Quality Measure Implementation Guide
1.0.0 - STU 1

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## : EXM146 - Appropriate Testing for Children with Pharyngitis - XML Representation

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    <Measure xmlns="http://hl7.org/fhir">
      <id value="EXM146-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-cqlmeasure"/>
        <profile
                 value="http://hl7.org/fhir/uv/cqm/StructureDefinition/cqm-computablemeasure"/>
      </meta>
      <text>
        <status value="extensions"/>
        <div xmlns="http://www.w3.org/1999/xhtml">
      <table class="narrative-table">
        <tbody>
    <tr>

    <th colspan="2" scope="row" class="row-header">Metadata</th>

    </tr>

    <tr>

    <th scope="row" class="row-header">Title</th>

    <td class="content-container">EXM146 - Appropriate Testing for Children with Pharyngitis</td>
    </tr>

    <tr>

    <th scope="row" class="row-header">Version</th>

    <td class="content-container">4.0.0</td>
    </tr>

    <tr>

    <th scope="row" class="row-header">Identifier</th>

    <td class="content-container">146</td>
    </tr>

    <tr>

    <th scope="row" class="row-header">Identifier</th>

    <td class="content-container">urn:oid:2.16.840.1.113883.4.642.40.61.29.7</td>
    </tr>

    <tr>

    <th scope="row" class="row-header">Effective Period</th>

    <td class="content-container">2018-01-01 through 2018-12-31</td>
    </tr>

    <tr>

    <th scope="row" class="row-header">Approval Date</th>

    <td class="content-container">2016-01-01</td>
    </tr>

    <tr>

    <th scope="row" class="row-header">Last Review Date</th>

    <td class="content-container">2016-09-01</td>
    </tr>

    <tr>

    <th scope="row" class="row-header">Experimental</th>

    <td class="content-container">true</td>
    </tr>

    <tr>

    <th scope="row" class="row-header">Use Context</th>

    <td class="content-container"><span title="{http://terminology.hl7.org/CodeSystem/usage-context-type venue}">Clinical Venue</span> = <span title="Codes:{http://hl7.org/fhir/uv/cqm/CodeSystem/intended-venue-codes ec}">EC</span></td>
    </tr>

    <tr>

    <th scope="row" class="row-header">Jurisdiction</th>

    <td class="content-container"><span title="Codes:{http://unstats.un.org/unsd/methods/m49/m49.htm 001}">Global (Whole world)</span></td>
    </tr>

    <tr>

    <th scope="row" class="row-header">Topic</th>

    <td class="content-container"><span title="Codes:{http://loinc.org 57024-2}">Health Quality Measure Document</span></td>
    </tr>

    <tr>

    <th scope="row" class="row-header">Steward (Publisher)</th>

    <td class="content-container">HL7 International / Clinical Quality Information</td>
    </tr>

    <tr>

    <th scope="row" class="row-header">Description</th>

    <td class="content-container"><div><p>Percentage of children 2-18 years of age who were diagnosed with pharyngitis, ordered an antibiotic and received a group A streptococcus (strep) test for the episode.</p>
    </div></td>
    </tr>

    <tr>

    <th scope="row" class="row-header">Purpose</th>

    <td class="content-container"><div><p>This measure has been developed to support improvement in clinical care.</p>
    </div></td>
    </tr>

    <tr>

    <th scope="row" class="row-header">Copyright</th>

    <td class="content-container"><div><p>Physician Performance Measure (Measures) and related data specifications were developed by the National Committee for Quality Assurance (NCQA).
    The Measures are copyrighted but can be reproduced and distributed, without modification, for noncommercial purposes (eg, use by healthcare providers in connection with their practices). Commercial use is defined as the sale, licensing, or distribution of the Measures for commercial gain, or incorporation of the Measures into a product or service that is sold, licensed or distributed for commercial gain. Commercial use of the Measures requires a license agreement between the user and NCQA. NCQA is not responsible for any use of the Measures.
    (c) 2008 -2014 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 2004-2013 American Medical Association. LOINC(R) copyright 2004-2013 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2013 International Health Terminology Standards Development Organisation. ICD-10 copyright 2013 World Health Organization. All Rights Reserved.</p>
    </div></td>
    </tr>

    <tr>

    <th scope="row" class="row-header">Disclaimer</th>

    <td class="content-container"><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 &quot;AS IS&quot; 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" class="row-header">Measure Basis</th>

    <td class="content-container">Encounter</td>
    </tr>

    <tr>

    <th scope="row" class="row-header">Measure Scoring</th>

    <td class="content-container"><span title="Codes:{http://terminology.hl7.org/CodeSystem/measure-scoring proportion}">Proportion</span></td>
    </tr>

    <tr>

    <th scope="row" class="row-header">Measure Type</th>

    <td class="content-container"><span title="Codes:{http://terminology.hl7.org/CodeSystem/measure-type process}">Process</span></td>
    </tr>

    <tr>

    <th scope="row" class="row-header">Rationale</th>

    <td class="content-container"><div><p>Group A streptococcal bacterial infections and other infections that cause pharyngitis (which are most often viral) often produce the same signs and symptoms (IDSA 2002). The American Academy of Pediatrics, the Centers for Disease Control and Prevention, and the Infectious Diseases Society of America all recommend a diagnostic test for Strep A to improve diagnostic accuracy and avoid unnecessary antibiotic treatment (Linder et al. 2005).  A study on antibiotic treatment of children with sore throat found that although only 15 to 36 percent of children with sore throat have Strep A pharyngitis, physicians prescribed antibiotics to 53 percent of children with a chief complaint of sore throat between 1995 and 2003 (Linder et al. 2005).</p>
    </div></td>
    </tr>

    <tr>

    <th scope="row" class="row-header">Clinical Recommendation Statement</th>

    <td class="content-container"><div><p>Institute for Clinical Systems Improvement (ICSI) (2007)
    Reduce unnecessary use of antibiotics. Antibiotic treatment should be reserved for a bacterial illness. Diagnosis of group A beta streptococcal Pharyngitis should be made by laboratory testing rather than clinically.
    Infectious Disease Society of America (Bisno et al. 2002)
    The signs and symptoms of group A streptococcal and other (most frequently viral) pharyngitides overlap broadly. Therefore, unless the physician is able with confidence to exclude the diagnosis of streptococcal pharyngitis on epidemiological and clinical grounds alone, a laboratory test should be done to determine whether group A streptococci are present in the pharynx.
    With the exception of very rare infections by certain other pharyngeal bacterial pathogens (eg, Corynebacterium diphtheriae and Neisseria gonorrhoeae), antimicrobial therapy is of no proven benefit as treatment for acute pharyngitis due to bacteria other than group A streptococci. Therefore, it is extremely important that physicians exclude the diagnosis of group A streptococcal pharyngitis to prevent inappropriate administration of antimicrobials to large numbers of patients with pharyngitis.
    Michigan Quality Improvement Consortium (2007)
    Probability of group A beta hemolytic streptococci (GABHS): Low; Testing: None; Treatment: Symptomatic treatment only. Avoid antibiotics. Probability of GABHS: Intermediate or High; Testing: Throat Culture (TC) OR Rapid Screen; Treatment: If TC is positive, use antibiotics. If TC is negative, use symptomatic treatment only. Avoid antibiotics. If treatment is started and culture result is negative, stop antibiotics. If Rapid Screen is positive, use antibiotics. If Rapid Screen is negative, culture (Culture is optional for age 16 and over) and only use antibiotics if throat culture is positive. (Michigan, 2007)</p>
    </div></td>
    </tr>

