Quality Measure Implementation Guide
1.0.0-ballot - ballot
Quality Measure Implementation Guide
1.0.0-ballot - ballot
This page is part of the Quality Measure Implementation Guide (v1.0.0-ballot: STU1 (v1.0.0) Ballot 1) based on FHIR (HL7® FHIR® Standard) R4. . 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="EXM124-FHIR"/>
<meta>
<profile
value="http://hl7.org/fhir/uv/cqm/StructureDefinition/cqm-proportionmeasure"/>
<profile
value="http://hl7.org/fhir/uv/cqm/StructureDefinition/cqm-computablemeasure"/>
<profile
value="http://hl7.org/fhir/uv/cqm/StructureDefinition/cqm-publishablemeasure"/>
<profile
value="http://hl7.org/fhir/uv/cqm/StructureDefinition/cqm-cqlmeasure"/>
</meta>
<text>
<status value="extensions"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<div>
<table class="grid dict">
<tr>
<th scope="row"><b>Title: </b></th>
<td style="padding-left: 4px;">EXM124 - Cervical Cancer Screening</td>
</tr>
<tr>
<th scope="row"><b>Id: </b></th>
<td style="padding-left: 4px;">EXM124-FHIR</td>
</tr>
<tr>
<th scope="row"><b>Version: </b></th>
<td style="padding-left: 4px;">9.0.000</td>
</tr>
<tr>
<th scope="row"><b>Url: </b></th>
<td style="padding-left: 4px;"><a href="Measure-EXM124-FHIR.html">EXM124 - Cervical Cancer Screening</a></td>
</tr>
<tr>
<th scope="row">
<b>
Official
</b>
</th>
<td style="padding-left: 4px;">
<p style="margin-bottom: 5px;">
<span>124</span>
</p>
</td>
</tr>
<tr>
<th scope="row">
<b>
Version Independent Identifier:
</b>
</th>
<td style="padding-left: 4px;">
<p style="margin-bottom: 5px;">
<span>http://example.org/fhir/us/cqm/Measure/EXM124-FHIR</span>
</p>
</td>
</tr>
<tr>
<th scope="row">
<b>
Version Specific Identifier:
</b>
</th>
<td style="padding-left: 4px;">
<p style="margin-bottom: 5px;">
<span>http://example.org/fhir/us/cqm/Measure/CMS124v7</span>
</p>
</td>
</tr>
<tr>
<th scope="row">
<b>
Short Name Identifier:
</b>
</th>
<td style="padding-left: 4px;">
<p style="margin-bottom: 5px;">
<span>Cervical Cancer Screening</span>
</p>
</td>
</tr>
<tr>
<th scope="row">
<b>
Official
</b>
</th>
<td style="padding-left: 4px;">
<p style="margin-bottom: 5px;">
<span>309</span>
</p>
</td>
</tr>
<tr>
<th scope="row"><b>Effective Period: </b></th>
<td style="padding-left: 4px;">2018-01-01..2018-12-31</td>
</tr>
<tr>
<th scope="row"><b>Experimental: </b></th>
<td style="padding-left: 4px;">true</td>
</tr>
<tr>
<th scope="row"><b>Publisher: </b></th>
<td style="padding-left: 4px;">HL7 International / Clinical Quality Information</td>
</tr>
<tr>
<th scope="row"><b>Description: </b></th>
<td style="padding-left: 4px;"><div><p>Percentage of women 21-64 years of age who were screened for cervical cancer using either of the following criteria:</p>
<ul>
<li>Women age 21-64 who had cervical cytology performed every 3 years</li>
<li>Women age 30-64 who had cervical cytology/human papillomavirus (HPV) co-testing performed every 5 years</li>
</ul>
</div></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>venue</td>
<td/>
</tr>
</table>
</td>
</tr>
<tr>
<th scope="row"><b>Jurisdiction: </b></th>
<td style="padding-left: 4px;">001</td>
</tr>
<tr>
<th scope="row"><b>Topic: </b></th>
<td style="padding-left: 4px;">57024-2</td>
</tr>
<tr>
<th scope="row"><b>Purpose: </b></th>
<td style="padding-left: 4px;"><div><p>This measure has been developed to support improvement in clinical care.</p>
</div></td>
</tr>
<tr>
<th scope="row"><b>Copyright: </b></th>
<td style="padding-left: 4px;"><div><p>This Physician Performance Measure (Measure) and related data specifications 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 (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 or requests for modification must be approved by NCQA and are subject to a license at the discretion of NCQA. (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 third party codes contained in the specifications.
CPT(R) contained in the Measure specifications is copyright 2004-2017 American Medical Association. LOINC(R) copyright 2004-2017 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R] ) copyright 2004-2017 International Health Terminology Standards Development Organisation. ICD-10 copyright 2017 World Health Organization. All Rights Reserved.</p>
</div></td>
</tr>
<tr>
<th scope="row"><b>Disclaimer: </b></th>
<td style="padding-left: 4px;"><div><p>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].</p>
</div></td>
</tr>
<tr>
<th scope="row"><b>Scoring: </b></th>
<td style="padding-left: 4px;">
<p style="margin-bottom: 5px;">
<span>Proportion </span>
</p>
</td>
</tr>
<tr>
<th scope="row"><b>Type: </b></th>
<td style="padding-left: 4px;">
<p style="margin-bottom: 5px;">
<span>process </span>
</p>
</td>
</tr>
<tr>
<th scope="row"><b>Rationale: </b></th>
<td style="padding-left: 4px;"><div><p>Breast cancer is one of the most common types of cancers, accounting for 15 percent of all new cancer diagnoses in the U.S. (Howlader et al, 2016). In 2013, 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 (Howlader et al, 2016).
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 (Howlader et al, 2016). 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 235; by age 50 it becomes 1 in 54; by age 60, it is 1 in 25 (National Business Group on Health, 2011).
