Quality Measure Implementation Guide
1.0.0-ballot - ballot International flag

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

Measure: EXM125 - Breast Cancer Screening (Experimental)

Official URL: http://hl7.org/fhir/uv/cqm/Measure/EXM125-FHIR Version: 8.0.000
Active as of 2022-02-22 Computable Name: EXM125
Other Identifiers: http://example.org/fhir/cqi/ecqm/Measure/Identifier/cms#125 (use: official, ), http://example.org/fhir/cqi/ecqm/Measure/Identifier/mips#112 (use: official, )

Usage:Venue: EC

Copyright/Legal: This Physician Performance Measure (Measure) and related data specifications were developed by the National Committee for Quality Assurance (NCQA). The Measure is copyrighted but can be reproduced and distributed, without modification, for noncommercial purposes (eg, use by healthcare providers in connection with their practices) without obtaining approval from NCQA. Commercial use is defined as the sale, licensing, or distribution of the Measure for commercial gain, or incorporation of the Measure into a product or service that is sold, licensed or distributed for commercial gain. All commercial uses must be approved by NCQA and are subject to a license at the discretion of NCQA. NCQA is not responsible for any use of the Measure. NCQA makes no representations, warranties, or endorsement about the quality of any organization or physician that uses or reports performance measures and NCQA has no liability to anyone who relies on such measures or specifications. (C) 2012-2017 National Committee for Quality Assurance. All Rights Reserved. Limited proprietary coding is contained in the Measure specifications for user convenience. Users of proprietary code sets should obtain all necessary licenses from the owners of the code sets. NCQA disclaims all liability for use or accuracy of any CPT or other codes contained in the specifications. CPT(R) contained in the Measure specifications is copyright 2004-2016 American Medical Association. LOINC(R) copyright 2004-2016 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2016 International Health Terminology Standards Development Organisation. ICD-10 copyright 2016 World Health Organization. All Rights Reserved. The American Hospital Association holds a copyright to the National Uniform Billing Committee (NUBC) codes contained in the measure specifications. The NUBC codes in the specifications are included with the permission of the AHA. The NUBC codes contained in the specifications may be used by health plans and other health care delivery organizations for the purpose of calculating and reporting Measure results or using Measure results for their internal quality improvement purposes. All other uses of the NUBC codes require a license from the AHA. Anyone desiring to use the NUBC codes in a commercial product to generate Measure results, or for any other commercial use, must obtain a commercial use license directly from the AHA. To inquire about licensing, contact ub04@healthforum.com.

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

This measure has been developed to support improvement in clinical care.

Title: EXM125 - Breast Cancer Screening
Id: EXM125-FHIR
Version: 8.0.000
Url: EXM125 - Breast Cancer Screening
Official

125

Official

112

Effective Period: 2018-01-01..2018-12-31
Experimental: true
Publisher: HL7 International / Clinical Quality Information
Description:

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

Use Context:
code value
venue
Jurisdiction: 001
Topic: 57024-2
Purpose:

This measure has been developed to support improvement in clinical care.

Copyright:

This Physician Performance Measure (Measure) and related data specifications were developed by the National Committee for Quality Assurance (NCQA). The Measure is copyrighted but can be reproduced and distributed, without modification, for noncommercial purposes (eg, use by healthcare providers in connection with their practices) without obtaining approval from NCQA. Commercial use is defined as the sale, licensing, or distribution of the Measure for commercial gain, or incorporation of the Measure into a product or service that is sold, licensed or distributed for commercial gain. All commercial uses must be approved by NCQA and are subject to a license at the discretion of NCQA. NCQA is not responsible for any use of the Measure. NCQA makes no representations, warranties, or endorsement about the quality of any organization or physician that uses or reports performance measures and NCQA has no liability to anyone who relies on such measures or specifications. (C) 2012-2017 National Committee for Quality Assurance. All Rights Reserved. Limited proprietary coding is contained in the Measure specifications for user convenience. Users of proprietary code sets should obtain all necessary licenses from the owners of the code sets. NCQA disclaims all liability for use or accuracy of any CPT or other codes contained in the specifications. CPT(R) contained in the Measure specifications is copyright 2004-2016 American Medical Association. LOINC(R) copyright 2004-2016 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2016 International Health Terminology Standards Development Organisation. ICD-10 copyright 2016 World Health Organization. All Rights Reserved. The American Hospital Association holds a copyright to the National Uniform Billing Committee (NUBC) codes contained in the measure specifications. The NUBC codes in the specifications are included with the permission of the AHA. The NUBC codes contained in the specifications may be used by health plans and other health care delivery organizations for the purpose of calculating and reporting Measure results or using Measure results for their internal quality improvement purposes. All other uses of the NUBC codes require a license from the AHA. Anyone desiring to use the NUBC codes in a commercial product to generate Measure results, or for any other commercial use, must obtain a commercial use license directly from the AHA. To inquire about licensing, contact ub04@healthforum.com.

