Quality Measure Implementation Guide (STU3 Ballot)
2.1.0 - ballot
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 
This page describes documents the use cases and conformance expectations of a terminology service to support authoring, distribution, and evaluation of FHIR-based quality measure specifications as described in this implementation guide.
This implementation guide is not advocating for any particular central authority for terminology content, rather the intent is to propose a capability statement that enables publishers to build consistent and interoperable terminology services that support authoring, distribution, and evaluation of FHIR-based knowledge artifacts.
This implementation guide is not prescriptive about authentication or authorization, but strongly recommends that these capabilities be addressed through standard mechanisms, as described in FHIR standard security mechanisms.
Beyond the basic required use cases of searching, retrieving, and expanding value sets, applications that reference value sets that are defined in terms of code systems from different authorities and with different publishing timelines face common challenges related to stable expansion of those value sets. To address that general problem, this implementation guide proposes a manifest that allows the dependencies for a collection of artifacts to be bound to specific versions, enumerated as part of the manifest, rather than requiring the artifacts to be constructed with versioned references. This approach is captured in the CQFMQualityProgram profile, and is designed around two central use cases:
The first use case is used while the collection of related artifacts is being authored. During this period, the set of code system versions that will be used by value sets referenced by the artifacts is selected and identified in a quality program version manifest (sometimes referred to as an “expansion profile” because it provides expansion rules for expanding value sets used by the artifacts). When authoring value sets and the artifacts that make use of them, this version manifest can be used to ensure stable expansions. Note that this definition will often evolve over the course of the development of collection of artifacts. Quality programs in this state are indicated with a status of draft.
The second use case applies when a release of the artifact collection is established, and the content is effectively locked to a particular set of code system versions, value set definition versions and in some cases expansion versions. The same profile is used, but quality programs in this state are indicated with a status of active. To support this use case, in addition to the code system version rules introduced by the manifest, a release may also provide an expansionUri, either at the root of the quality program (if all the value sets use the same expansion identifier), or per value set by providing an expansionUri on the relatedArtifact. The expansionUri capability may also be used selectively to override expansions for specific value sets, with the behavior falling back to the manifest’s expansion calculation rules if no expansionUri is specified for the value set.
To support organization of version manifests and releases, the Quality Program profile can also be used to define quality programs that contain multiple manifests and releases over multiple years. This usage is represented by an overall Quality Program that then contains multiple “component-of” version manifests and releases. In addition, each version manifest or release indicates that it is “part-of” the Quality Program overall.
SHALL Represent basic CodeSystem information, as specified by the ShareableCodeSystem profile, which includes url, version, name, status, experimental, publisher, description, caseSensitive, content, and concept.
For published CodeSystems, SHALL represent publishable CodeSystem information, as specified by the CQFMPublishableCodeSystem profile.
SHALL support CodeSystem read by the server-defined id for the CodeSystem
SHALL support CodeSystem/$lookup
SHALL support CodeSystem/$validate-code
When determining the URI for a code system, the HL7 Universal Terminology Governance (UTG) site is the source of truth. If a code system is not identified there, submit a request with the HL7 Terminology Authority to identify an appropriate URL. For example, HCPCS Level II codes are not specified yet, discussion can be found here.
In accordance with the FHIR specification, CodeSystem resources, and references to code systems SHALL use the URI as specified by the HL7 terminology authority. In addition, version identifiers for code systems are specified according to the rules identified by the code system authority. For example, for SNOMED-CT, this means the version string is required to specify the edition and the version:
http://snomed.info/sct/731000124108/version/20150301
The edition identifier for the US Edition is 731000124108, and the version in the
above example is the March 2015 release, specified as YYYYMMDD, 20150301.
Note that when a code system authority has not established a versioning system, terminology servers may, as a practical matter, determine an appropriate versioning system to enable consistent use of content from that code system. However, in this case, the selected versioning scheme SHALL be brought to the HL7 Terminology Authority for consideration as the standard versioning scheme for that code system.
SHALL Represent computable ValueSet information, as specified by the CQFMComputableValueSet profile, which specifies the definition of a value set using established extensions, or with the compose element, including in particular the ability to use the inactive element of the include to indicate that a specific code is inactive in the code system but should still be included in the expansion.
SHALL Represent executable ValueSet information, as specified by the CQFMExecutableValueSet profile, which specifies the complete content of a value set using the expansion element, including inactive codes specified in the compose.
For published ValueSets, SHALL represent publishable ValueSet information, as specified by the CQFMPublishableValueSet profile.
SHALL support ValueSet read, by the server-defined id for the ValueSet
manifest parameter (defined in the cqfm-valueset-expand)expansion parameter (defined in the cqfm-valueset-expand)preview parameter (defined in the cqfm-valueset-expand)SHALL Represent basic quality program release information, as specified by the CQFMQualityProgram profile, which includes identifier, title, type, date, useContext, effectivePeriod, measure, library, and terminology references
For published quality programs, SHALL represent publishable quality program information as specified by the CQFMPublishableLibrary profile.
SHALL support Quality Program (Library) read, by the server-defined id for the quality program library
The above capabilities are formally captured in the following capability statement:
TODO: Support paged operations for: Code lookup, validation, expansion TODO: Consider how Measure value set and terminology usage is determined by the Terminology Service
This is the computable representation of an example Chronic Liver Disease value set. It contains two concepts that are active (as of the 2019-09 release of the US Edition of SNOMED-CT) and one concept that was last active in the 2015-03 release).