In the U.S., costs associated with a diagnosis of breast cancer range from $451 to $2,520, factoring in continued testing, multiple office visits and procedures. The total costs related to breast cancer add up to nearly $7 billion per year in the U.S., including $2 billion spent on late-stage treatment (National Business Group on Health, 2011). If breast cancer is detected through mammography screening and diagnosed in its earliest stages, treatment may be less expensive (Feig, 2011).</p>
</div></td>
</tr>
<tr>
<th scope="row"><b>Clinical recommendation statement: </b></th>
<td style="padding-left: 4px;"><div><p>The U.S. Preventive Services Task Force (USPSTF) recommends biennial screening mammography for women aged 50-74 years (B recommendation).<br/>
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)<br/>
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)</p>
</div></td>
</tr>
<tr>
<th scope="row"><b>Improvement Notation: </b></th>
<td style="padding-left: 4px;">
<p style="margin-bottom: 5px;">
<span>Increased score indicates improvement </span>
</p>
</td>
</tr>
<tr>
<th scope="row"><b>Guidance (Usage): </b></th>
<td style="padding-left: 4px;">To ensure the measure is only looking for a cervical cytology test only after a woman turns 21 years of age, the youngest age in the initial population is 23.
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.
Include only cytology and HPV "co-testing"; in co-testing, both cytology and HPV tests are performed (i.e., the samples are collected and both tests are ordered, regardless of the cytology result) on the same date of service. Do not include reflex testing. In addition, if the medical record indicates the HPV test was performed only after determining the cytology result, this is considered reflex testing and does not meet criteria for the measure.</td>
</tr>
<tr>
<th scope="row"><b>Population Criteria: </b></th>
<td style="padding-left: 4px;">
<table class="grid-dict">
<tr>
<td>Initial Population:</td>
<td>Women 23-64 years of age with a visit during the measurement period</td>
</tr>
<tr>
<td>Numerator:</td>
<td>Women with one or more screenings for cervical cancer. Appropriate screenings are defined by any one of the following criteria:
* Cervical cytology performed during the measurement period or the two years prior to the measurement period for women who are at least 21 years old at the time of the test
* Cervical human papillomavirus (HPV) testing performed during the measurement period or the four years prior to the measurement period for women who are 30 years or older at the time of the test</td>
</tr>
<tr>
<td>Denominator:</td>
<td>Equals Initial Population</td>
</tr>
<tr>
<td>Denominator Exclusion:</td>
<td>Women who had a hysterectomy with no residual cervix or a congenital absence of cervix.
Exclude patients who are in hospice care for any part of the measurement period.
Exclude patients receiving palliative care during the measurement period.</td>
</tr>
</table>
</td>
</tr>
<tr>
<th scope="row"><b> Supplemental Data Elements: </b></th>
<td style="padding-left: 4px;">
<p>SDE Ethnicity</p>
<p>SDE Payer</p>
<p>Race</p>
Sex
</td>
</tr>
<tr>
<th scope="row"><b>Libraries: </b></th>
<td style="padding-left: 4px;">
<table class="grid-dict">
<tr>
<td><a href="Library-EXM124-FHIR.html">EXM124 - Cervical Cancer Screening Library</a></td>
</tr>
</table>
</td>
</tr>
<tr>
<th scope="row"><b>Terminology and Other Dependencies: </b></th>
<td style="padding-left: 4px;">
<li><a href="Library-SupplementalDataElements.html">Supplemental Data Elements Libraryversion: null2.0.0)</a></li>
<li><code>http://fhir.org/guides/cqf/common/Library/FHIRHelpers|4.0.1</code></li>
<li><a href="Library-MATGlobalCommonFunctions.html">MAT Global Common Functions FHIR Libraryversion: null5.0.000)</a></li>
<li><a href="Library-AdultOutpatientEncounters.html">Adult Outpatient Encounters Common Libraryversion: null2.0.000)</a></li>
<li><a href="Library-Hospice.html">Hospice FHIR Libraryversion: null2.0.000)</a></li>
<li><code>http://snomed.info/sct|http://snomed.info/sct/731000124108/version/201709</code></li>
<li><code>http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.108.12.1017</code></li>
<li><code>http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.110.12.1059</code></li>
<li><code>http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1001</code></li>
<li><code>http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.526.3.1240</code></li>
<li><code>http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1025</code></li>
<li><code>http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1023</code></li>
<li><code>http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1016</code></li>
<li><code>http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591</code></li>
<li><code>http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.666.5.307</code></li>
<li><code>http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1108.15</code></li>
<li><code>http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1014</code></li>
</td>
</tr>
<tr>
<th scope="row"><b>Parameters:</b></th>
<td style="padding-left: 4px;">
<table class="grid-dict">
<tr>
<th><b>name</b></th>
<th><b>use</b></th>
<th><b>min</b></th>
<th><b>max</b></th>
<th><b>type</b></th>
</tr>
<tr>
<td>Measurement Period</td>
<td>In</td>
<td>0</td>
<td>1</td>
<td>Period</td>
</tr>
<tr>
<td>SDE Sex</td>
<td>Out</td>
<td>0</td>
<td>1</td>
<td>Coding</td>
</tr>
<tr>
<td>Numerator</td>
<td>Out</td>
<td>0</td>
<td>1</td>
<td>boolean</td>
</tr>
<tr>
<td>Denominator</td>
<td>Out</td>
<td>0</td>
<td>1</td>
<td>boolean</td>
</tr>
<tr>