    <tr>

    <th scope="row" class="row-header">Improvement Notation</th>

    <td class="content-container"><span title="Codes:{http://terminology.hl7.org/CodeSystem/measure-improvement-notation increase}">Increased score indicates improvement</span></td>
    </tr>

        <tr>

    <th colspan="2" scope="row" class="row-header">Measure Group (Rate) (ID: primary)</th>

    </tr>

        <tr>

    <th scope="row" class="row-header">Initial Population</th>

          <td class="content-container">

            <em>ID</em>: primary-exm146-initial-population
            <br/>

              <em>Description</em>: No description provided

                  <em>Criteria</em>: <a href="#primary-primary-exm146-initial-population">Initial Population</a>

          </td>
        </tr>

        <tr>

    <th scope="row" class="row-header">Numerator</th>

          <td class="content-container">

            <em>ID</em>: primary-exm146-numerator
            <br/>

              <em>Description</em>: No description provided

                  <em>Criteria</em>: <a href="#primary-primary-exm146-numerator">Numerator</a>

          </td>
        </tr>

        <tr>

    <th scope="row" class="row-header">Denominator</th>

          <td class="content-container">

            <em>ID</em>: primary-exm146-denominator
            <br/>

              <em>Description</em>: No description provided

                  <em>Criteria</em>: <a href="#primary-primary-exm146-denominator">Denominator</a>

          </td>
        </tr>

        <tr>

    <th scope="row" class="row-header">Denominator Exclusion</th>

          <td class="content-container">

            <em>ID</em>: primary-exm146-denominator-exclusion
            <br/>

              <em>Description</em>: No description provided

                  <em>Criteria</em>: <a href="#primary-primary-exm146-denominator-exclusion">Denominator Exclusions</a>

          </td>
        </tr>

    <tr>

    <th colspan="2" scope="row" class="row-header">Measure Logic</th>

    </tr>

    <tr>

    <th scope="row" class="row-header">Primary Library</th>

    <td class="content-container"><a href="Library-EXM146.html">EXM146 - Example Proportion Measure Library</a></td>
    </tr>

    <tr>
      <th scope="row" class="row-header">Contents</th>
      <td class="content-container">
        <em><a href="#population-criteria">Population Criteria</a></em>
        <br/>
        <em><a href="#definitions">Logic Definitions</a></em>
        <br/>
        <em><a href="#terminology">Terminology</a></em>
        <br/>
        <em><a href="#dependencies">Dependencies</a></em>
        <br/>
        <em><a href="#data-requirements">Data Requirements</a></em>
        <br/>
      </td>
    </tr>

      <tr>

    <th colspan="2" scope="row" class="row-header"><a name="population-criteria"> </a>Population Criteria</th>

    </tr>

        <tr>

    <th colspan="2" scope="row" class="row-header">Measure Group (Rate) (ID: primary)</th>

    </tr>

                <tr>
      <th scope="row" rowspan="2" class="row-header">

        Initial Population

      </th>
    </tr>
    <tr>

      <td>

          <a name="primary-primary-exm146-initial-population"> </a>

        <pre style="border: none;" class="content-container highlight language-cql"><code class="language-cql">define &quot;Initial Population&quot;:
       &quot;Pharyngitis Encounters With Antibiotics&quot;</code></pre>

          <a href="#exm146-initial-population"><em>Definition</em></a>

      </td>

    </tr>

                <tr>
      <th scope="row" rowspan="2" class="row-header">

        Numerator

      </th>
    </tr>
    <tr>

      <td>

          <a name="primary-primary-exm146-numerator"> </a>

        <pre style="border: none;" class="content-container highlight language-cql"><code class="language-cql">define &quot;Numerator&quot;:
       &quot;Strep Test Encounters&quot;</code></pre>

          <a href="#exm146-numerator"><em>Definition</em></a>

      </td>

    </tr>

                <tr>
      <th scope="row" rowspan="2" class="row-header">

        Denominator

      </th>
    </tr>
    <tr>

      <td>

          <a name="primary-primary-exm146-denominator"> </a>

        <pre style="border: none;" class="content-container highlight language-cql"><code class="language-cql">define &quot;Denominator&quot;:
       &quot;Initial Population&quot;</code></pre>

          <a href="#exm146-denominator"><em>Definition</em></a>

      </td>

    </tr>

                <tr>
      <th scope="row" rowspan="2" class="row-header">

        Denominator Exclusion

      </th>
    </tr>
    <tr>

      <td>

          <a name="primary-primary-exm146-denominator-exclusion"> </a>

        <pre style="border: none;" class="content-container highlight language-cql"><code class="language-cql">define &quot;Denominator Exclusions&quot;:
      &quot;Excluded Encounters&quot;</code></pre>

          <a href="#exm146-denominator-exclusions"><em>Definition</em></a>

      </td>

    </tr>

      <tr>

    <th colspan="2" scope="row" class="row-header"><a name="definitions"> </a>Logic Definitions</th>

    </tr>

    <tr>
      <th scope="row" rowspan="2" class="row-header">
        Logic Definition
      </th>

      <td class="content-container"><em>Library Name:</em> EXM146</td>

    </tr>
    <tr>

      <td>

          <a name="exm146-is-between-2-and-17-years-of-age-at-start-of-measurement-period"> </a>

        <pre style="border: none;" class="content-container highlight language-cql"><code class="language-cql">define &quot;Is Between 2 and 17 Years of Age at Start of Measurement Period&quot;:
       AgeInYearsAt(start of &quot;Measurement Period&quot;) &gt;= 2
          and AgeInYearsAt(start of &quot;Measurement Period&quot;) &lt;= 17</code></pre>
      </td>

    </tr>

    <tr>
      <th scope="row" rowspan="2" class="row-header">
        Logic Definition
      </th>

      <td class="content-container"><em>Library Name:</em> EXM146</td>

    </tr>
    <tr>

      <td>

          <a name="exm146-measurement-period-encounters"> </a>

        <pre style="border: none;" class="content-container highlight language-cql"><code class="language-cql">define &quot;Measurement Period Encounters&quot;:
       [Encounter: &quot;Ambulatory/ED Visit&quot;] Encounter
          where Encounter.period during &quot;Measurement Period&quot;
            and Encounter.status = 'finished'
            and &quot;Is Between 2 and 17 Years of Age at Start of Measurement Period&quot;</code></pre>
      </td>

    </tr>

    <tr>
      <th scope="row" rowspan="2" class="row-header">
        Logic Definition
      </th>

      <td class="content-container"><em>Library Name:</em> EXM146</td>

    </tr>
    <tr>

      <td>

          <a name="exm146-pharyngitis"> </a>

        <pre style="border: none;" class="content-container highlight language-cql"><code class="language-cql">define &quot;Pharyngitis&quot;:
       ([Condition: code in &quot;Acute Pharyngitis&quot;]
         union [Condition: code in &quot;Acute Tonsillitis&quot;]) Pharyngitis
         where Pharyngitis.clinicalStatus ~ Global.active
           and Pharyngitis.verificationStatus ~ Global.confirmed</code></pre>
      </td>

    </tr>

    <tr>
      <th scope="row" rowspan="2" class="row-header">
        Logic Definition
      </th>

      <td class="content-container"><em>Library Name:</em> EXM146</td>

    </tr>
    <tr>

      <td>

          <a name="exm146-antibiotics"> </a>

        <pre style="border: none;" class="content-container highlight language-cql"><code class="language-cql">define &quot;Antibiotics&quot;:
       [MedicationRequest: medication in &quot;Antibiotic Medications&quot;] Prescription
         where Prescription.status = 'active'
           and Prescription.intent = 'order'</code></pre>
      </td>

