Quality Measure Implementation Guide (STU3 Ballot)
2.1.0 - ballot

This page is part of the Quality Measure STU2 for FHIR R4 Implementation Guide (v2.1.0: STU3 Ballot 1) based on FHIR R4. The current version which supercedes this version is 3.0.0. For a full list of available versions, see the Directory of published versions

Example Measure: Pneumococcal Vaccination Status for Older Adults

Id: PVSComponent
Url: http://hl7.org/fhir/us/cqfmeasures/Measure/PVSComponent
Version: 0.0.001
Name: PVSComponent
Title: Pneumococcal Vaccination Status for Older Adults
Status: draft
Experimental: true
Scoring:

system: http://terminology.hl7.org/CodeSystem/measure-scoring

code: proportion

display: Proportion

Improvement Notation:

system: http://terminology.hl7.org/CodeSystem/measure-improvement-notation

code: increase

Type:

system: http://terminology.hl7.org/CodeSystem/measure-type

code: process

Date: 2021-04-03T13:00:06-06:00
Publisher: Clinical Quality Information WG
Description: This is an example only.
Parameters:
nameuseminmaxtype
Measurement Period in 0 1 Period
SDE Sex out 0 1 Coding
Numerator out 0 1 boolean
Denominator out 0 1 boolean
Initial Population out 0 1 boolean
Patient out 0 1 Patient
Qualifying Encounters out 0 * Encounter
SDE Payer out 0 * Any
SDE Ethnicity out 0 * Coding
Denominator Exclusions out 0 1 boolean
Has Hospice out 0 1 boolean
SDE Race out 0 * Coding
Data Requirements:
typepathvalueSet or systemcode
Immunization vaccineCode http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.110.12.1027
Procedure code http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.110.12.1034
Patient
Encounter type http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1001
Encounter type http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.526.3.1240
Encounter type http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1025
Encounter type http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1023
Encounter type http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1016
Encounter type http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.11.1065
Encounter type http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1012
Encounter type http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1014
Coverage type http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591
Patient
Encounter type http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.666.5.307
ServiceRequest code http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1108.15
Procedure code http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1108.15
Direct Reference Codes:
displaycodesystem
Discharge to home for hospice care (procedure) 428361000124107 http://snomed.info/sct/731000124108/version/201709
Discharge to healthcare facility for hospice care (procedure) 428371000124100 http://snomed.info/sct/731000124108/version/201709
Supplemental Data:
expressionsystem
SDE Ethnicity http://terminology.hl7.org/CodeSystem/measure-data-usage
SDE Payer http://terminology.hl7.org/CodeSystem/measure-data-usage
SDE Race http://terminology.hl7.org/CodeSystem/measure-data-usage
SDE Sex http://terminology.hl7.org/CodeSystem/measure-data-usage
Jurisdiction: US
Effective Period: 2022-01-01..2022-12-31
Related Artifacts:

Dependencies

  • http://hl7.org/fhir/us/cqfmeasures/Library/SupplementalDataElements|2.0.000
  • http://fhir.org/guides/cqf/common/Library/FHIRHelpers|4.0.1
  • http://hl7.org/fhir/us/cqfmeasures/Library/MATGlobalCommonFunctions|5.0.000
  • http://fhir.org/guides/cqf/common/Library/FHIRHelpers|4.0.1
  • http://hl7.org/fhir/us/cqfmeasures/Library/Hospice|2.0.000
  • http://fhir.org/guides/cqf/common/Library/FHIRHelpers|4.0.1
  • http://hl7.org/fhir/us/cqfmeasures/Library/MATGlobalCommonFunctions|5.0.000
  • http://snomed.info/sct|http://snomed.info/sct/731000124108/version/201709
  • http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.110.12.1027
  • http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.110.12.1034
  • 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/2.16.840.1.113883.3.464.1003.101.11.1065
  • http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1012
  • http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1014
  • 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
Logic Definitions:
Library NameNamesequence
PVSComponent SDE Sex
define "SDE Sex":
  SDE."SDE Sex"


Library NameNamesequence
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 NameNamesequence
PVSComponent Numerator
define "Numerator":
  exists ( [Immunization: "Pneumococcal Vaccine"] PneumococcalVaccine
        where PneumococcalVaccine.status = 'completed'
          and PneumococcalVaccine.occurrence as dateTime on or before
          end of "Measurement Period"
    )
      or exists ( [Procedure: "Pneumococcal Vaccine Administered"] PneumococcalVaccineGiven
          where PneumococcalVaccineGiven.status = 'completed'
            and PneumococcalVaccineGiven.performed as Period on or before
            end of "Measurement Period"
      )


Library NameNamesequence
PVSComponent Denominator
define "Denominator":
  "Initial Population"


Library NameNamesequence
PVSComponent Initial Population
define "Initial Population":
  Global."CalendarAgeInYearsAt" ( FHIRHelpers.ToDate ( Patient.birthDate ), start of "Measurement Period" ) >= 65
      and exists "Qualifying Encounters"


Library NameNamesequence
PVSComponent 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"]
      union [Encounter: "Discharge Services - Nursing Facility"]
      union [Encounter: "Nursing Facility Visit"]
      union [Encounter: "Care Services in Long-Term Residential Facility"] ) ValidEncounter
      where ValidEncounter.period during "Measurement Period"
        and ValidEncounter.status = 'finished'


Library NameNamesequence
PVSComponent SDE Payer
define "SDE Payer":
  SDE."SDE Payer"


Library NameNamesequence
SupplementalDataElements SDE Payer
define "SDE Payer":
  [Coverage: type in "Payer"] Payer
        return {
          code: Payer.type,
          period: Payer.period
        }


Library NameNamesequence
PVSComponent Initial Population
define "Initial Population":
  Global."CalendarAgeInYearsAt" ( FHIRHelpers.ToDate ( Patient.birthDate ), start of "Measurement Period" ) >= 65
      and exists "Qualifying Encounters"


Library NameNamesequence
PVSComponent SDE Ethnicity
define "SDE Ethnicity":
  SDE."SDE Ethnicity"


Library NameNamesequence
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 NameNamesequence
PVSComponent Denominator Exclusions
define "Denominator Exclusions":
  Hospice."Has Hospice"


Library NameNamesequence
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 NameNamesequence
PVSComponent SDE Race
define "SDE Race":
  SDE."SDE Race"


Library NameNamesequence
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