location).type in "Intensive Care Unit"
    			and Global."LengthInDays"(Location.period)>= 1
    			and Location.period starts during TJC."CalendarDayOfOrDayAfter"(start of QualifyingEncounter.period)
	    )

define "Encounter With Principal Diagnosis of Mental Disorder or Stroke":
  "Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter
    where Global."PrincipalDiagnosis"(QualifyingEncounter).code in "Mental Health Diagnoses"
        or Global."PrincipalDiagnosis"(QualifyingEncounter).code in "Hemorrhagic Stroke"
        or Global."PrincipalDiagnosis"(QualifyingEncounter).code in "Ischemic Stroke"

/* NOTE: 2 options to express Principal Procedure to retrive "encounter Procedure as an url" and proedure "rank as extension" in R4
          VTE-1 uses Option 1 - generic extension funtion
          VTE-2 uses Option 2 - Specific extension functions
  TODO:  Mapping Table needs revision on using "Encounter.procedure.code", "Encounter.procedure.sequence"
*/

define "Encounter With Principal Procedure of SCIP VTE Selected Surgery":
  from
      "Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter,
      "SCIP VTE Selected Surgery" SelectedProcedure
      let EncounterProcedure: Global.GetExtension(QualifyingEncounter, 'qicore-encounter-procedure')
  where FHIRHelpers.ToInteger(Global.GetExtension(EncounterProcedure, 'rank').value as FHIR.positiveInt) = 1
      and Global.GetId(FHIRHelpers.ToString((Global.GetExtension(EncounterProcedure, 'procedure').value as FHIR.Reference).reference)) = SelectedProcedure.id
      and Global."Normalize Interval"(SelectedProcedure.performed) during QualifyingEncounter.period

define "SCIP VTE Selected Surgery":
  (	["Procedure": "General Surgery"]
    union ["Procedure": "Gynecological Surgery"]
    union ["Procedure": "Hip Fracture Surgery"]
    union ["Procedure": "Hip Replacement Surgery"]
    union ["Procedure": "Intracranial Neurosurgery"]
    union ["Procedure": "Knee Replacement Surgery"]
    union ["Procedure": "Urological Surgery"] ) Procedure
  where Procedure.status = 'completed'

define "Encounter With Intervention Comfort Measures From Day of Start of Hospitalization To Day After Admission":
	"Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter
		with "Intervention Comfort Measures" ComfortMeasure
		such that Coalesce(start of Global."Normalize Interval"(ComfortMeasure.performed), ComfortMeasure.authoredOn) during VTEICU."FromDayOfStartOfHospitalizationToDayAfterAdmission"(QualifyingEncounter)

define "Intervention Comfort Measures":
	(["ServiceRequest": "Comfort Measures"] P
    		where P.intent = 'order'
  )
  	union
    	(["Procedure": "Comfort Measures"] InterventionPerformed
      	where InterventionPerformed.status in {'completed', 'in-progress'})

define "Encounter With Intervention Comfort Measures on Day of or Day After Procedure":
  from
  		"Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter,
  		["Procedure": "General or Neuraxial Anesthesia"] AnesthesiaProcedure,
  		"Intervention Comfort Measures" ComfortMeasure
		where AnesthesiaProcedure.status = 'completed'
				and Global."Normalize Interval"(AnesthesiaProcedure.performed) ends 1 day after day of start of QualifyingEncounter.period
        and Coalesce(start of Global."Normalize Interval"(ComfortMeasure.performed), ComfortMeasure.authoredOn) during TJC."CalendarDayOfOrDayAfter"(end of Global."Normalize Interval"(AnesthesiaProcedure.performed))
    return QualifyingEncounter

define "Numerator":
    "Encounter With VTE Prophylaxis Received on Day of or Day After Admission or Procedure"
    union ( "Encounter With Medication Oral Factor Xa Inhibitor Administered on Day of or Day After Admission or Procedure"
    			  intersect ( "Encounter With Prior or Present Diagnosis of Atrial Fibrillation or VTE"
    						    union "Encounter With Prior or Present Procedure of Hip or Knee Replacement Surgery"
    			            )
          )
    union "Encounter With Low Risk for VTE or Anticoagulant Administered"
    union "Encounter With No VTE Prophylaxis Due to Medical Reason"
    union "Encounter With No VTE Prophylaxis Due to Patient Refusal"