    </tr>

    <tr>
      <th scope="row" rowspan="2" class="row-header">
        Logic Definition
      </th>

      <td class="content-container"><em>Library Name:</em> EXM146</td>

    </tr>
    <tr>

      <td>

          <a name="exm146-pharyngitis-encounters-with-antibiotics"> </a>

        <pre style="border: none;" class="content-container highlight language-cql"><code class="language-cql">define &quot;Pharyngitis Encounters With Antibiotics&quot;:
       &quot;Measurement Period Encounters&quot; Encounters
          with &quot;Pharyngitis&quot; Pharyngitis such that
             Common.&quot;Includes Or Starts During&quot;(Pharyngitis, Encounters)
          with &quot;Antibiotics&quot; Antibiotics such that Antibiotics.authoredOn
             3 days or less after FHIRHelpers.ToInterval(Encounters.period)</code></pre>
      </td>

    </tr>

    <tr>
      <th scope="row" rowspan="2" class="row-header">
        Logic Definition
      </th>

      <td class="content-container"><em>Library Name:</em> EXM146</td>

    </tr>
    <tr>

      <td>

          <a name="exm146-strep-test-encounters"> </a>

        <pre style="border: none;" class="content-container highlight language-cql"><code class="language-cql">define &quot;Strep Test Encounters&quot;:
       &quot;Pharyngitis Encounters With Antibiotics&quot; Encounters
          with [Observation: code in &quot;Group A Streptococcus Test&quot;] Tests
             such that Tests.value is not null
                and Tests.effective starts during
                   Interval[start of FHIRHelpers.ToInterval(Encounters.period) - 3 days,
                     end of FHIRHelpers.ToInterval(Encounters.period) + 3 days]</code></pre>
      </td>

    </tr>

    <tr>
      <th scope="row" rowspan="2" class="row-header">
        Logic Definition
      </th>

      <td class="content-container"><em>Library Name:</em> EXM146</td>

    </tr>
    <tr>

      <td>

          <a name="exm146-numerator"> </a>

        <pre style="border: none;" class="content-container highlight language-cql"><code class="language-cql">define &quot;Numerator&quot;:
       &quot;Strep Test Encounters&quot;</code></pre>
      </td>

    </tr>

    <tr>
      <th scope="row" rowspan="2" class="row-header">
        Logic Definition
      </th>

      <td class="content-container"><em>Library Name:</em> EXM146</td>

    </tr>
    <tr>

      <td>

          <a name="exm146-initial-population"> </a>

        <pre style="border: none;" class="content-container highlight language-cql"><code class="language-cql">define &quot;Initial Population&quot;:
       &quot;Pharyngitis Encounters With Antibiotics&quot;</code></pre>
      </td>

    </tr>

    <tr>
      <th scope="row" rowspan="2" class="row-header">
        Logic Definition
      </th>

      <td class="content-container"><em>Library Name:</em> EXM146</td>

    </tr>
    <tr>

      <td>

          <a name="exm146-denominator"> </a>

        <pre style="border: none;" class="content-container highlight language-cql"><code class="language-cql">define &quot;Denominator&quot;:
       &quot;Initial Population&quot;</code></pre>
      </td>

    </tr>

    <tr>
      <th scope="row" rowspan="2" class="row-header">
        Logic Definition
      </th>

      <td class="content-container"><em>Library Name:</em> EXM146</td>

    </tr>
    <tr>

      <td>

          <a name="exm146-pharyngitis-with-prior-antibiotics"> </a>

        <pre style="border: none;" class="content-container highlight language-cql"><code class="language-cql">define &quot;Pharyngitis With Prior Antibiotics&quot;:
       &quot;Pharyngitis&quot; Pharyngitis
          with &quot;Antibiotics&quot; Antibiotics such that
             Antibiotics.authoredOn 30 days or less before Pharyngitis.onset</code></pre>
      </td>

    </tr>

    <tr>
      <th scope="row" rowspan="2" class="row-header">
        Logic Definition
      </th>

      <td class="content-container"><em>Library Name:</em> EXM146</td>

    </tr>
    <tr>

      <td>

          <a name="exm146-excluded-encounters"> </a>

        <pre style="border: none;" class="content-container highlight language-cql"><code class="language-cql">define &quot;Excluded Encounters&quot;:
       &quot;Pharyngitis Encounters With Antibiotics&quot; Encounters
          with &quot;Pharyngitis With Prior Antibiotics&quot; Pharyngitis such that
             Common.&quot;Includes Or Starts During&quot;(Pharyngitis, Encounters)</code></pre>
      </td>

    </tr>

    <tr>
      <th scope="row" rowspan="2" class="row-header">
        Logic Definition
      </th>

      <td class="content-container"><em>Library Name:</em> EXM146</td>

    </tr>
    <tr>

      <td>

          <a name="exm146-denominator-exclusions"> </a>

        <pre style="border: none;" class="content-container highlight language-cql"><code class="language-cql">define &quot;Denominator Exclusions&quot;:
      &quot;Excluded Encounters&quot;</code></pre>
      </td>

    </tr>

    <tr>
      <th scope="row" rowspan="2" class="row-header">
        Logic Definition
      </th>

      <td class="content-container"><em>Library Name:</em> Common</td>

    </tr>
    <tr>

      <td>

          <a name="common-includes-or-starts-during"> </a>

        <pre style="border: none;" class="content-container highlight language-cql"><code class="language-cql">define function
       &quot;Includes Or Starts During&quot;(Condition Condition, Encounter Encounter):
          Interval[Condition.onset, Condition.abatement] includes Encounter.period
             or Condition.onset during Encounter.period</code></pre>
      </td>

    </tr>

    <tr>
      <th scope="row" rowspan="2" class="row-header">
        Logic Definition
      </th>

      <td class="content-container"><em>Library Name:</em> FHIRHelpers</td>

    </tr>
    <tr>

      <td>

          <a name="fhirhelpers-tointerval"> </a>

        <pre style="border: none;" class="content-container highlight language-cql"><code class="language-cql">/*
    @description: Converts the given [Period](https://hl7.org/fhir/datatypes.html#Period)
    value to a CQL DateTime Interval
    @comment: If the start value of the given period is unspecified, the starting
    boundary of the resulting interval will be open (meaning the start of the interval
    is unknown, as opposed to interpreted as the beginning of time).
    */
    define function ToInterval(period FHIR.Period):
        if period is null then
            null
        else
            if period.&quot;start&quot; is null then
                Interval(period.&quot;start&quot;.value, period.&quot;end&quot;.value]
            else
                Interval[period.&quot;start&quot;.value, period.&quot;end&quot;.value]</code></pre>
      </td>

    </tr>

    <tr>
      <th scope="row" rowspan="2" class="row-header">
        Logic Definition
      </th>

      <td class="content-container"><em>Library Name:</em> FHIRHelpers</td>

    </tr>
    <tr>

      <td>

          <a name="fhirhelpers-tostring"> </a>

        <pre style="border: none;" class="content-container highlight language-cql"><code class="language-cql">define function ToString(value EncounterStatus): value.value</code></pre>
      </td>

    </tr>

    <tr>
      <th scope="row" rowspan="2" class="row-header">
        Logic Definition
      </th>