<td>SDE Payer</td>
<td>Out</td>
<td>0</td>
<td>*</td>
<td>Resource</td>
</tr>
<tr>
<td>Initial Population</td>
<td>Out</td>
<td>0</td>
<td>1</td>
<td>boolean</td>
</tr>
<tr>
<td>SDE Ethnicity</td>
<td>Out</td>
<td>0</td>
<td>*</td>
<td>Coding</td>
</tr>
<tr>
<td>Denominator Exclusion</td>
<td>Out</td>
<td>0</td>
<td>1</td>
<td>boolean</td>
</tr>
<tr>
<td>SDE Race</td>
<td>Out</td>
<td>0</td>
<td>*</td>
<td>Coding</td>
</tr>
</table>
</td>
</tr>
<tr>
<th scope="row"><b>DataRequirements:</b></th>
<td style="padding-left: 4px;">
<table class="grid-dict">
<tr>
<th><b>Resource Type</b></th>
<th><b>Resource Elements</b></th>
<th><b>Valueset Name</b></th>
<th><b>Valueset</b></th>
</tr>
<tr>
<td>Coverage(<a href="http://hl7.org/fhir/R4/coverage.html">Coverage</a>)</td>
<td>
period
type
</td>
<td>
Payer
</td>
<td><code>http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591</code></td>
</tr>
<tr>
<td>Patient(<a href="http://hl7.org/fhir/R4/patient.html">Patient</a>)</td>
<td>
extension
value
url
</td>
<td>
</td>
<td/>
</tr>
<tr>
<td>Encounter(<a href="http://hl7.org/fhir/R4/encounter.html">Encounter</a>)</td>
<td>
type
</td>
<td>
Office Visit
</td>
<td><code>http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1001</code></td>
</tr>
<tr>
<td>Encounter(<a href="http://hl7.org/fhir/R4/encounter.html">Encounter</a>)</td>
<td>
type
</td>
<td>
Annual Wellness Visit
</td>
<td><code>http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.526.3.1240</code></td>
</tr>
<tr>
<td>Encounter(<a href="http://hl7.org/fhir/R4/encounter.html">Encounter</a>)</td>
<td>
type
</td>
<td>
Preventive Care Services - Established Office Visit, 18 and Up
</td>
<td><code>http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1025</code></td>
</tr>
<tr>
<td>Encounter(<a href="http://hl7.org/fhir/R4/encounter.html">Encounter</a>)</td>
<td>
type
</td>
<td>
Preventive Care Services-Initial Office Visit, 18 and Up
</td>
<td><code>http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1023</code></td>
</tr>
<tr>
<td>Encounter(<a href="http://hl7.org/fhir/R4/encounter.html">Encounter</a>)</td>
<td>
type
</td>
<td>
Home Healthcare Services
</td>
<td><code>http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1016</code></td>
</tr>
<tr>
<td>Encounter(<a href="http://hl7.org/fhir/R4/encounter.html">Encounter</a>)</td>
<td>
period
hospitalization
hospitalization.dischargeDisposition
type
status
</td>
<td>
Encounter Inpatient
</td>
<td><code>http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.666.5.307</code></td>
</tr>
<tr>
<td>ServiceRequest(<a href="http://hl7.org/fhir/R4/servicerequest.html">ServiceRequest</a>)</td>
<td>
code
authoredOn
intent
</td>
<td>
Hospice care ambulatory
</td>
<td><code>http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1108.15</code></td>
</tr>
<tr>
<td>Procedure(<a href="http://hl7.org/fhir/R4/procedure.html">Procedure</a>)</td>
<td>
code
performed
status
</td>
<td>
Hospice care ambulatory
</td>
<td><code>http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1108.15</code></td>
</tr>
<tr>
<td>Procedure(<a href="http://hl7.org/fhir/R4/procedure.html">Procedure</a>)</td>
<td>
code
performed
status
</td>
<td>
Hysterectomy with No Residual Cervix
</td>
<td><code>http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1014</code></td>
</tr>
<tr>
<td>Condition(<a href="http://hl7.org/fhir/R4/condition.html">Condition</a>)</td>
<td>
code
onset
</td>
<td>
</td>
<td/>
</tr>
<tr>
<td>Observation(<a href="http://hl7.org/fhir/R4/observation.html">Observation</a>)</td>
<td>
effective
code
value
status
</td>
<td>
Pap Test
</td>
<td><code>http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.108.12.1017</code></td>
</tr>
<tr>
<td>Observation(<a href="http://hl7.org/fhir/R4/observation.html">Observation</a>)</td>
<td>
effective
code
value
status
</td>
<td>
HPV Test
</td>
<td><code>http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.110.12.1059</code></td>
</tr>
</table>
</td>
</tr>
<tr>
<th scope="row"><b>Direct Reference Codes:</b></th>
<td style="padding-left: 4px;">
<table class="grid-dict">
<tr>
<th><b>display</b></th>
<th><b>code</b></th>
<th><b>system</b></th>
</tr>
<tr>
<td>Discharge to home for hospice care (procedure)</td>
<td>428361000124107</td>
<td><a href="https://browser.ihtsdotools.org/">http://snomed.info/sct</a></td>
</tr>
<tr>
<td>Discharge to healthcare facility for hospice care (procedure)</td>
<td>428371000124100</td>
<td><a href="https://browser.ihtsdotools.org/">http://snomed.info/sct</a></td>
</tr>
<tr>
<td>Congenital absence of cervix (disorder)</td>
<td>37687000</td>
<td><a href="https://browser.ihtsdotools.org/">http://snomed.info/sct</a></td>
</tr>
</table>
</td>
</tr>
<tr>
<th scope="row"><b>Logic Definitions:</b></th>
<td style="padding-left: 4px;">
<table class="grid-dict">
<tr>
<th><b>Group</b></th>
<th><b>Scoring</b></th>
<th><b>Population Criteria</b></th>
<th><b>Expression</b></th>
</tr>
<tr>
<td> </td>
<td colspan="3" style="padding-left: 4px;">
<b>Measure scoring:</b>
<p style="margin-bottom: 5px;">
<span>Proportion</span>
</p>
</td>
<tr>
<td/>
<td/>
<td>Initial Population</td>
<td>
<pre><code class="language-cql">define "Initial Population":
Patient.gender = 'female'
and Global."CalendarAgeInYearsAt"(FHIRHelpers.ToDate(Patient.birthDate), start of "Measurement Period") in Interval[23, 64]
and exists AdultOutpatientEncounters."Qualifying Encounters"</code></pre>
</td>
</tr>
<tr>
<td/>
<td/>
<td>Numerator</td>
<td>
<pre><code class="language-cql">// and NoCervixBirth.clinicalStatus ~ ToConcept(Global."active") because this is an excluion, all statuses are acceptable
define "Numerator":