define "Encounter With VTE Prophylaxis Received on Day of or Day After Admission or Procedure":
 	( from
   			"Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter,
   			"VTE Prophylaxis by Medication Administered or Device Applied" VTEProphylaxis
  		where Coalesce(Global."Normalize Interval"(VTEProphylaxis.effective), Global."Normalize Interval"(VTEProphylaxis.performed)) starts during TJC."CalendarDayOfOrDayAfter"(start of QualifyingEncounter.period)
  		return QualifyingEncounter
 	)
 	union (
    from
  			"Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter,
  			["Procedure": "General or Neuraxial Anesthesia"] AnesthesiaProcedure,
  			"VTE Prophylaxis by Medication Administered or Device Applied" VTEProphylaxis
			where Global."Normalize Interval"(AnesthesiaProcedure.performed) ends 1 day after day of start of QualifyingEncounter.period
				and Coalesce(Global."Normalize Interval"(VTEProphylaxis.effective), Global."Normalize Interval"(VTEProphylaxis.performed)) starts during TJC."CalendarDayOfOrDayAfter"(end of Global."Normalize Interval"(AnesthesiaProcedure.performed))
			return QualifyingEncounter
	)

// 10/29: Replaced DeviceUseStatement with Procedure with a new value set and procedure.usdCode for specifying devices
define "VTE Prophylaxis by Medication Administered or Device Applied":
  ( ["MedicationAdministration": medication in "Low Dose Unfractionated Heparin for VTE Prophylaxis"] VTEMedication
      where VTEMedication.status ='completed'
			     and VTEMedication.dosage.route in "Subcutaneous route"
  )
   union (["MedicationAdministration": medication in "Low Molecular Weight Heparin for VTE Prophylaxis"] LMWH where LMWH.status = 'completed')
    union (["MedicationAdministration": medication in "Injectable Factor Xa Inhibitor for VTE Prophylaxis"] FactorXa where FactorXa.status = 'completed')
     union (["MedicationAdministration": medication in "Warfarin"] Warfarin where Warfarin.status = 'completed')
      union (
          ["Procedure": "Device Application"] DeviceApplied
          where DeviceApplied.status = 'complete'
                and (DeviceApplied.usedCode in "Intermittent pneumatic compression devices (IPC)"
                    or DeviceApplied.usedCode in"Venous foot pumps (VFP)"
                    or DeviceApplied.usedCode in "Graduated compression stockings (GCS)"
                    )
          )

define "Encounter With Medication Oral Factor Xa Inhibitor Administered on Day of or Day After Admission or Procedure":
	( from
    		"Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter,
  			["MedicationAdministration": medication in "Oral Factor Xa Inhibitor for VTE Prophylaxis or VTE Treatment"] FactorXaMedication
    where FactorXaMedication.status = 'completed'
      and Global."Normalize Interval"(FactorXaMedication.effective) starts during TJC."CalendarDayOfOrDayAfter"(start of QualifyingEncounter.period)
    return QualifyingEncounter
    )
    union ( from
    				  "Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter,
      				["Procedure": "General or Neuraxial Anesthesia"] AnesthesiaProcedure,
      				["MedicationAdministration": medication in "Oral Factor Xa Inhibitor for VTE Prophylaxis or VTE Treatment"] FactorXaMedication
      			where FactorXaMedication.status = 'completed'
                and AnesthesiaProcedure.status = 'completed'
      			    and Global."Normalize Interval"(AnesthesiaProcedure.performed) ends 1 day after day of start of QualifyingEncounter.period
      					and Global."Normalize Interval"(FactorXaMedication.effective) starts during TJC."CalendarDayOfOrDayAfter"(end of Global."Normalize Interval"(AnesthesiaProcedure.performed))
      			return QualifyingEncounter
      		)