      <td class="content-container"><em>Library Name:</em> FHIRHelpers</td>

    </tr>
    <tr>

      <td>

          <a name="fhirhelpers-toconcept"> </a>

        <pre style="border: none;" class="content-container highlight language-cql"><code class="language-cql">/*
    @description: Converts the given FHIR [CodeableConcept](https://hl7.org/fhir/datatypes.html#CodeableConcept) value to a CQL Concept.
    */
    define function ToConcept(concept FHIR.CodeableConcept):
        if concept is null then
            null
        else
            System.Concept {
                codes: concept.coding C return ToCode(C),
                display: concept.text.value
            }</code></pre>
      </td>

    </tr>

    <tr>
      <th scope="row" rowspan="2" class="row-header">
        Logic Definition
      </th>

      <td class="content-container"><em>Library Name:</em> FHIRHelpers</td>

    </tr>
    <tr>

      <td>

          <a name="fhirhelpers-tocode"> </a>

        <pre style="border: none;" class="content-container highlight language-cql"><code class="language-cql">/*
    @description: Converts the given FHIR [Coding](https://hl7.org/fhir/datatypes.html#Coding) value to a CQL Code.
    */
    define function ToCode(coding FHIR.Coding):
        if coding is null then
            null
        else
            System.Code {
              code: coding.code.value,
              system: coding.system.value,
              version: coding.version.value,
              display: coding.display.value
            }</code></pre>
      </td>

    </tr>

    <tr>
      <th scope="row" rowspan="2" class="row-header">
        Logic Definition
      </th>

      <td class="content-container"><em>Library Name:</em> FHIRHelpers</td>

    </tr>
    <tr>

      <td>

          <a name="fhirhelpers-todatetime"> </a>

        <pre style="border: none;" class="content-container highlight language-cql"><code class="language-cql">define function ToDateTime(value dateTime): value.value</code></pre>
      </td>

    </tr>

    <tr>
      <th scope="row" rowspan="2" class="row-header">
        Logic Definition
      </th>

      <td class="content-container"><em>Library Name:</em> FHIRHelpers</td>

    </tr>
    <tr>

      <td>

          <a name="fhirhelpers-tostring"> </a>

        <pre style="border: none;" class="content-container highlight language-cql"><code class="language-cql">define function ToString(value MedicationRequestStatus): value.value</code></pre>
      </td>

    </tr>

    <tr>
      <th scope="row" rowspan="2" class="row-header">
        Logic Definition
      </th>

      <td class="content-container"><em>Library Name:</em> FHIRHelpers</td>

    </tr>
    <tr>

      <td>

          <a name="fhirhelpers-tostring"> </a>

        <pre style="border: none;" class="content-container highlight language-cql"><code class="language-cql">define function ToString(value MedicationRequestIntent): value.value</code></pre>
      </td>

    </tr>

      <tr>

    <th colspan="2" scope="row" class="row-header"><a name="terminology"> </a>Terminology</th>

    </tr>

    <tr>

    <th scope="row" class="row-header">Code System</th>

      <td class="content-container">

        <em>Description</em>: Code system ConditionClinicalStatusCodes

        <br/>

        <em>Resource</em>: <a href="http://terminology.hl7.org/6.5.0/CodeSystem-condition-clinical.html">Condition Clinical Status Codes</a>
        <br/>
        <em>Canonical URL</em>: <tt>http://terminology.hl7.org/CodeSystem/condition-clinical</tt>

      </td>
    </tr>

    <tr>

    <th scope="row" class="row-header">Code System</th>

      <td class="content-container">

        <em>Description</em>: Code system ConditionVerificationStatusCodes

        <br/>

        <em>Resource</em>: <a href="http://terminology.hl7.org/6.5.0/CodeSystem-condition-ver-status.html">ConditionVerificationStatus</a>
        <br/>
        <em>Canonical URL</em>: <tt>http://terminology.hl7.org/CodeSystem/condition-ver-status</tt>

      </td>
    </tr>

    <tr>

    <th scope="row" class="row-header">Value Set</th>

      <td class="content-container">

        <em>Description</em>: Value set Ambulatory/ED Visit

        <br/>

        <em>Resource</em>: <a href="https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.464.1003.101.12.1061/expansion">Ambulatory/ED Visit</a>
        <br/>
        <em>Canonical URL</em>: <tt>http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1061</tt>

      </td>
    </tr>

    <tr>

    <th scope="row" class="row-header">Value Set</th>

      <td class="content-container">

        <em>Description</em>: Value set Acute Pharyngitis

        <br/>

        <em>Resource</em>: <a href="https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.464.1003.102.12.1011/expansion">Acute Pharyngitis</a>
        <br/>
        <em>Canonical URL</em>: <tt>http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.102.12.1011</tt>

      </td>
    </tr>

    <tr>

    <th scope="row" class="row-header">Value Set</th>

      <td class="content-container">

        <em>Description</em>: Value set Acute Tonsillitis

        <br/>

        <em>Resource</em>: <a href="https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.464.1003.102.12.1012/expansion">Acute Tonsillitis</a>
        <br/>
        <em>Canonical URL</em>: <tt>http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.102.12.1012</tt>

      </td>
    </tr>

    <tr>

    <th scope="row" class="row-header">Value Set</th>

      <td class="content-container">

        <em>Description</em>: Value set Antibiotic Medications

        <br/>

        <em>Resource</em>: <a href="https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.464.1003.196.12.1001/expansion">Antibiotic Medications for Pharyngitis</a>
        <br/>
        <em>Canonical URL</em>: <tt>http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.196.12.1001</tt>

      </td>
    </tr>

    <tr>

    <th scope="row" class="row-header">Value Set</th>

      <td class="content-container">

        <em>Description</em>: Value set Group A Streptococcus Test

        <br/>

        <em>Resource</em>: <a href="https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.464.1003.198.12.1012/expansion">Group A Streptococcus Test</a>
        <br/>
        <em>Canonical URL</em>: <tt>http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1012</tt>

      </td>
    </tr>

      <tr>
        <th scope="row" class="row-header">Direct Reference Code</th>
        <td class="content-container">

          <em>Code</em>: active
          <br/>
          <em>System</em>: <tt>http://terminology.hl7.org/CodeSystem/condition-clinical</tt>
        </td>
      </tr>

      <tr>
        <th scope="row" class="row-header">Direct Reference Code</th>
        <td class="content-container">

          <em>Code</em>: confirmed
          <br/>
          <em>System</em>: <tt>http://terminology.hl7.org/CodeSystem/condition-ver-status</tt>
        </td>
      </tr>

      <tr>

    <th colspan="2" scope="row" class="row-header"><a name="dependencies"> </a>Dependencies</th>

    </tr>

    <tr>

    <th scope="row" class="row-header">Dependency</th>

      <td class="content-container">

        <em>Description</em>: Library FHIRHelpers

        <br/>

        <em>Resource</em>: <a href="http://hl7.org/fhir/uv/cql/STU2/Library-FHIRHelpers.html">http://hl7.org/fhir/uv/cql/Library/FHIRHelpers|4.0.1</a>
        <br/>
        <em>Canonical URL</em>: <tt>http://hl7.org/fhir/uv/cql/Library/FHIRHelpers|4.0.1</tt>

      </td>
    </tr>

    <tr>

    <th scope="row" class="row-header">Dependency</th>

      <td class="content-container">

        <em>Description</em>: Library Global

        <br/>

        <em>Resource</em>: <a href="Library-MATGlobalCommonFunctions.html">MAT Global Common Functions FHIR Libraryversion: null5.0.000)</a>
        <br/>
        <em>Canonical URL</em>: <tt>http://hl7.org/fhir/uv/cqm/Library/MATGlobalCommonFunctions|5.0.000</tt>

