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: Breast Cancer Screening

Id: measure-exm125-FHIR
Url: http://hl7.org/fhir/us/cqfmeasures/Measure/measure-exm125-FHIR
Version: 8.0.000
Identifier:

value: 146

Identifier:

value: 0002

Name: EXM125
Title: Breast Cancer Screening
Status: active
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

display: Increased score indicates improvement

Type:

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

code: process

Date: 2021-04-03
Publisher: Clinical Quality Information WG
Description: Percentage of women 50-74 years of age who had a mammogram to screen for breast cancer
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 Exclusion out 0 1 boolean
Has Hospice out 0 1 boolean
Unilateral Mastectomy Procedure out 0 * Procedure
Right Mastectomy out 0 * Condition
Left Mastectomy out 0 * Condition
History Bilateral Mastectomy out 0 * Condition
Bilateral Mastectomy Procedure out 0 * Procedure
SDE Race out 0 * Coding
Data Requirements:
typepathvalueSet or systemcode
DiagnosticReport code http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.108.12.1018
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
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
Procedure code http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1020
Condition code http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1070
Condition code http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1071
Condition code http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1069
Condition code http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1071
Condition code http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1068
Procedure code http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1005
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
active
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
Use Context:
codevalue
program
Jurisdiction: US
Topic: 57024-2
Purpose: Women 51-74 years of age with a visit during the measurement period
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.
Approval Date: 2016-01-01
Last Review Date: 2016-09-01
Effective Period: 2018-01-01..2018-12-31
Related Artifacts:

Dependencies

  • http://hl7.org/fhir/us/cqfmeasures/Library/SupplementalDataElements|2.0.000
  • 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/AdultOutpatientEncounters|2.0.000
  • 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://terminology.hl7.org/CodeSystem/condition-clinical
  • 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
Logic Definitions:
Library NameNamesequence
EXM125 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
EXM125 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 NameNamesequence
EXM125 Denominator
define "Denominator":
		"Initial Population"


Library NameNamesequence
EXM125 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 NameNamesequence
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 NameNamesequence
EXM125 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
EXM125 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 NameNamesequence
EXM125 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
EXM125 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 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
EXM125 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 NameNamesequence
EXM125 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 NameNamesequence
EXM125 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 NameNamesequence
EXM125 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 NameNamesequence
EXM125 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 NameNamesequence
EXM125 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