/*NOTE: Feedback at Digitial Quality Summit 2019 indicates verificationStatus may be difficult for implementers to retrieve
        both condition.clinicalStatus and condition.verificationStatus = 'confirmed'
*/
define "Encounter With Prior or Present Diagnosis of Atrial Fibrillation or VTE":
	( "Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter
		with ["Condition": code in "Atrial Fibrillation/Flutter"] AtrialFibrillation
		such that FHIRHelpers.ToConcept(AtrialFibrillation.clinicalStatus) in { Global."active", Global."recurrence", Global."relapse" }
			and Global."Normalize Interval"(AtrialFibrillation.onset) starts on or before end of QualifyingEncounter.period
    )
    union ( "Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter
    				where Global.EncounterDiagnosis(QualifyingEncounter).code in "Atrial Fibrillation/Flutter"
    			)
    union ( "Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter
    				with ["Condition": code in "Venous Thromboembolism"] VTEDiagnosis
    				such that  FHIRHelpers.ToConcept(VTEDiagnosis.clinicalStatus) in { Global."inactive", Global."remission", Global."resolved" }
      					//and VTEDiagnosis.verificationStatus = 'confirmed'
    				and Global."Normalize Interval"(VTEDiagnosis.onset) before start of QualifyingEncounter.period
      		)

define "Encounter With Prior or Present Procedure of Hip or Knee Replacement Surgery":
	"Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter
	with ( ["Procedure": "Hip Replacement Surgery"]
    			union ["Procedure": "Knee Replacement Surgery"] ) HipKneeProcedure
	such that HipKneeProcedure.status = 'completed'
	     and Global."Normalize Interval"(HipKneeProcedure.performed) starts on or before end of QualifyingEncounter.period


define "Encounter With Low Risk for VTE or Anticoagulant Administered":
   "Low Risk for VTE or Anticoagulant Administered From Day of Start of Hospitalization To Day After Admission"
   	 union "Low Risk for VTE or Anticoagulant Administered on Day of or Day After Procedure"

define "Low Risk for VTE or Anticoagulant Administered From Day of Start of Hospitalization To Day After Admission":
 	"Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter
    with "Is In Low Risk for VTE or On Anticoagulant" VTERiskAssessment
    such that Global."Normalize Interval"(VTERiskAssessment.effective) starts during VTEICU."FromDayOfStartOfHospitalizationToDayAfterAdmission"(QualifyingEncounter)

define "Is In Low Risk for VTE or On Anticoagulant":
	  ( ["Observation": "Risk for venous thromboembolism"] VTERiskAssessment
			  where VTERiskAssessment.value in "Low Risk"
        and VTERiskAssessment.status in {'final','amended', 'corrected'}
	  )
  union ( ["Observation": "INR"] INRLabTest
        where INRLabTest.value as Quantity > 3.0
            and INRLabTest.status in {'final','amended', 'corrected'}
        return "Observation" { id: INRLabTest.id, effective: INRLabTest.issued }
        )
  union ((( ["MedicationAdministration": "Unfractionated Heparin"] UnfractionatedHeparin
          where UnfractionatedHeparin.dosage.route in "Intravenous route"
         )
         union ["MedicationAdministration": "Direct Thrombin Inhibitor"]
         union ["MedicationAdministration": "Glycoprotein IIb/IIIa Inhibitors"] ) AnticoagulantMedication
         where AnticoagulantMedication.status = 'complete'
         return "Observation" { id: AnticoagulantMedication.id, effective: AnticoagulantMedication.effective }
      )

define "Low Risk for VTE or Anticoagulant Administered on Day of or Day After Procedure":
 	from
   		"Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter,
   		["Procedure": "General or Neuraxial Anesthesia"] AnesthesiaProcedure,
   		"Is In Low Risk for VTE or On Anticoagulant" VTERiskAssessment
	where Global."Normalize Interval"(AnesthesiaProcedure.performed) ends 1 day after day of start of QualifyingEncounter.period
 			and Global."Normalize Interval"(VTERiskAssessment.effective) starts during TJC."CalendarDayOfOrDayAfter"(end of Global."Normalize Interval"(AnesthesiaProcedure.performed))
	return QualifyingEncounter