exists "Cervical Cytology Within 3 Years"
or exists "HPV Test Within 5 Years for Women Age 30 and Older"</code></pre>
</td>
</tr>
<tr>
<td/>
<td/>
<td>Denominator</td>
<td>
<pre><code class="language-cql">define "Denominator":
"Initial Population"</code></pre>
</td>
</tr>
<tr>
<td/>
<td/>
<td>Denominator Exclusion</td>
<td>
<pre><code class="language-cql">define "Denominator Exclusion":
Hospice."Has Hospice"
or exists "Absence of Cervix"</code></pre>
</td>
</tr>
</tr>
</table>
<table class="grid-dict">
<tr>
<th><b>Library Name</b></th>
<th><b>Name</b></th>
</tr>
<tr>
<td>SupplementalDataElements</td>
<td>SDE Sex</td>
</tr>
<tr>
<td/>
<td>
<pre class="highlight language-cql"><code class="language-cql">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</code></pre>
</td>
</tr>
<tr>
<th><b>Library Name</b></th>
<th><b>Name</b></th>
</tr>
<tr>
<td>EXM124-FHIR</td>
<td>SDE Sex</td>
</tr>
<tr>
<td/>
<td>
<pre class="highlight language-cql"><code class="language-cql">define "SDE Sex":
SDE."SDE Sex"</code></pre>
</td>
</tr>
<tr>
<th><b>Library Name</b></th>
<th><b>Name</b></th>
</tr>
<tr>
<td>EXM124-FHIR</td>
<td>Cervical Cytology Within 3 Years</td>
</tr>
<tr>
<td/>
<td>
<pre class="highlight language-cql"><code class="language-cql">define "Cervical Cytology Within 3 Years":
[Observation: "Pap Test"] CervicalCytology
where CervicalCytology.value is not null
and CervicalCytology.status in { 'final', 'amended', 'corrected', 'preliminary' }
and Global."Normalize Interval"(CervicalCytology.effective) ends 3 years or less on or before end of "Measurement Period"</code></pre>
</td>
</tr>
<tr>
<th><b>Library Name</b></th>
<th><b>Name</b></th>
</tr>
<tr>
<td>EXM124-FHIR</td>
<td>HPV Test Within 5 Years for Women Age 30 and Older</td>
</tr>
<tr>
<td/>
<td>
<pre class="highlight language-cql"><code class="language-cql">define "HPV Test Within 5 Years for Women Age 30 and Older":
[Observation: "HPV Test"] HPVTest
where HPVTest.value is not null
and HPVTest.status in { 'final', 'amended', 'corrected', 'preliminary' }
and Global."CalendarAgeInYearsAt"(FHIRHelpers.ToDate(Patient.birthDate), start of Global."Normalize Interval"(HPVTest.effective))>= 30
and Global."Normalize Interval"(HPVTest.effective) ends 5 years or less on or before end of "Measurement Period"</code></pre>
</td>
</tr>
<tr>
<th><b>Library Name</b></th>
<th><b>Name</b></th>
</tr>
<tr>
<td>EXM124-FHIR</td>
<td>Numerator</td>
</tr>
<tr>
<td/>
<td>
<pre class="highlight language-cql"><code class="language-cql">// and NoCervixBirth.clinicalStatus ~ ToConcept(Global."active") because this is an excluion, all statuses are acceptable
define "Numerator":
exists "Cervical Cytology Within 3 Years"
or exists "HPV Test Within 5 Years for Women Age 30 and Older"</code></pre>
</td>
</tr>
<tr>
<th><b>Library Name</b></th>
<th><b>Name</b></th>
</tr>
<tr>
<td>AdultOutpatientEncounters</td>
<td>Qualifying Encounters</td>
</tr>
<tr>
<td/>
<td>
<pre class="highlight language-cql"><code class="language-cql">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'</code></pre>
</td>
</tr>
<tr>
<th><b>Library Name</b></th>
<th><b>Name</b></th>
</tr>
<tr>
<td>EXM124-FHIR</td>
<td>Initial Population</td>
</tr>
<tr>
<td/>
<td>
<pre class="highlight language-cql"><code class="language-cql">define "Initial Population":
Patient.gender = 'female'
and Global."CalendarAgeInYearsAt"(FHIRHelpers.ToDate(Patient.birthDate), start of "Measurement Period") in Interval[23, 64]
and exists AdultOutpatientEncounters."Qualifying Encounters"</code></pre>
</td>
</tr>
<tr>
<th><b>Library Name</b></th>
<th><b>Name</b></th>
</tr>
<tr>
<td>EXM124-FHIR</td>
<td>Denominator</td>
</tr>
<tr>
<td/>
<td>
<pre class="highlight language-cql"><code class="language-cql">define "Denominator":
"Initial Population"</code></pre>
</td>
</tr>
<tr>
<th><b>Library Name</b></th>
<th><b>Name</b></th>
</tr>
<tr>
<td>SupplementalDataElements</td>
<td>SDE Payer</td>
</tr>
<tr>
<td/>
<td>
<pre class="highlight language-cql"><code class="language-cql">define "SDE Payer":
[Coverage: type in "Payer"] Payer
return {
code: Payer.type,
period: Payer.period
}</code></pre>
</td>
</tr>
<tr>
<th><b>Library Name</b></th>
<th><b>Name</b></th>
</tr>
<tr>
<td>EXM124-FHIR</td>
<td>SDE Payer</td>
</tr>
<tr>
<td/>
<td>
<pre class="highlight language-cql"><code class="language-cql">define "SDE Payer":
SDE."SDE Payer"</code></pre>
</td>
</tr>
<tr>
<th><b>Library Name</b></th>
<th><b>Name</b></th>
</tr>
<tr>
<td>SupplementalDataElements</td>
<td>SDE Ethnicity</td>
</tr>
<tr>
<td/>
<td>
<pre class="highlight language-cql"><code class="language-cql">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</code></pre>
</td>
</tr>
<tr>
<th><b>Library Name</b></th>
<th><b>Name</b></th>
</tr>
<tr>
<td>EXM124-FHIR</td>
<td>SDE Ethnicity</td>
</tr>
<tr>
<td/>
<td>
<pre class="highlight language-cql"><code class="language-cql">define "SDE Ethnicity":
SDE."SDE Ethnicity"</code></pre>
</td>
</tr>
<tr>
<th><b>Library Name</b></th>
<th><b>Name</b></th>
</tr>
<tr>
<td>Hospice</td>
<td>Has Hospice</td>
</tr>
<tr>
<td/>
<td>
<pre class="highlight language-cql"><code class="language-cql">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"
)</code></pre>
</td>
</tr>
<tr>
<th><b>Library Name</b></th>
<th><b>Name</b></th>
</tr>
<tr>
<td>EXM124-FHIR</td>
<td>Absence of Cervix</td>
</tr>
<tr>
<td/>
<td>
<pre class="highlight language-cql"><code class="language-cql">define "Absence of Cervix":
([Procedure: "Hysterectomy with No Residual Cervix"] NoCervixProcedure
where Global."Normalize Interval"(NoCervixProcedure.performed) ends on or before end of "Measurement Period"
and NoCervixProcedure.status = 'completed'