Disclaimer:

The performance Measure is not a clinical guideline and does not establish a standard of medical care, and has not been tested for all potential applications. THE MEASURE AND SPECIFICATIONS ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND.

Scoring:

Proportion

Type:

process

Rationale:

Breast cancer is one of the most common types of cancers, accounting for a quarter of all new cancer diagnoses for women in the U.S. (BreastCancer.Org, 2011). It ranks as the second leading cause of cancer-related mortality in women, accounting for nearly 40,000 estimated deaths in 2013 (American Cancer Society, 2011). According to the National Cancer Institute's Surveillance Epidemiology and End Results program, the chance of a woman being diagnosed with breast cancer in a given year increases with age. By age 30, it is one in 2,212. By age 40, the chances increase to one in 235, by age 50, it becomes one in 54, and, by age 60, it is one in 25. From 2004 to 2008, the median age at the time of breast cancer diagnosis was 61 years among adult women (Tangka et al, 2010). 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 varying 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 (Lavigne et al, 2008; Boykoff et al, 2009).

Clinical recommendation statement:

The U.S. Preventive Services Task Force (USPSTF) recommends biennial screening mammography for women aged 50-74 years (B recommendation). The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient's values regarding specific benefits and harms (C recommendation). The Task Force concludes the evidence is insufficient to assess the additional benefits and harms of screening mammography in women 75 years and older (I statement). U.S. Preventive Services Task Force (2009) Grade: B recommendation. The USPSTF recommends biennial screening mammography for women aged 50 to 74 years. Grade: C recommendation. The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient's values regarding specific benefits and harms. Grade: I Statement. The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of screening mammography in women 75 years or older. Grade: D recommendation. The USPSTF recommends against teaching breast self-examination (BSE). Grade: I Statement. The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of clinical breast examination (CBE) beyond screening mammography in women 40 years or older. Grade: I Statement. The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of either digital mammography or magnetic resonance imaging (MRI) instead of film mammography as screening modalities for breast cancer.

Improvement Notation:

Increased score indicates improvement

Supplemental Data Elements:

SDE Ethnicity

SDE Payer

SDE Race

SDE Sex

Libraries:
EXM125 - Breast Cancer Screening Library
Terminology and Other Dependencies:
  • Supplemental Data Elements Libraryversion: null2.0.0)
  • http://fhir.org/guides/cqf/common/Library/FHIRHelpers|4.0.1
  • MAT Global Common Functions FHIR Libraryversion: null5.0.000)
  • Adult Outpatient Encounters Common Libraryversion: null2.0.000)
  • Hospice FHIR Libraryversion: null2.0.000)
  • http://snomed.info/sct|http://snomed.info/sct/731000124108/version/201709
  • Condition Clinical Status Codes
  • http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.108.12.1018
  • http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1001
  • http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.526.3.1240
  • http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1025
  • http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1023
  • http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1016
  • http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591
  • http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.666.5.307
  • http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1108.15
  • http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1020
  • http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1070
  • http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1071
  • http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.122.12.1035
  • http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1069
  • http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.122.12.1036
  • http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1068
  • http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1005
  • Parameters:
    name use min max type
    Measurement Period In 0 1 Period
    SDE Sex Out 0 1 Coding
    Numerator Out 0 1 boolean
    Denominator Out 0 1 boolean
    SDE Payer Out 0 * Resource
    Initial Population Out 0 1 boolean
    SDE Ethnicity Out 0 * Coding
    Denominator Exclusion Out 0 1 boolean
    SDE Race Out 0 * Coding
    DataRequirements:
    Resource Type Resource Elements Valueset Name Valueset
    Coverage(Coverage) period type Payer http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591
    Patient(Patient) extension value url
    Condition(Condition) code clinicalStatus Status Post Right Mastectomy http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1070
    Condition(Condition) code clinicalStatus Status Post Left Mastectomy http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1069
    Condition(Condition) bodySite code clinicalStatus Unilateral Mastectomy, Unspecified Laterality http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1071
    Condition(Condition) code clinicalStatus onset History of bilateral mastectomy http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1068
    Procedure(Procedure) code performed status Bilateral Mastectomy http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1005
    Procedure(Procedure) code performed status Unilateral Mastectomy http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1020
    Procedure(Procedure) code performed status Hospice care ambulatory http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1108.15
    Encounter(Encounter) type Office Visit http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1001
    Encounter(Encounter) type Annual Wellness Visit http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.526.3.1240
    Encounter(Encounter) type Preventive Care Services - Established Office Visit, 18 and Up http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1025
    Encounter(Encounter) type Preventive Care Services-Initial Office Visit, 18 and Up http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1023
    Encounter(Encounter) type Home Healthcare Services http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1016
    Encounter(Encounter) period hospitalization hospitalization.dischargeDisposition type status Encounter Inpatient http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.666.5.307
    ServiceRequest(ServiceRequest) code authoredOn intent Hospice care ambulatory http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1108.15
    DiagnosticReport(DiagnosticReport) effective code status Mammography http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.108.12.1018
    Direct Reference Codes:
    display code system
    Discharge to home for hospice care (procedure) 428361000124107 http://snomed.info/sct
    Discharge to healthcare facility for hospice care (procedure) 428371000124100 http://snomed.info/sct
    active http://terminology.hl7.org/CodeSystem/condition-clinical
    Logic Definitions:
    Group Scoring Population Criteria Expression
    Measure scoring:

    Proportion

    Initial Population
    define "Initial Population":
    		Patient.gender = 'female'
    				and Global."CalendarAgeInYearsAt"(FHIRHelpers.ToDate(Patient.birthDate), start of "Measurement Period") in Interval[51, 74]
    				and exists AdultOutpatientEncounters."Qualifying Encounters"
    Numerator
    define "Numerator":
    		exists (
    				[DiagnosticReport: "Mammography"] Mammogram
    						where ( Global."Normalize Interval"(Mammogram.effective) ends 27 months or less before day of end of "Measurement Period" )
    								and Mammogram.status in { 'final', 'amended', 'corrected', 'appended' }
    		)
    Denominator
    define "Denominator":
    		"Initial Population"
    Denominator Exclusion
    define "Denominator Exclusion":
    		Hospice."Has Hospice"
    				or ( Count("Unilateral Mastectomy Procedure") = 2 )
    				or ( exists "Right Mastectomy" and exists "Left Mastectomy" )
    				or exists "History Bilateral Mastectomy"
    				or exists "Bilateral Mastectomy Procedure"
    Library Name Name
    SupplementalDataElements SDE Sex
    define "SDE Sex":
      case
          when Patient.gender = 'male' then Code { code: 'M', system: 'http://hl7.org/fhir/v3/AdministrativeGender', display: 'Male' }
          when Patient.gender = 'female' then Code { code: 'F', system: 'http://hl7.org/fhir/v3/AdministrativeGender', display: 'Female' }
          else null
        end
    Library Name Name
    EXM125-FHIR SDE Sex
    define "SDE Sex":
      SDE."SDE Sex"
    Library Name Name
    EXM125-FHIR Numerator
    define "Numerator":
    		exists (
    				[DiagnosticReport: "Mammography"] Mammogram
    						where ( Global."Normalize Interval"(Mammogram.effective) ends 27 months or less before day of end of "Measurement Period" )
    								and Mammogram.status in { 'final', 'amended', 'corrected', 'appended' }
    		)
    Library Name Name
    AdultOutpatientEncounters Qualifying Encounters
    define "Qualifying Encounters":
    	(
        [Encounter: "Office Visit"]
      		union [Encounter: "Annual Wellness Visit"]
      		union [Encounter: "Preventive Care Services - Established Office Visit, 18 and Up"]
      		union [Encounter: "Preventive Care Services-Initial Office Visit, 18 and Up"]
      		union [Encounter: "Home Healthcare Services"]
      ) ValidEncounter
    		where ValidEncounter.period during "Measurement Period"
      		and ValidEncounter.status  = 'finished'
    Library Name Name
    EXM125-FHIR Initial Population
    define "Initial Population":
    		Patient.gender = 'female'
    				and Global."CalendarAgeInYearsAt"(FHIRHelpers.ToDate(Patient.birthDate), start of "Measurement Period") in Interval[51, 74]
    				and exists AdultOutpatientEncounters."Qualifying Encounters"
    Library Name Name
    EXM125-FHIR Denominator
    define "Denominator":
    		"Initial Population"
    Library Name Name
    SupplementalDataElements SDE Payer
    define "SDE Payer":
      [Coverage: type in "Payer"] Payer
            return {
              code: Payer.type,
              period: Payer.period
            }
    Library Name Name
    EXM125-FHIR SDE Payer
    define "SDE Payer":
      SDE."SDE Payer"
    Library Name Name
    SupplementalDataElements SDE Ethnicity
    define "SDE Ethnicity":
      (flatten (
          Patient.extension Extension
            where Extension.url = 'http://hl7.org/fhir/us/core/StructureDefinition/us-core-ethnicity'
              return Extension.extension
        )) E
          where E.url = 'ombCategory'
            or E.url = 'detailed'
          return E.value as Coding
    Library Name Name
    EXM125-FHIR SDE Ethnicity
    define "SDE Ethnicity":
      SDE."SDE Ethnicity"
    Library Name Name
    Hospice Has Hospice
    define "Has Hospice":
    	exists (
        [Encounter: "Encounter Inpatient"] DischargeHospice
    			where DischargeHospice.status = 'finished'
    		    and (
    	        DischargeHospice.hospitalization.dischargeDisposition ~ "Discharge to home for hospice care (procedure)"