define "Encounter With No VTE Prophylaxis Due to Medical Reason":
   ( "No VTE Prophylaxis Medication Due to Medical Reason From Day of Start of Hospitalization To Day After Admission"
     intersect "No VTE Prophylaxis Device Due to Medical Reason From Day of Start of Hospitalization To Day After Admission"
   )
   union ( "No VTE Prophylaxis Medication Due to Medical Reason on Day of or Day After Procedure"
       intersect "No VTE Prophylaxis Device Due to Medical Reason on Day of or Day After Procedure"
       )

define "No VTE Prophylaxis Medication Due to Medical Reason From Day of Start of Hospitalization To Day After Admission":
   	"Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter
       with	"No VTE Prophylaxis Medication Administered or Ordered" NoVTEMedication
     	such that Coalesce(NoVTEMedication.statusReason,NoVTEMedication.reasonCode) in "Medical Reason"
      			and Coalesce(NoVTEMedication.authoredOn, start of Global."Normalize Interval"(NoVTEMedication.effective)) during VTEICU."FromDayOfStartOfHospitalizationToDayAfterAdmission"(QualifyingEncounter)

define "No VTE Prophylaxis Medication Administered or Ordered":
   ((	["MedicationAdministration": medication in "Low Dose Unfractionated Heparin for VTE Prophylaxis"]
     union
	    ["MedicationAdministration": medication in "Low Molecular Weight Heparin for VTE Prophylaxis"]
     union
	    ["MedicationAdministration": medication in "Injectable Factor Xa Inhibitor for VTE Prophylaxis"]
     union
	    ["MedicationAdministration": medication in "Warfarin"]
       ) MedicationAdm
       where MedicationAdm.status = 'not-done'
        )
  union
	   ((	["MedicationRequest": medication in "Low Dose Unfractionated Heparin for VTE Prophylaxis"]
  	union
  	 ["MedicationRequest": medication in "Low Molecular Weight Heparin for VTE Prophylaxis"]
    union
    	["MedicationRequest": medication in "Injectable Factor Xa Inhibitor for VTE Prophylaxis"]
    union
    	["MedicationRequest": medication in "Warfarin"]
    ) MedicationOrder
    	where	MedicationOrder.doNotPerform is true
        and MedicationOrder.status in {'completed', 'cancelled'}
        //11/5 discussion: all expressions for QI-Core must include a status.
        //Therefore, we need ServiceRequest.status = completed; and MedicationRequest.status = cancelled (or completed, since cancelled indicates it was once ordered but intentionally never filled).
        //So the not done issue is handled by ServiceRequest.doNotPerform = True  Or MedicationRequest.doNotPerform = True
    )

define "No VTE Prophylaxis Medication Due to Medical Reason on Day of or Day After Procedure":
	from
  		"Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter,
  		["Procedure": "General or Neuraxial Anesthesia"] AnesthesiaProcedure,
  		"No VTE Prophylaxis Medication Administered or Ordered" NoVTEMedication
	where Coalesce(NoVTEMedication.statusReason,NoVTEMedication.reasonCode) in "Medical Reason"
			and AnesthesiaProcedure.status = 'completed'
			and Global."Normalize Interval"(AnesthesiaProcedure.performed) ends 1 day after day of start of QualifyingEncounter.period
			and Coalesce(NoVTEMedication.authoredOn, start of Global."Normalize Interval"(NoVTEMedication.effective)) during TJC."CalendarDayOfOrDayAfter"(end of Global."Normalize Interval"(AnesthesiaProcedure.performed))
  return QualifyingEncounter

define "No VTE Prophylaxis Device Due to Medical Reason From Day of Start of Hospitalization To Day After Admission":
  "Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter
  	with "No VTE Prophylaxis Device Applied or Ordered" NoVTEDevice
      such that NoVTEDevice.requestStatusReason in "Medical Reason"
        and  NoVTEDevice.authoredOn during VTEICU."FromDayOfStartOfHospitalizationToDayAfterAdmission"(QualifyingEncounter)