)
union [Condition : "Congenital absence of cervix (disorder)"] NoCervixBirth
where Global."Normalize Interval"(NoCervixBirth.onset) starts on or before end of "Measurement Period"</code></pre>
</td>
</tr>
<tr>
<th><b>Library Name</b></th>
<th><b>Name</b></th>
</tr>
<tr>
<td>EXM124-FHIR</td>
<td>Denominator Exclusion</td>
</tr>
<tr>
<td/>
<td>
<pre class="highlight language-cql"><code class="language-cql">define "Denominator Exclusion":
Hospice."Has Hospice"
or exists "Absence of Cervix"</code></pre>
</td>
</tr>
<tr>
<th><b>Library Name</b></th>
<th><b>Name</b></th>
</tr>
<tr>
<td>SupplementalDataElements</td>
<td>SDE Race</td>
</tr>
<tr>
<td/>
<td>
<pre class="highlight language-cql"><code class="language-cql">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</code></pre>
</td>
</tr>
<tr>
<th><b>Library Name</b></th>
<th><b>Name</b></th>
</tr>
<tr>
<td>EXM124-FHIR</td>
<td>SDE Race</td>
</tr>
<tr>
<td/>
<td>
<pre class="highlight language-cql"><code class="language-cql">define "SDE Race":
SDE."SDE Race"</code></pre>
</td>
</tr>
</table>
</td>
</tr>
</table>
</div>
</div>
</text>
<contained>
<Library>
<id value="effective-data-requirements-exm124"/>
<meta>
<profile
value="http://hl7.org/fhir/uv/crmi/StructureDefinition/crmi-moduledefinitionlibrary"/>
</meta>
<extension
url="http://hl7.org/fhir/StructureDefinition/cqf-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/StructureDefinition/cqf-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/StructureDefinition/cqf-directReferenceCode">
<valueCoding>
<system value="http://snomed.info/sct"/>
<version
value="http://snomed.info/sct/731000124108/version/201709"/>
<code value="37687000"/>
<display value="Congenital absence of cervix (disorder)"/>
</valueCoding>
</extension>
<extension
url="http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition">
<extension url="libraryName">
<valueString value="SupplementalDataElements"/>
</extension>
<extension url="name">
<valueString value="SDE Sex"/>
</extension>
<extension url="statement">
<valueString
value="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"/>
</extension>
<extension url="displaySequence">
<valueInteger value="0"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition">
<extension url="libraryName">
<valueString value="EXM124-FHIR"/>
</extension>
<extension url="name">
<valueString value="SDE Sex"/>
</extension>
<extension url="statement">
<valueString
value="define "SDE Sex":
SDE."SDE Sex""/>
</extension>
<extension url="displaySequence">
<valueInteger value="1"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition">
<extension url="libraryName">
<valueString value="EXM124-FHIR"/>
</extension>
<extension url="name">
<valueString value="Cervical Cytology Within 3 Years"/>
</extension>
<extension url="statement">
<valueString
value="define "Cervical Cytology Within 3 Years":
[Observation: "Pap Test"] CervicalCytology
where CervicalCytology.value is not null
and CervicalCytology.status in { 'final', 'amended', 'corrected', 'preliminary' }
and Global."Normalize Interval"(CervicalCytology.effective) ends 3 years or less on or before end of "Measurement Period""/>
</extension>
<extension url="displaySequence">
<valueInteger value="2"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition">
<extension url="libraryName">
<valueString value="EXM124-FHIR"/>
</extension>
<extension url="name">
<valueString
value="HPV Test Within 5 Years for Women Age 30 and Older"/>
</extension>
<extension url="statement">
<valueString
value="define "HPV Test Within 5 Years for Women Age 30 and Older":
[Observation: "HPV Test"] HPVTest
where HPVTest.value is not null
and HPVTest.status in { 'final', 'amended', 'corrected', 'preliminary' }
and Global."CalendarAgeInYearsAt"(FHIRHelpers.ToDate(Patient.birthDate), start of Global."Normalize Interval"(HPVTest.effective))>= 30
and Global."Normalize Interval"(HPVTest.effective) ends 5 years or less on or before end of "Measurement Period""/>
</extension>
<extension url="displaySequence">
<valueInteger value="3"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition">
<extension url="libraryName">
<valueString value="EXM124-FHIR"/>
</extension>
<extension url="name">
<valueString value="Numerator"/>
</extension>
<extension url="statement">
<valueString
value="// and NoCervixBirth.clinicalStatus ~ ToConcept(Global."active") because this is an excluion, all statuses are acceptable
define "Numerator":
exists "Cervical Cytology Within 3 Years"
or exists "HPV Test Within 5 Years for Women Age 30 and Older""/>
</extension>
<extension url="displaySequence">
<valueInteger value="4"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/StructureDefinition/cqf-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="5"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition">
<extension url="libraryName">
<valueString value="EXM124-FHIR"/>
</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[23, 64]
and exists AdultOutpatientEncounters."Qualifying Encounters""/>
</extension>
<extension url="displaySequence">
<valueInteger value="6"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition">
<extension url="libraryName">
<valueString value="EXM124-FHIR"/>
</extension>
<extension url="name">
<valueString value="Denominator"/>
</extension>
<extension url="statement">
<valueString
value="define "Denominator":
"Initial Population""/>
</extension>
<extension url="displaySequence">
<valueInteger value="7"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition">
<extension url="libraryName">
<valueString value="SupplementalDataElements"/>
</extension>
<extension url="name">
<valueString value="SDE Payer"/>