      </td>
    </tr>

    <tr>

    <th scope="row" class="row-header">Dependency</th>

      <td class="content-container">

        <em>Description</em>: Library Common

        <br/>

        <em>Resource</em>: <a href="Library-Common.html">Common Libraryversion: null2.0.0)</a>
        <br/>
        <em>Canonical URL</em>: <tt>http://hl7.org/fhir/uv/cqm/Library/Common|2.0.0</tt>

      </td>
    </tr>

      <tr>

    <th colspan="2" scope="row" class="row-header"><a name="data-requirements"> </a>Data Requirements</th>

    </tr>

    <tr>
      <th scope="row" class="row-header">Data Requirement</th>
      <td class="content-container">
        <em>Type</em>: Patient
        <br/>

        <em>Profile(s)</em>:

        <a href="http://hl7.org/fhir/R4/patient.html">Patient</a>
        <br/>

      </td>
    </tr>

    <tr>
      <th scope="row" class="row-header">Data Requirement</th>
      <td class="content-container">
        <em>Type</em>: Encounter
        <br/>

        <em>Profile(s)</em>:

        <a href="http://hl7.org/fhir/R4/encounter.html">Encounter</a>
        <br/>

        <em>Must Support Elements</em>: type, period, status
        <br/>

        <em>Code Filter(s)</em>:
        <br/>

        <span class="tab-one"><em>Path</em>: type</span>
        <br/>

        <span class="tab-one"><em>ValueSet</em>:</span> <a href="https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.464.1003.101.12.1061/expansion">Ambulatory/ED Visit</a>
        <br/>

      </td>
    </tr>

    <tr>
      <th scope="row" class="row-header">Data Requirement</th>
      <td class="content-container">
        <em>Type</em>: Condition
        <br/>

        <em>Profile(s)</em>:

        <a href="http://hl7.org/fhir/R4/condition.html">Condition</a>
        <br/>

        <em>Must Support Elements</em>: code, clinicalStatus, verificationStatus, onset
        <br/>

        <em>Code Filter(s)</em>:
        <br/>

        <span class="tab-one"><em>Path</em>: code</span>
        <br/>

        <span class="tab-one"><em>ValueSet</em>:</span> <a href="https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.464.1003.102.12.1011/expansion">Acute Pharyngitis</a>
        <br/>

      </td>
    </tr>

    <tr>
      <th scope="row" class="row-header">Data Requirement</th>
      <td class="content-container">
        <em>Type</em>: Condition
        <br/>

        <em>Profile(s)</em>:

        <a href="http://hl7.org/fhir/R4/condition.html">Condition</a>
        <br/>

        <em>Must Support Elements</em>: code, clinicalStatus, verificationStatus, onset
        <br/>

        <em>Code Filter(s)</em>:
        <br/>

        <span class="tab-one"><em>Path</em>: code</span>
        <br/>

        <span class="tab-one"><em>ValueSet</em>:</span> <a href="https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.464.1003.102.12.1012/expansion">Acute Tonsillitis</a>
        <br/>

      </td>
    </tr>

    <tr>
      <th scope="row" class="row-header">Data Requirement</th>
      <td class="content-container">
        <em>Type</em>: MedicationRequest
        <br/>

        <em>Profile(s)</em>:

        <a href="http://hl7.org/fhir/R4/medicationrequest.html">MedicationRequest</a>
        <br/>

        <em>Must Support Elements</em>: medication, status, intent, authoredOn
        <br/>

        <em>Code Filter(s)</em>:
        <br/>

        <span class="tab-one"><em>Path</em>: medication</span>
        <br/>

        <span class="tab-one"><em>ValueSet</em>:</span> <a href="https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.464.1003.196.12.1001/expansion">Antibiotic Medications for Pharyngitis</a>
        <br/>

      </td>
    </tr>

    <tr>
      <th scope="row" class="row-header">Data Requirement</th>
      <td class="content-container">
        <em>Type</em>: Observation
        <br/>

        <em>Profile(s)</em>:

        <a href="http://hl7.org/fhir/R4/observation.html">Observation</a>
        <br/>

        <em>Must Support Elements</em>: code, value, effective
        <br/>

        <em>Code Filter(s)</em>:
        <br/>

        <span class="tab-one"><em>Path</em>: code</span>
        <br/>

        <span class="tab-one"><em>ValueSet</em>:</span> <a href="https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.464.1003.198.12.1012/expansion">Group A Streptococcus Test</a>
        <br/>

      </td>
    </tr>

    <tr>
      <th colspan="2" scope="row" class="row-header">Generated using version 0.4.9 of the sample-content-ig Liquid templates</th>
    </tr>