//11/5: ServiceRequest not done reason is an extension in QI-Core R4 as ServiceRequest.extension:statusReason
define function GetStatusReason(requestReason ServiceRequest):
      Global.GetBaseExtension(requestReason, 'request-statusReason')

define "No VTE Prophylaxis Device Applied or Ordered":
  ((
    ["ServiceRequest": "Venous foot pumps (VFP)"]
    union ["ServiceRequest": "Intermittent pneumatic compression devices (IPC)"]
    union ["ServiceRequest": "Graduated compression stockings (GCS)"]
    ) DeviceOrder
    where DeviceOrder.status = 'completed'
    //11/5 discussion: all expressions for QI-Core must include a status
    //ServiceRequest.status -  draft | active | suspended | completed | entered-in-error | cancelled
        and DeviceOrder.doNotPerform is true
    return {id: DeviceOrder.id, requestStatusReason: GetStatusReason(DeviceOrder), authoredOn: DeviceOrder.authoredOn}
    )
  union
    (
      ["Procedure": "Device Application"] DeviceApplied
      let DeviceNotDoneTiming: Global.GetExtension(DeviceApplied, 'qicore-recorded').value
      where (DeviceApplied.usedCode in "Intermittent pneumatic compression devices (IPC)"
            or DeviceApplied.usedCode in "Venous foot pumps (VFP)"
            or DeviceApplied.usedCode in "Graduated compression stockings (GCS)"
            )
         and  DeviceApplied.status = 'not-done'
         return {id: DeviceApplied.id, requestStatusReason: DeviceApplied.statusReason, authoredOn: DeviceNotDoneTiming}

    )

define "No VTE Prophylaxis Device Due to Medical Reason on Day of or Day After Procedure":
  from
  		"Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter,
  		["Procedure": "General or Neuraxial Anesthesia"] AnesthesiaProcedure,
  		"No VTE Prophylaxis Device Applied or Ordered" NoVTEDevice
  where  NoVTEDevice.requestStatusReason in "Medical Reason"
      and AnesthesiaProcedure.status = 'completed'
  		and Global."Normalize Interval"(AnesthesiaProcedure.performed) ends 1 day after day of start of QualifyingEncounter.period
      and NoVTEDevice.authoredOn during TJC."CalendarDayOfOrDayAfter"(end of Global."Normalize Interval"(AnesthesiaProcedure.performed))
  return QualifyingEncounter

define "Encounter With No VTE Prophylaxis Due to Patient Refusal":
 "No VTE Prophylaxis Due to Patient Refusal From Day of Start of Hospitalization To Day After Admission"
 	union "No VTE Prophylaxis Due to Patient Refusal on Day of or Day After Procedure"

define "No VTE Prophylaxis Due to Patient Refusal From Day of Start of Hospitalization To Day After Admission":
 	"Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter
	 with "No VTE Prophylaxis Medication or Device Due to Patient Refusal" PatientRefusal
   such that Coalesce(start of Global."Normalize Interval"(PatientRefusal.effective), PatientRefusal.authoredOn)
         during VTEICU."FromDayOfStartOfHospitalizationToDayAfterAdmission"(QualifyingEncounter)

define "No VTE Prophylaxis Medication or Device Due to Patient Refusal":
    ( "No VTE Prophylaxis Medication Administered or Ordered" NoVTEMedication
        where Coalesce(NoVTEMedication.statusReason,NoVTEMedication.reasonCode) in "Patient Refusal"
    )
  union ("No VTE Prophylaxis Device Applied or Ordered" NoVTEDevice
           where NoVTEDevice.requestStatusReason in "Patient Refusal"
        )

define "No VTE Prophylaxis Due to Patient Refusal on Day of or Day After Procedure":
 	from
   		"Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter,
   		["Procedure": "General or Neuraxial Anesthesia"] AnesthesiaProcedure,
   		"No VTE Prophylaxis Medication or Device Due to Patient Refusal" PatientRefusal
	where Global."Normalize Interval"(AnesthesiaProcedure.performed) ends 1 day after day of start of QualifyingEncounter.period
 			and Coalesce(start of Global."Normalize Interval"(PatientRefusal.effective), PatientRefusal.authoredOn)
             during TJC."CalendarDayOfOrDayAfter"(end of Global."Normalize Interval"(AnesthesiaProcedure.performed))
	return QualifyingEncounter

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