</extension>
<extension url="statement">
<valueString
value="define "SDE Payer":
[Coverage: type in "Payer"] Payer
return {
code: Payer.type,
period: Payer.period
}"/>
</extension>
<extension url="displaySequence">
<valueInteger value="8"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition">
<extension url="libraryName">
<valueString value="EXM124-FHIR"/>
</extension>
<extension url="name">
<valueString value="SDE Payer"/>
</extension>
<extension url="statement">
<valueString
value="define "SDE Payer":
SDE."SDE Payer""/>
</extension>
<extension url="displaySequence">
<valueInteger value="9"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition">
<extension url="libraryName">
<valueString value="SupplementalDataElements"/>
</extension>
<extension url="name">
<valueString value="SDE Ethnicity"/>
</extension>
<extension url="statement">
<valueString
value="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"/>
</extension>
<extension url="displaySequence">
<valueInteger value="10"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition">
<extension url="libraryName">
<valueString value="EXM124-FHIR"/>
</extension>
<extension url="name">
<valueString value="SDE Ethnicity"/>
</extension>
<extension url="statement">
<valueString
value="define "SDE Ethnicity":
SDE."SDE Ethnicity""/>
</extension>
<extension url="displaySequence">
<valueInteger value="11"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/StructureDefinition/cqf-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="12"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition">
<extension url="libraryName">
<valueString value="EXM124-FHIR"/>
</extension>
<extension url="name">
<valueString value="Absence of Cervix"/>
</extension>
<extension url="statement">
<valueString
value="define "Absence of Cervix":
([Procedure: "Hysterectomy with No Residual Cervix"] NoCervixProcedure
where Global."Normalize Interval"(NoCervixProcedure.performed) ends on or before end of "Measurement Period"
and NoCervixProcedure.status = 'completed'
)
union [Condition : "Congenital absence of cervix (disorder)"] NoCervixBirth
where Global."Normalize Interval"(NoCervixBirth.onset) starts on or before end of "Measurement Period""/>
</extension>
<extension url="displaySequence">
<valueInteger value="13"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition">
<extension url="libraryName">
<valueString value="EXM124-FHIR"/>
</extension>
<extension url="name">
<valueString value="Denominator Exclusion"/>
</extension>
<extension url="statement">
<valueString
value="define "Denominator Exclusion":
Hospice."Has Hospice"
or exists "Absence of Cervix""/>
</extension>
<extension url="displaySequence">
<valueInteger value="14"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition">
<extension url="libraryName">
<valueString value="SupplementalDataElements"/>
</extension>
<extension url="name">
<valueString value="SDE Race"/>
</extension>
<extension url="statement">
<valueString
value="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"/>
</extension>
<extension url="displaySequence">
<valueInteger value="15"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition">
<extension url="libraryName">
<valueString value="EXM124-FHIR"/>
</extension>
<extension url="name">
<valueString value="SDE Race"/>
</extension>
<extension url="statement">
<valueString
value="define "SDE Race":
SDE."SDE Race""/>
</extension>
<extension url="displaySequence">
<valueInteger value="16"/>
</extension>
</extension>
<url
value="http://hl7.org/fhir/uv/cqm/Library/effective-data-requirements-exm124"/>
<version value="1.0.0"/>
<name value="EffectiveDataRequirements"/>
<title value="Module Definition Library - EXM124"/>
<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"/>
<description
value="This library is used as an example module definition in the FHIR Quality Measure Implementation Guide"/>
<relatedArtifact>
<type value="depends-on"/>
<display value="Library SDE"/>
<resource
value="http://hl7.org/fhir/uv/cqm/Library/SupplementalDataElements|2.0.000"/>
</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 Global"/>
<resource
value="http://hl7.org/fhir/uv/cqm/Library/MATGlobalCommonFunctions|5.0.000"/>
</relatedArtifact>
<relatedArtifact>
<type value="depends-on"/>
<display value="Library AdultOutpatientEncounters"/>
<resource
value="http://hl7.org/fhir/uv/cqm/Library/AdultOutpatientEncounters|2.0.000"/>
</relatedArtifact>
<relatedArtifact>
<type value="depends-on"/>
<display value="Library Hospice"/>
<resource value="http://hl7.org/fhir/uv/cqm/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="Value set Pap Test"/>
<resource
value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.108.12.1017"/>
</relatedArtifact>
<relatedArtifact>
<type value="depends-on"/>
<display value="Value set HPV Test"/>
<resource
value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.110.12.1059"/>
</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 Payer"/>
<resource
value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591"/>
</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 Hysterectomy with No Residual Cervix"/>
<resource
value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1014"/>
</relatedArtifact>
<parameter>
<name value="Measurement Period"/>
<use value="in"/>
<min value="0"/>
<max value="1"/>
<type value="Period"/>
</parameter>
<parameter>
<name value="SDE Sex"/>
<use value="out"/>
<min value="0"/>
<max value="1"/>
<type value="Coding"/>
</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="SDE Payer"/>
<use value="out"/>
<min value="0"/>
<max value="*"/>
<type value="Resource"/>