    				    or DischargeHospice.hospitalization.dischargeDisposition ~ "Discharge to healthcare facility for hospice care (procedure)"
    	    	)
    				and DischargeHospice.period ends during "Measurement Period"
    	)
        or exists (
          [ServiceRequest: "Hospice care ambulatory"] HospiceOrder
            where HospiceOrder.intent = 'order'
                and HospiceOrder.authoredOn in "Measurement Period"
        )
        or exists (
          [Procedure: "Hospice care ambulatory"] HospicePerformed
            where HospicePerformed.status = 'completed'
              and Global."Normalize Interval"(HospicePerformed.performed) overlaps "Measurement Period"
        )
    Library Name Name
    EXM125-FHIR Unilateral Mastectomy Procedure
    define "Unilateral Mastectomy Procedure":
    		[Procedure: "Unilateral Mastectomy"] UnilateralMastectomyProcedure
    				where Global."Normalize Interval"(UnilateralMastectomyProcedure.performed) ends before day of end of "Measurement Period"
    						and UnilateralMastectomyProcedure.status = 'completed'
    Library Name Name
    EXM125-FHIR Right Mastectomy
    define "Right Mastectomy":
    		(
    				( [Condition: "Status Post Right Mastectomy"] C
              where C.clinicalStatus ~ ToConcept(Global."active")
            )
    				union (
    						[Condition: "Unilateral Mastectomy, Unspecified Laterality"] UnilateralMastectomyDiagnosis
    								where UnilateralMastectomyDiagnosis.bodySite in "Right"
                      and UnilateralMastectomyDiagnosis.clinicalStatus ~ ToConcept(Global."active")
    				)
    		) RightMastectomy
    				where Global."Normalize Interval"(RightMastectomy.onset) starts before day of end of "Measurement Period"
    Library Name Name
    EXM125-FHIR Left Mastectomy
    define "Left Mastectomy":
    		(
    		    ( [Condition: "Status Post Left Mastectomy"] C
              where C.clinicalStatus ~ ToConcept(Global."active")
            )
    				union (
    						[Condition: "Unilateral Mastectomy, Unspecified Laterality"] UnilateralMastectomyDiagnosis
    								where UnilateralMastectomyDiagnosis.bodySite in "Left"
                      and UnilateralMastectomyDiagnosis.clinicalStatus ~ ToConcept(Global."active")
    				)
    		) LeftMastectomy
    				where Global."Normalize Interval"(LeftMastectomy.onset) starts before day of end of "Measurement Period"
    Library Name Name
    EXM125-FHIR History Bilateral Mastectomy
    define "History Bilateral Mastectomy":
    		[Condition: "History of bilateral mastectomy"] BilateralMastectomyHistory
    				where Global."Normalize Interval"(BilateralMastectomyHistory.onset) starts before day of end of "Measurement Period"
              and BilateralMastectomyHistory.clinicalStatus ~ ToConcept(Global."active")
    Library Name Name
    EXM125-FHIR Bilateral Mastectomy Procedure
    define "Bilateral Mastectomy Procedure":
    		[Procedure: "Bilateral Mastectomy"] BilateralMastectomyPerformed
    				where Global."Normalize Interval"(BilateralMastectomyPerformed.performed) ends before day of end of "Measurement Period"
    						and BilateralMastectomyPerformed.status = 'completed'
    Library Name Name
    EXM125-FHIR Denominator Exclusion
    define "Denominator Exclusion":
    		Hospice."Has Hospice"
    				or ( Count("Unilateral Mastectomy Procedure") = 2 )
    				or ( exists "Right Mastectomy" and exists "Left Mastectomy" )
    				or exists "History Bilateral Mastectomy"
    				or exists "Bilateral Mastectomy Procedure"
    Library Name Name
    SupplementalDataElements SDE Race
    define "SDE Race":
      (flatten (
          Patient.extension Extension
            where Extension.url = 'http://hl7.org/fhir/us/core/StructureDefinition/us-core-race'
              return Extension.extension
        )) E
          where E.url = 'ombCategory'
            or E.url = 'detailed'
          return E.value as Coding
    Library Name Name
    EXM125-FHIR SDE Race
    define "SDE Race":
      SDE."SDE Race"