        </tbody>
      </table>
    </div>
      </text>
      <contained>
        <Library>
          <id value="effective-data-requirements"/>
          <extension
                     url="http://hl7.org/fhir/StructureDefinition/cqf-directReferenceCode">
            <valueCoding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/condition-clinical"/>
              <code value="active"/>
            </valueCoding>
          </extension>
          <extension
                     url="http://hl7.org/fhir/StructureDefinition/cqf-directReferenceCode">
            <valueCoding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/condition-ver-status"/>
              <code value="confirmed"/>
            </valueCoding>
          </extension>
          <extension
                     url="http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition">
            <extension url="libraryName">
              <valueString value="EXM146"/>
            </extension>
            <extension url="name">
              <valueString
                           value="Is Between 2 and 17 Years of Age at Start of Measurement Period"/>
            </extension>
            <extension url="statement">
              <valueString
                           value="define &quot;Is Between 2 and 17 Years of Age at Start of Measurement Period&quot;:
       AgeInYearsAt(start of &quot;Measurement Period&quot;) &gt;= 2
          and AgeInYearsAt(start of &quot;Measurement Period&quot;) &lt;= 17"/>
            </extension>
            <extension url="displaySequence">
              <valueInteger value="0"/>
            </extension>
          </extension>
          <extension
                     url="http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition">
            <extension url="libraryName">
              <valueString value="EXM146"/>
            </extension>
            <extension url="name">
              <valueString value="Measurement Period Encounters"/>
            </extension>
            <extension url="statement">
              <valueString
                           value="define &quot;Measurement Period Encounters&quot;:
       [Encounter: &quot;Ambulatory/ED Visit&quot;] Encounter
          where Encounter.period during &quot;Measurement Period&quot;
            and Encounter.status = 'finished'
            and &quot;Is Between 2 and 17 Years of Age at Start of Measurement Period&quot;"/>
            </extension>
            <extension url="displaySequence">
              <valueInteger value="1"/>
            </extension>
          </extension>
          <extension
                     url="http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition">
            <extension url="libraryName">
              <valueString value="EXM146"/>
            </extension>
            <extension url="name">
              <valueString value="Pharyngitis"/>
            </extension>
            <extension url="statement">
              <valueString
                           value="define &quot;Pharyngitis&quot;:
       ([Condition: code in &quot;Acute Pharyngitis&quot;]
         union [Condition: code in &quot;Acute Tonsillitis&quot;]) Pharyngitis
         where Pharyngitis.clinicalStatus ~ Global.active
           and Pharyngitis.verificationStatus ~ Global.confirmed"/>
            </extension>
            <extension url="displaySequence">
              <valueInteger value="2"/>
            </extension>
          </extension>
          <extension
                     url="http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition">
            <extension url="libraryName">
              <valueString value="EXM146"/>
            </extension>
            <extension url="name">
              <valueString value="Antibiotics"/>
            </extension>
            <extension url="statement">
              <valueString
                           value="define &quot;Antibiotics&quot;:
       [MedicationRequest: medication in &quot;Antibiotic Medications&quot;] Prescription
         where Prescription.status = 'active'
           and Prescription.intent = 'order'"/>
            </extension>
            <extension url="displaySequence">
              <valueInteger value="3"/>
            </extension>
          </extension>
          <extension
                     url="http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition">
            <extension url="libraryName">
              <valueString value="EXM146"/>
            </extension>
            <extension url="name">
              <valueString value="Pharyngitis Encounters With Antibiotics"/>
            </extension>
            <extension url="statement">
              <valueString
                           value="define &quot;Pharyngitis Encounters With Antibiotics&quot;:
       &quot;Measurement Period Encounters&quot; Encounters
          with &quot;Pharyngitis&quot; Pharyngitis such that
             Common.&quot;Includes Or Starts During&quot;(Pharyngitis, Encounters)
          with &quot;Antibiotics&quot; Antibiotics such that Antibiotics.authoredOn
             3 days or less after FHIRHelpers.ToInterval(Encounters.period)"/>
            </extension>
            <extension url="displaySequence">
              <valueInteger value="4"/>
            </extension>
          </extension>
          <extension
                     url="http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition">
            <extension url="libraryName">
              <valueString value="EXM146"/>
            </extension>
            <extension url="name">
              <valueString value="Strep Test Encounters"/>
            </extension>
            <extension url="statement">
              <valueString
                           value="define &quot;Strep Test Encounters&quot;:
       &quot;Pharyngitis Encounters With Antibiotics&quot; Encounters
          with [Observation: code in &quot;Group A Streptococcus Test&quot;] Tests
             such that Tests.value is not null
                and Tests.effective starts during
                   Interval[start of FHIRHelpers.ToInterval(Encounters.period) - 3 days,
                     end of FHIRHelpers.ToInterval(Encounters.period) + 3 days]"/>
            </extension>
            <extension url="displaySequence">
              <valueInteger value="5"/>
            </extension>
          </extension>
          <extension
                     url="http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition">
            <extension url="libraryName">
              <valueString value="EXM146"/>
            </extension>
            <extension url="name">
              <valueString value="Numerator"/>
            </extension>
            <extension url="statement">
              <valueString
                           value="define &quot;Numerator&quot;:
       &quot;Strep Test Encounters&quot;"/>
            </extension>
            <extension url="displaySequence">
              <valueInteger value="6"/>
            </extension>
          </extension>
          <extension
                     url="http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition">
            <extension url="libraryName">
              <valueString value="EXM146"/>
            </extension>
            <extension url="name">
              <valueString value="Initial Population"/>
            </extension>
            <extension url="statement">
              <valueString
                           value="define &quot;Initial Population&quot;:
       &quot;Pharyngitis Encounters With Antibiotics&quot;"/>
            </extension>
            <extension url="displaySequence">
              <valueInteger value="7"/>
            </extension>
          </extension>
          <extension
                     url="http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition">
            <extension url="libraryName">
              <valueString value="EXM146"/>
            </extension>
            <extension url="name">
              <valueString value="Denominator"/>
            </extension>
            <extension url="statement">
              <valueString
                           value="define &quot;Denominator&quot;:
       &quot;Initial Population&quot;"/>
            </extension>
            <extension url="displaySequence">
              <valueInteger value="8"/>
            </extension>
          </extension>
          <extension
                     url="http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition">
            <extension url="libraryName">
              <valueString value="EXM146"/>
            </extension>
            <extension url="name">
              <valueString value="Pharyngitis With Prior Antibiotics"/>
            </extension>
            <extension url="statement">
              <valueString
                           value="define &quot;Pharyngitis With Prior Antibiotics&quot;:
       &quot;Pharyngitis&quot; Pharyngitis
          with &quot;Antibiotics&quot; Antibiotics such that
             Antibiotics.authoredOn 30 days or less before Pharyngitis.onset"/>
            </extension>
            <extension url="displaySequence">
              <valueInteger value="9"/>
            </extension>
          </extension>
          <extension
                     url="http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition">
            <extension url="libraryName">
              <valueString value="EXM146"/>
            </extension>
            <extension url="name">
              <valueString value="Excluded Encounters"/>
            </extension>
            <extension url="statement">
              <valueString
                           value="define &quot;Excluded Encounters&quot;:
       &quot;Pharyngitis Encounters With Antibiotics&quot; Encounters
          with &quot;Pharyngitis With Prior Antibiotics&quot; Pharyngitis such that
             Common.&quot;Includes Or Starts During&quot;(Pharyngitis, Encounters)"/>
            </extension>
            <extension url="displaySequence">
              <valueInteger value="10"/>
            </extension>
          </extension>
          <extension
                     url="http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition">
            <extension url="libraryName">
              <valueString value="EXM146"/>
            </extension>
            <extension url="name">
              <valueString value="Denominator Exclusions"/>
            </extension>
            <extension url="statement">
              <valueString
                           value="define &quot;Denominator Exclusions&quot;:
      &quot;Excluded Encounters&quot;"/>
            </extension>
            <extension url="displaySequence">
              <valueInteger value="11"/>
            </extension>
          </extension>
          <extension
                     url="http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition">
            <extension url="libraryName">
              <valueString value="FHIRHelpers"/>
            </extension>
            <extension url="name">
              <valueString value="ToInterval"/>