</parameter>
<parameter>
<name value="Initial Population"/>
<use value="out"/>
<min value="0"/>
<max value="1"/>
<type value="boolean"/>
</parameter>
<parameter>
<name value="SDE Ethnicity"/>
<use value="out"/>
<min value="0"/>
<max value="*"/>
<type value="Coding"/>
</parameter>
<parameter>
<name value="Denominator Exclusion"/>
<use value="out"/>
<min value="0"/>
<max value="1"/>
<type value="boolean"/>
</parameter>
<parameter>
<name value="SDE Race"/>
<use value="out"/>
<min value="0"/>
<max value="*"/>
<type value="Coding"/>
</parameter>
<dataRequirement>
<type value="Coverage"/>
<profile value="http://hl7.org/fhir/StructureDefinition/Coverage"/>
<mustSupport value="period"/>
<mustSupport value="type"/>
<codeFilter>
<path value="type"/>
<valueSet
value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591"/>
</codeFilter>
</dataRequirement>
<dataRequirement>
<type value="Patient"/>
<profile value="http://hl7.org/fhir/StructureDefinition/Patient"/>
<mustSupport value="extension"/>
<mustSupport value="value"/>
<mustSupport value="url"/>
</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/2.16.840.1.113883.3.464.1003.101.12.1001"/>
</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="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="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/2.16.840.1.113883.3.464.1003.198.12.1014"/>
</codeFilter>
</dataRequirement>
<dataRequirement>
<type value="Condition"/>
<profile value="http://hl7.org/fhir/StructureDefinition/Condition"/>
<mustSupport value="code"/>
<mustSupport value="onset"/>
<codeFilter>
<path value="code"/>
<code>
<system value="http://snomed.info/sct"/>
<version
value="http://snomed.info/sct/731000124108/version/201709"/>
<code value="37687000"/>
<display value="Congenital absence of cervix (disorder)"/>
</code>
</codeFilter>
</dataRequirement>
<dataRequirement>
<type value="Observation"/>
<profile value="http://hl7.org/fhir/StructureDefinition/Observation"/>
<mustSupport value="effective"/>
<mustSupport value="code"/>
<mustSupport value="value"/>
<mustSupport value="status"/>
<codeFilter>
<path value="code"/>
<valueSet
value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.108.12.1017"/>
</codeFilter>
</dataRequirement>
<dataRequirement>
<type value="Observation"/>
<profile value="http://hl7.org/fhir/StructureDefinition/Observation"/>
<mustSupport value="effective"/>
<mustSupport value="code"/>
<mustSupport value="value"/>
<mustSupport value="status"/>
<codeFilter>
<path value="code"/>
<valueSet
value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.110.12.1059"/>
</codeFilter>
</dataRequirement>
</Library>
</contained>
<extension
url="http://hl7.org/fhir/uv/cqm/StructureDefinition/cqm-populationBasis">
<valueCode value="boolean"/>
</extension>
<extension
url="http://hl7.org/fhir/uv/crmi/StructureDefinition/crmi-effectiveDataRequirements">
<valueCanonical value="#effective-data-requirements-exm124"/>
</extension>
<url value="http://hl7.org/fhir/uv/cqm/Measure/EXM124-FHIR"/>
<identifier>
<use value="official"/>
<system value="http://example.org/fhir/cqi/ecqm/Measure/Identifier/cms"/>
<value value="124"/>
</identifier>
<identifier>
<use value="official"/>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/artifact-identifier-type"/>
<code value="version-independent"/>
<display value="Version Independent"/>
</coding>
</type>
<system value="urn:ietf:rfc:3986"/>
<value value="http://example.org/fhir/us/cqm/Measure/EXM124-FHIR"/>
</identifier>
<identifier>
<use value="official"/>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/artifact-identifier-type"/>
<code value="version-specific"/>
<display value="Version Specific"/>
</coding>
</type>
<system value="urn:ietf:rfc:3986"/>
<value value="http://example.org/fhir/us/cqm/Measure/CMS124v7"/>
</identifier>
<identifier>
<use value="usual"/>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/artifact-identifier-type"/>
<code value="short-name"/>
<display value="Short Name"/>
</coding>
</type>
<value value="Cervical Cancer Screening"/>
</identifier>
<identifier>
<use value="official"/>
<system value="http://example.org/fhir/cqi/ecqm/Measure/Identifier/mips"/>
<value value="309"/>
</identifier>
<version value="9.0.000"/>
<name value="EXM124"/>
<title value="EXM124 - Cervical Cancer Screening"/>
<status value="active"/>
<experimental value="true"/>
<date value="2022-02-22"/>
<publisher value="HL7 International / Clinical Quality Information"/>
<contact>
<telecom>
<system value="url"/>
<value value="http://www.hl7.org/Special/committees/cqi"/>
</telecom>
</contact>
<description
value="Percentage of women 21-64 years of age who were screened for cervical cancer using either of the following criteria:
* Women age 21-64 who had cervical cytology performed every 3 years
* Women age 30-64 who had cervical cytology/human papillomavirus (HPV) co-testing performed every 5 years"/>
<useContext>
<code>
<system
value="http://terminology.hl7.org/CodeSystem/usage-context-type"/>
<code value="venue"/>
<display value="Venue"/>
</code>
<valueCodeableConcept>
<coding>
<system
value="http://hl7.org/fhir/uv/cqm/CodeSystem/intended-venue-codes"/>
<code value="ec"/>
<display value="EC"/>
</coding>
</valueCodeableConcept>
</useContext>
<jurisdiction>
<coding>
<system value="http://unstats.un.org/unsd/methods/m49/m49.htm"/>
<code value="001"/>
</coding>
</jurisdiction>
<purpose
value="This measure has been developed to support improvement in clinical care."/>
<usage
value="To ensure the measure is only looking for a cervical cytology test only after a woman turns 21 years of age, the youngest age in the initial population is 23.
