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: Colorectal Cancer Screening

Id: measure-exm130-FHIR
Url: http://hl7.org/fhir/us/cqfmeasures/Measure/measure-exm130-FHIR
Version: 8.0.000
Identifier:

value: 130

Identifier:

value: 0034

Name: EXM130
Title: Colorectal 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 adults 50-75 years of age who had appropriate screening for colorectal cancer
Parameters:
nameuseminmaxtype
Measurement Period in 0 1 Period
SDE Sex out 0 1 Coding
Numerator out 0 1 boolean
Colonoscopy Performed out 0 * Procedure
Fecal Occult Blood Test Performed out 0 * Observation
Flexible Sigmoidoscopy Performed out 0 * Procedure
Fecal Immunochemical Test DNA out 0 * Observation
CT Colonography Performed out 0 * Procedure
Denominator out 0 1 boolean
SDE Payer out 0 * Any
Initial Population out 0 1 boolean
Patient out 0 1 Patient
Qualifying Encounters out 0 * Encounter
SDE Ethnicity out 0 * Coding
Denominator Exclusion out 0 1 boolean
Has Hospice out 0 1 boolean
Malignant Neoplasm Ever out 0 * Condition
Total Colectomy Performed out 0 * Procedure
SDE Race out 0 * Coding
Data Requirements:
typepathvalueSet or systemcode
Procedure code http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.108.12.1020
Observation code http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1011
Procedure code http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1010
Observation code http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.108.12.1039
Procedure code http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.108.12.1038
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/2.16.840.1.113883.3.464.1003.101.12.1001
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
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
Condition code http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.108.12.1001
Procedure code http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1019
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
Use Context:
codevalue
program
Jurisdiction: US
Topic: 57024-2
Purpose: Patients 50-75 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). NCQA is not responsible for any use of the Measure. NCQA makes no representations, warranties, or endorsement about the quality of any organization or physician that uses or reports performance measures and NCQA has no liability to anyone who relies on such measures or specifications. NCQA holds a copyright in the Measure. The Measure can be reproduced and distributed, without modification, for noncommercial purposes (eg, use by healthcare providers in connection with their practices) without obtaining approval from NCQA. Commercial use is defined as the sale, licensing, or distribution of the Measure for commercial gain, or incorporation of the Measure into a product or service that is sold, licensed or distributed for commercial gain. All commercial uses or requests for modification must be approved by NCQA and are subject to a license at the discretion of NCQA. (C) 2012-2017 National Committee for Quality Assurance. All Rights Reserved. Limited proprietary coding is contained in the Measure specifications for user convenience. Users of proprietary code sets should obtain all necessary licenses from the owners of the code sets. NCQA disclaims all liability for use or accuracy of any third party codes contained in the specifications. CPT(R) contained in the Measure specifications is copyright 2004-2017 American Medical Association. LOINC(R) copyright 2004-2017 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R] ) copyright 2004-2017 International Health Terminology Standards Development Organisation. ICD-10 copyright 2017 World Health Organization. All Rights Reserved.
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. Due to technical limitations, registered trademarks are indicated by (R) or [R] and unregistered trademarks are indicated by (TM) or [TM].
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://fhir.org/guides/cqf/common/Library/FHIRHelpers|4.0.1
  • http://hl7.org/fhir/us/cqfmeasures/Library/MATGlobalCommonFunctions|5.0.000
  • 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://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.108.12.1020
  • http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1011
  • http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1010
  • http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.108.12.1039
  • http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.108.12.1038
  • http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591
  • http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1001
  • 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/2.16.840.1.113883.3.666.5.307
  • http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1108.15
  • http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.108.12.1001
  • http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1019
Logic Definitions:
Library NameNamesequence
EXM130 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
EXM130 Numerator
define "Numerator":
	exists "Colonoscopy Performed"
		or exists "Fecal Occult Blood Test Performed"
		or exists "Flexible Sigmoidoscopy Performed"
		or exists "Fecal Immunochemical Test DNA"
		or exists "CT Colonography Performed"


Library NameNamesequence
EXM130 Colonoscopy Performed
define "Colonoscopy Performed":
	[Procedure: "Colonoscopy"] Colonoscopy
		where Colonoscopy.status = 'completed'
		  and Global."Normalize Interval"(Colonoscopy.performed) ends 10 years or less on or before end of "Measurement Period"


Library NameNamesequence
EXM130 Fecal Occult Blood Test Performed
define "Fecal Occult Blood Test Performed":
	[Observation: "Fecal Occult Blood Test (FOBT)"] FecalOccultResult
		where FecalOccultResult.status in {'final', 'amended', 'corrected', 'preliminary'}
			and FecalOccultResult.value is not null
			and Global."Normalize Interval"(FecalOccultResult.effective) during day of "Measurement Period"


Library NameNamesequence
EXM130 Flexible Sigmoidoscopy Performed
define "Flexible Sigmoidoscopy Performed":
	[Procedure: "Flexible Sigmoidoscopy"] FlexibleSigmoidoscopy
		where FlexibleSigmoidoscopy.status = 'completed'
			and Global."Normalize Interval"(FlexibleSigmoidoscopy.performed) ends 5 years or less on or before end of "Measurement Period"


Library NameNamesequence
EXM130 Fecal Immunochemical Test DNA
define "Fecal Immunochemical Test DNA":
	[Observation: "FIT DNA"] FitDNA
		where FitDNA.status in {'final', 'amended', 'corrected', 'preliminary'}
			and FitDNA.value is not null
			and Global."Normalize Interval"(FitDNA.effective) occurs 3 years or less on or before day of end of "Measurement Period"


Library NameNamesequence
EXM130 CT Colonography Performed
define "CT Colonography Performed":
	[Procedure: "CT Colonography"] Colonography
		where Colonography.status = 'completed'
			and Global."Normalize Interval"(Colonography.performed) ends 5 years or less on or before end of "Measurement Period"


Library NameNamesequence
EXM130 Denominator
define "Denominator":
	true


Library NameNamesequence
EXM130 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
EXM130 Initial Population
define "Initial Population":
	Global."CalendarAgeInYearsAt"(FHIRHelpers.ToDate(Patient.birthDate), start of "Measurement Period") in Interval[50, 75]
			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
EXM130 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
EXM130 Denominator Exclusion
define "Denominator Exclusion":
	Hospice."Has Hospice"
		or exists "Malignant Neoplasm Ever"
		or exists "Total Colectomy Performed"


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
EXM130 Malignant Neoplasm Ever
define "Malignant Neoplasm Ever":
	[Condition: "Malignant Neoplasm of Colon"] ColorectalCancer
		where Global."Normalize Interval"(ColorectalCancer.onset) starts on or before end of "Measurement Period"


Library NameNamesequence
EXM130 Total Colectomy Performed
define "Total Colectomy Performed":
	[Procedure: "Total Colectomy"] Colectomy
		where Colectomy.status = 'completed'
			and Global."Normalize Interval"(Colectomy.performed) starts on or before end of "Measurement Period"


Library NameNamesequence
EXM130 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