            </extension>
            <extension url="statement">
              <valueString
                           value="/*
    @description: Converts the given [Period](https://hl7.org/fhir/datatypes.html#Period)
    value to a CQL DateTime Interval
    @comment: If the start value of the given period is unspecified, the starting
    boundary of the resulting interval will be open (meaning the start of the interval
    is unknown, as opposed to interpreted as the beginning of time).
    */
    define function ToInterval(period FHIR.Period):
        if period is null then
            null
        else
            if period.&quot;start&quot; is null then
                Interval(period.&quot;start&quot;.value, period.&quot;end&quot;.value]
            else
                Interval[period.&quot;start&quot;.value, period.&quot;end&quot;.value]"/>
            </extension>
            <extension url="displaySequence">
              <valueInteger value="12"/>
            </extension>
          </extension>
          <extension
                     url="http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition">
            <extension url="libraryName">
              <valueString value="FHIRHelpers"/>
            </extension>
            <extension url="name">
              <valueString value="ToString"/>
            </extension>
            <extension url="statement">
              <valueString
                           value="define function ToString(value EncounterStatus): value.value"/>
            </extension>
            <extension url="displaySequence">
              <valueInteger value="13"/>
            </extension>
          </extension>
          <extension
                     url="http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition">
            <extension url="libraryName">
              <valueString value="FHIRHelpers"/>
            </extension>
            <extension url="name">
              <valueString value="ToConcept"/>
            </extension>
            <extension url="statement">
              <valueString
                           value="/*
    @description: Converts the given FHIR [CodeableConcept](https://hl7.org/fhir/datatypes.html#CodeableConcept) value to a CQL Concept.
    */
    define function ToConcept(concept FHIR.CodeableConcept):
        if concept is null then
            null
        else
            System.Concept {
                codes: concept.coding C return ToCode(C),
                display: concept.text.value
            }"/>
            </extension>
            <extension url="displaySequence">
              <valueInteger value="14"/>
            </extension>
          </extension>
          <extension
                     url="http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition">
            <extension url="libraryName">
              <valueString value="FHIRHelpers"/>
            </extension>
            <extension url="name">
              <valueString value="ToCode"/>
            </extension>
            <extension url="statement">
              <valueString
                           value="/*
    @description: Converts the given FHIR [Coding](https://hl7.org/fhir/datatypes.html#Coding) value to a CQL Code.
    */
    define function ToCode(coding FHIR.Coding):
        if coding is null then
            null
        else
            System.Code {
              code: coding.code.value,
              system: coding.system.value,
              version: coding.version.value,
              display: coding.display.value
            }"/>
            </extension>
            <extension url="displaySequence">
              <valueInteger value="15"/>
            </extension>
          </extension>
          <extension
                     url="http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition">
            <extension url="libraryName">
              <valueString value="Common"/>
            </extension>
            <extension url="name">
              <valueString value="Includes Or Starts During"/>
            </extension>
            <extension url="statement">
              <valueString
                           value="define function
       &quot;Includes Or Starts During&quot;(Condition Condition, Encounter Encounter):
          Interval[Condition.onset, Condition.abatement] includes Encounter.period
             or Condition.onset during Encounter.period"/>
            </extension>
            <extension url="displaySequence">
              <valueInteger value="16"/>
            </extension>
          </extension>
          <extension
                     url="http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition">
            <extension url="libraryName">
              <valueString value="FHIRHelpers"/>
            </extension>
            <extension url="name">
              <valueString value="ToDateTime"/>
            </extension>
            <extension url="statement">
              <valueString
                           value="define function ToDateTime(value dateTime): value.value"/>
            </extension>
            <extension url="displaySequence">
              <valueInteger value="17"/>
            </extension>
          </extension>
          <extension
                     url="http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition">
            <extension url="libraryName">
              <valueString value="FHIRHelpers"/>
            </extension>
            <extension url="name">
              <valueString value="ToString"/>
            </extension>
            <extension url="statement">
              <valueString
                           value="define function ToString(value MedicationRequestStatus): value.value"/>
            </extension>
            <extension url="displaySequence">
              <valueInteger value="18"/>
            </extension>
          </extension>
          <extension
                     url="http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition">
            <extension url="libraryName">
              <valueString value="FHIRHelpers"/>
            </extension>
            <extension url="name">
              <valueString value="ToString"/>
            </extension>
            <extension url="statement">
              <valueString
                           value="define function ToString(value MedicationRequestIntent): value.value"/>
            </extension>
            <extension url="displaySequence">
              <valueInteger value="19"/>
            </extension>
          </extension>
          <name value="EffectiveDataRequirements"/>
          <status value="active"/>
          <type>
            <coding>
              <system value="http://terminology.hl7.org/CodeSystem/library-type"/>
              <code value="module-definition"/>
            </coding>
          </type>
          <relatedArtifact>
            <type value="depends-on"/>
            <display value="Library FHIRHelpers"/>
            <resource
                      value="http://hl7.org/fhir/uv/cql/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 Common"/>
            <resource value="http://hl7.org/fhir/uv/cqm/Library/Common|2.0.0"/>
          </relatedArtifact>
          <relatedArtifact>
            <type value="depends-on"/>
            <display value="Code system ConditionClinicalStatusCodes"/>
            <resource
                      value="http://terminology.hl7.org/CodeSystem/condition-clinical"/>
          </relatedArtifact>
          <relatedArtifact>
            <type value="depends-on"/>
            <display value="Code system ConditionVerificationStatusCodes"/>
            <resource
                      value="http://terminology.hl7.org/CodeSystem/condition-ver-status"/>
          </relatedArtifact>
          <relatedArtifact>
            <type value="depends-on"/>
            <display value="Value set Ambulatory/ED Visit"/>
            <resource
                      value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1061"/>
          </relatedArtifact>
          <relatedArtifact>
            <type value="depends-on"/>
            <display value="Value set Acute Pharyngitis"/>
            <resource
                      value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.102.12.1011"/>
          </relatedArtifact>
          <relatedArtifact>
            <type value="depends-on"/>
            <display value="Value set Acute Tonsillitis"/>
            <resource
                      value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.102.12.1012"/>
          </relatedArtifact>
          <relatedArtifact>
            <type value="depends-on"/>
            <display value="Value set Antibiotic Medications"/>
            <resource
                      value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.196.12.1001"/>
          </relatedArtifact>
          <relatedArtifact>
            <type value="depends-on"/>
            <display value="Value set Group A Streptococcus Test"/>
            <resource
                      value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1012"/>
          </relatedArtifact>
          <parameter>
            <name value="Measurement Period"/>
            <use value="in"/>
            <min value="0"/>
            <max value="1"/>
            <type value="Period"/>
          </parameter>
          <parameter>
            <name value="Numerator"/>
            <use value="out"/>
            <min value="0"/>
            <max value="*"/>
            <type value="Encounter"/>
          </parameter>
          <parameter>
            <name value="Denominator"/>
            <use value="out"/>
            <min value="0"/>
            <max value="*"/>
            <type value="Encounter"/>
          </parameter>
          <parameter>
            <name value="Initial Population"/>
            <use value="out"/>
            <min value="0"/>
            <max value="*"/>
            <type value="Encounter"/>
          </parameter>
          <parameter>
            <name value="Denominator Exclusions"/>
            <use value="out"/>
            <min value="0"/>
            <max value="*"/>
            <type value="Encounter"/>
          </parameter>
          <dataRequirement>
            <type value="Patient"/>
            <profile value="http://hl7.org/fhir/StructureDefinition/Patient"/>
          </dataRequirement>
          <dataRequirement>
            <type value="Encounter"/>
            <profile value="http://hl7.org/fhir/StructureDefinition/Encounter"/>
            <mustSupport value="type"/>
            <mustSupport value="period"/>
            <mustSupport value="status"/>
            <codeFilter>
              <path value="type"/>
              <valueSet
                        value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1061"/>
            </codeFilter>
          </dataRequirement>
          <dataRequirement>
            <type value="Condition"/>
            <profile value="http://hl7.org/fhir/StructureDefinition/Condition"/>
            <mustSupport value="code"/>