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.
Include only cytology and HPV "co-testing"; in co-testing, both cytology and HPV tests are performed (i.e., the samples are collected and both tests are ordered, regardless of the cytology result) on the same date of service. Do not include reflex testing. In addition, if the medical record indicates the HPV test was performed only after determining the cytology result, this is considered reflex testing and does not meet criteria for the measure."/>
<copyright
value="This Physician Performance Measure (Measure) and related data specifications 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 (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 or requests for modification must be approved by NCQA and are subject to a license at the discretion of NCQA. (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 third party codes contained in the specifications.
CPT(R) contained in the Measure specifications is copyright 2004-2017 American Medical Association. LOINC(R) copyright 2004-2017 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R] ) copyright 2004-2017 International Health Terminology Standards Development Organisation. ICD-10 copyright 2017 World Health Organization. All Rights Reserved."/>
<approvalDate value="2016-01-01"/>
<lastReviewDate value="2016-09-01"/>
<effectivePeriod>
<start value="2018-01-01"/>
<end value="2018-12-31"/>
</effectivePeriod>
<topic>
<coding>
<system value="http://loinc.org"/>
<code value="57024-2"/>
<display value="Health Quality Measure Document"/>
</coding>
</topic>
<library value="http://hl7.org/fhir/uv/cqm/Library/EXM124-FHIR"/>
<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. (Howlader et al, 2016). In 2013, 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 (Howlader et al, 2016).
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 (Howlader et al, 2016). 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 235; by age 50 it becomes 1 in 54; by age 60, it is 1 in 25 (National Business Group on Health, 2011).
In the U.S., costs associated with a diagnosis of breast cancer range from $451 to $2,520, factoring in continued testing, multiple office visits and procedures. The total costs related to breast cancer add up to nearly $7 billion per year in the U.S., including $2 billion spent on late-stage treatment (National Business Group on Health, 2011). If breast cancer is detected through mammography screening and diagnosed in its earliest stages, treatment may be less expensive (Feig, 2011)."/>
<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"/>
<display value="Increased score indicates improvement"/>
</coding>
</improvementNotation>
<group>
<description
value="Percentage of women 21-64 years of age who were screened for cervical cancer using either of the following criteria:
* Women age 21-64 who had cervical cytology performed every 3 years
* Women age 30-64 who had cervical cytology/human papillomavirus (HPV) co-testing performed every 5 years"/>
<population>
<code>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/measure-population"/>
<code value="initial-population"/>
<display value="Initial Population"/>
</coding>
</code>
<description
value="Women 23-64 years of age with a visit during the measurement period"/>
<criteria>
<language value="text/cql-identifier"/>
<expression value="Initial Population"/>
</criteria>
</population>
<population>
<code>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/measure-population"/>
<code value="numerator"/>
<display value="Numerator"/>
</coding>
</code>
<description
value="Women with one or more screenings for cervical cancer. Appropriate screenings are defined by any one of the following criteria:
* Cervical cytology performed during the measurement period or the two years prior to the measurement period for women who are at least 21 years old at the time of the test
* Cervical human papillomavirus (HPV) testing performed during the measurement period or the four years prior to the measurement period for women who are 30 years or older at the time of the test"/>
<criteria>
<language value="text/cql-identifier"/>
<expression value="Numerator"/>
</criteria>
</population>
<population>
<code>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/measure-population"/>
<code value="denominator"/>
<display value="Denominator"/>
</coding>
</code>
<description value="Equals Initial Population"/>
<criteria>
<language value="text/cql-identifier"/>
<expression value="Denominator"/>
</criteria>
</population>
<population>
<code>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/measure-population"/>
<code value="denominator-exclusion"/>
<display value="Denominator Exclusion"/>
</coding>
</code>
<description
value="Women who had a hysterectomy with no residual cervix or a congenital absence of cervix.
Exclude patients who are in hospice care for any part of the measurement period.
Exclude patients receiving palliative care during the measurement period."/>
<criteria>
<language value="text/cql-identifier"/>
<expression value="Denominator Exclusion"/>
</criteria>
</population>
</group>
<supplementalData>
<usage>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/measure-data-usage"/>
<code value="supplemental-data"/>
</coding>
</usage>
<criteria>
<language value="text/cql-identifier"/>
<expression value="SDE Ethnicity"/>
</criteria>
</supplementalData>
<supplementalData>
<usage>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/measure-data-usage"/>
<code value="supplemental-data"/>
</coding>
</usage>
<criteria>
<language value="text/cql-identifier"/>
<expression value="SDE Payer"/>
</criteria>
</supplementalData>
<supplementalData>
<usage>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/measure-data-usage"/>
<code value="supplemental-data"/>
</coding>
</usage>
<description value="Race"/>
<criteria>
<language value="text/cql-identifier"/>
<expression value="SDE Race"/>
</criteria>
</supplementalData>
<supplementalData>
<code>
<text value="Sex"/>
</code>
<usage>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/measure-data-usage"/>
<code value="supplemental-data"/>
</coding>
</usage>
<criteria>
<language value="text/cql-identifier"/>
<expression value="SDE Sex"/>
</criteria>
</supplementalData>
</Measure>
IG © 2019+ HL7 International / Clinical Quality Information. Package hl7.fhir.uv.cqm#1.0.0-ballot based on FHIR 4.0.1. Generated 2024-12-16
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