            <mustSupport value="clinicalStatus"/>
            <mustSupport value="verificationStatus"/>
            <mustSupport value="onset"/>
            <codeFilter>
              <path value="code"/>
              <valueSet
                        value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.102.12.1011"/>
            </codeFilter>
          </dataRequirement>
          <dataRequirement>
            <type value="Condition"/>
            <profile value="http://hl7.org/fhir/StructureDefinition/Condition"/>
            <mustSupport value="code"/>
            <mustSupport value="clinicalStatus"/>
            <mustSupport value="verificationStatus"/>
            <mustSupport value="onset"/>
            <codeFilter>
              <path value="code"/>
              <valueSet
                        value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.102.12.1012"/>
            </codeFilter>
          </dataRequirement>
          <dataRequirement>
            <type value="MedicationRequest"/>
            <profile
                     value="http://hl7.org/fhir/StructureDefinition/MedicationRequest"/>
            <mustSupport value="medication"/>
            <mustSupport value="status"/>
            <mustSupport value="intent"/>
            <mustSupport value="authoredOn"/>
            <codeFilter>
              <path value="medication"/>
              <valueSet
                        value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.196.12.1001"/>
            </codeFilter>
          </dataRequirement>
          <dataRequirement>
            <type value="Observation"/>
            <profile value="http://hl7.org/fhir/StructureDefinition/Observation"/>
            <mustSupport value="code"/>
            <mustSupport value="value"/>
            <mustSupport value="effective"/>
            <codeFilter>
              <path value="code"/>
              <valueSet
                        value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1012"/>
            </codeFilter>
          </dataRequirement>
        </Library>
      </contained>
      <extension
                 url="http://hl7.org/fhir/uv/cqm/StructureDefinition/cqm-populationBasis">
        <valueCode value="Encounter"/>
      </extension>
      <extension
                 url="http://hl7.org/fhir/uv/crmi/StructureDefinition/crmi-softwaresystem">
        <valueReference>🔗
          <reference value="Device/software-system-example"/>
        </valueReference>
      </extension>
      <extension
                 url="http://hl7.org/fhir/uv/crmi/StructureDefinition/crmi-effectiveDataRequirements" id="effective-data-requirements">
        <valueCanonical value="#effective-data-requirements"/>
      </extension>
      <url value="http://hl7.org/fhir/uv/cqm/Measure/EXM146-FHIR"/>
      <identifier>
        <use value="official"/>
        <system value="http://example.org/fhir/cqi/ecqm/Measure/Identifier/exm"/>
        <value value="146"/>
      </identifier>
      <identifier>
        <system value="urn:ietf:rfc:3986"/>
        <value value="urn:oid:2.16.840.1.113883.4.642.40.61.29.7"/>
      </identifier>
      <version value="4.0.0"/>
      <name value="EXM146"/>
      <title value="EXM146 - Appropriate Testing for Children with Pharyngitis"/>
      <status value="active"/>
      <experimental value="true"/>
      <date value="2025-08-13"/>
      <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 children 2-18 years of age who were diagnosed with pharyngitis, ordered an antibiotic and received a group A streptococcus (strep) test for the episode."/>
      <useContext>
        <code>
          <system
                  value="http://terminology.hl7.org/CodeSystem/usage-context-type"/>
          <code value="venue"/>
          <display value="Clinical 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."/>
      <copyright
                 value="Physician Performance Measure (Measures) and related data specifications were developed by the National Committee for Quality Assurance (NCQA).
    The Measures are copyrighted but can be reproduced and distributed, without modification, for noncommercial purposes (eg, use by healthcare providers in connection with their practices). Commercial use is defined as the sale, licensing, or distribution of the Measures for commercial gain, or incorporation of the Measures into a product or service that is sold, licensed or distributed for commercial gain. Commercial use of the Measures requires a license agreement between the user and NCQA. NCQA is not responsible for any use of the Measures.
    (c) 2008 -2014 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 2004-2013 American Medical Association. LOINC(R) copyright 2004-2013 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2013 International Health Terminology Standards Development Organisation. ICD-10 copyright 2013 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/EXM146"/>
      <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 &quot;AS IS&quot; 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="Group A streptococcal bacterial infections and other infections that cause pharyngitis (which are most often viral) often produce the same signs and symptoms (IDSA 2002). The American Academy of Pediatrics, the Centers for Disease Control and Prevention, and the Infectious Diseases Society of America all recommend a diagnostic test for Strep A to improve diagnostic accuracy and avoid unnecessary antibiotic treatment (Linder et al. 2005).  A study on antibiotic treatment of children with sore throat found that although only 15 to 36 percent of children with sore throat have Strep A pharyngitis, physicians prescribed antibiotics to 53 percent of children with a chief complaint of sore throat between 1995 and 2003 (Linder et al. 2005)."/>
      <clinicalRecommendationStatement
                                       value="Institute for Clinical Systems Improvement (ICSI) (2007)
     Reduce unnecessary use of antibiotics. Antibiotic treatment should be reserved for a bacterial illness. Diagnosis of group A beta streptococcal Pharyngitis should be made by laboratory testing rather than clinically.
    Infectious Disease Society of America (Bisno et al. 2002)
    The signs and symptoms of group A streptococcal and other (most frequently viral) pharyngitides overlap broadly. Therefore, unless the physician is able with confidence to exclude the diagnosis of streptococcal pharyngitis on epidemiological and clinical grounds alone, a laboratory test should be done to determine whether group A streptococci are present in the pharynx.
    With the exception of very rare infections by certain other pharyngeal bacterial pathogens (eg, Corynebacterium diphtheriae and Neisseria gonorrhoeae), antimicrobial therapy is of no proven benefit as treatment for acute pharyngitis due to bacteria other than group A streptococci. Therefore, it is extremely important that physicians exclude the diagnosis of group A streptococcal pharyngitis to prevent inappropriate administration of antimicrobials to large numbers of patients with pharyngitis.
    Michigan Quality Improvement Consortium (2007)
    Probability of group A beta hemolytic streptococci (GABHS): Low; Testing: None; Treatment: Symptomatic treatment only. Avoid antibiotics. Probability of GABHS: Intermediate or High; Testing: Throat Culture (TC) OR Rapid Screen; Treatment: If TC is positive, use antibiotics. If TC is negative, use symptomatic treatment only. Avoid antibiotics. If treatment is started and culture result is negative, stop antibiotics. If Rapid Screen is positive, use antibiotics. If Rapid Screen is negative, culture (Culture is optional for age 16 and over) and only use antibiotics if throat culture is positive. (Michigan, 2007)"/>
      <improvementNotation>
        <coding>
          <system
                  value="http://terminology.hl7.org/CodeSystem/measure-improvement-notation"/>
          <code value="increase"/>
          <display value="Increased score indicates improvement"/>
        </coding>
      </improvementNotation>
      <guidance
                value="This is an episode of care measure that examines all eligible episodes for the patient during the measurement period. If the patient has more than one episode, include all episodes in the measure."/>
      <group id="group-1">
        <extension
                   url="http://hl7.org/fhir/5.0/StructureDefinition/extension-Measure.group.linkId">
          <valueString value="primary"/>
        </extension>
        <population>
          <extension
                     url="http://hl7.org/fhir/5.0/StructureDefinition/extension-Measure.group.population.linkId">
            <valueString value="primary-exm146-initial-population"/>
          </extension>
          <code>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/measure-population"/>
              <code value="initial-population"/>
              <display value="Initial Population"/>
            </coding>
          </code>
          <criteria>
            <language value="text/cql-identifier"/>
            <expression value="Initial Population"/>
          </criteria>
        </population>
        <population>
          <extension
                     url="http://hl7.org/fhir/5.0/StructureDefinition/extension-Measure.group.population.linkId">
            <valueString value="primary-exm146-numerator"/>
          </extension>
          <code>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/measure-population"/>
              <code value="numerator"/>
              <display value="Numerator"/>
            </coding>
          </code>
          <criteria>
            <language value="text/cql-identifier"/>
            <expression value="Numerator"/>
          </criteria>
        </population>
        <population>
          <extension
                     url="http://hl7.org/fhir/5.0/StructureDefinition/extension-Measure.group.population.linkId">
            <valueString value="primary-exm146-denominator"/>
          </extension>
          <code>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/measure-population"/>
              <code value="denominator"/>
              <display value="Denominator"/>
            </coding>
          </code>
          <criteria>
            <language value="text/cql-identifier"/>
            <expression value="Denominator"/>
          </criteria>
        </population>
        <population>
          <extension
                     url="http://hl7.org/fhir/5.0/StructureDefinition/extension-Measure.group.population.linkId">
            <valueString value="primary-exm146-denominator-exclusion"/>
          </extension>
          <code>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/measure-population"/>
              <code value="denominator-exclusion"/>
              <display value="Denominator Exclusion"/>
            </coding>
          </code>
          <criteria>
            <language value="text/cql-identifier"/>
            <expression value="Denominator Exclusions"/>
          </criteria>
        </population>
      </group>
    </Measure>