The compose element of this value set is:
"compose": {
"include": [
{
"system": "http://snomed.info/sct",
"concept": [
{
"code": "1116000",
"display": "Chronic aggressive type B viral hepatitis (disorder)"
},
{
"code": "10295004",
"display": "Chronic viral hepatitis (disorder)"
}
]
},
{
"system": "http://snomed.info/sct",
"version": "http://snomed.info/sct/731000124108/version/20150301",
"concept": [
{
"code": "111370006",
"display": "Cirrhosis of liver not due to alcohol (disorder)"
}
]
}
]
}
Note specifically the use of the inactive element to indicate that the
value set definition contains inactive codes, and the use of separate
include elements, one for the codes that do not specify a code system version,
and one for the legacy code from version http://snomed.info/sct/731000124108/version/20150301.
Given the following $expand:
[base]/ValueSet/chronic-liver-disease-legacy-example/$expand
The expected result expansion is:
"expansion": {
"timestamp": "2021-02-05T08:57:00-06:00",
"contains": [
{
"system": "http://snomed.info/sct",
"code": "1116000",
"display": "Chronic aggressive type B viral hepatitis (disorder)"
},
{
"system": "http://snomed.info/sct",
"code": "10295004",
"display": "Chronic viral hepatitis (disorder)"
},
{
"system": "http://snomed.info/sct",
"inactive": true,
"code": "111370006",
"display": "Cirrhosis of liver not due to alcohol (disorder)"
}
]
}
Note the use of the inactive element to indicate the code 111370006 is inactive in the
current version of SNOMED (i.e. the version of SNOMED that was active when this
expansion was produced, and the use of the timestamp to ensure that date is known).
Given the following $expand:
[base]/ValueSet/chronic-liver-disease-legacy-example/$expand?activeOnly=true
The expected result expansion is:
"expansion": {
"timestamp": "2021-02-05T08:57:00-06:00",
"parameter": [
{
"name": "activeOnly",
"valueBoolean": true
}
],
"contains": [
{
"system": "http://snomed.info/sct",
"code": "1116000",
"display": "Chronic aggressive type B viral hepatitis (disorder)"
},
{
"system": "http://snomed.info/sct",
"code": "10295004",
"display": "Chronic viral hepatitis (disorder)"
}
]
}
The result of the activeOnly parameter is to exclude the inactive code, even
though it was explicitly included in the value set definition.
Given the following $expand:
[base]/ValueSet/chronic-liver-disease-legacy-example/$expand?valueSetVersion=2020-05&system-version=http://snomed.info/sct|http://snomed.info/sct/731000124108/version/20150301
The expected result expansion is:
"expansion": {
"timestamp": "2021-02-05T08:57:00-06:00",
"parameter": [
{
"name": "valueSetVersion",
"valueString": "2020-05"
},
{
"name": "system-version",
"valueUri": "http://snomed.info/sct|http://snomed.info/sct/731000124108/version/20190901"
}
],
"contains": [
{
"system": "http://snomed.info/sct",
"code": "1116000",
"display": "Chronic aggressive type B viral hepatitis (disorder)"
},
{
"system": "http://snomed.info/sct",
"code": "10295004",
"display": "Chronic viral hepatitis (disorder)"
},
{
"system": "http://snomed.info/sct",
"inactive": true,
"code": "111370006",
"display": "Cirrhosis of liver not due to alcohol (disorder)"
}
]
}
Note this expansion contains the same codes as the current example, but is explicitly
bound to the 2019-09 version of the US Edition of the SNOMED code system (http://snomed.info/sct/731000124108/version/20190901).
A Quality Program has 3 different manifestations:
The following example illustrates an overall quality program that contains multiple version manifests and releases over time:
Note that as an organizer, this library just contains the program-level information. Version manifests and releases over time use the part-of extension to indicate that they are part of a quality program.
The following example illustrates a version manifest (or expansion profile) that is a draft of a quality program release used to provide expansion rules while the artifacts for a program are being authored. Specifically, the manifest uses the relatedArtifact element to declare the version of the SNOMED-CT code system to be used:
"relatedArtifact": [
{
"type": "depends-on",
"resource": "http://snomed.info/sct|http://snomed.info/sct/731000124108/version/20190901",
"display": "SNOMED-CT US Edition, 2019-09-01"
}
]
The full example is available here:
The following example illustrates a program release that is an active instance of a quality program release used to provide stable extensions for the released artifacts in a quality program.
Specifically, the program release uses the expansionUri extension at the library level to indicate that all value sets used with artifacts in the program should expand using this expansion identifier:
{
"url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-expansionUri",
"valueUri": "eCQM%20Update%202020-05-07"
}
In addition, the program release specifies versions of code systems, value sets, and measures included in the release:
{
"type": "depends-on",
"resource": "http://snomed.info/sct|http://snomed.info/sct/731000124108/version/20190901",
"display": "SNOMED-CT US Edition, 2019-09-01"
},
{
"type": "depends-on",
"resource": "http://hl7.org/fhir/us/cqfmeasures/ValueSet/chronic-liver-disease-legacy-example|2020-05",
"display": "Chronic Liver Disease, Legacy Example (2020-05)"
},
{
"type": "composed-of",
"resource": "http://hl7.org/fhir/us/cqfmeasures/Measure/measure-exm124-FHIR|9.0.0",
"display": "Cervical Cancer Screening"
},
{
"type": "composed-of",
"resource": "http://hl7.org/fhir/us/cqfmeasures/Measure/measure-exm125-FHIR",
"display": "Breast Cancer Screening"
},
{
"type": "composed-of",
"resource": "http://hl7.org/fhir/us/cqfmeasures/Measure/measure-exm130-FHIR",
"display":"Colorectal Cancer Screening"
},
{
"type": "composed-of",
"resource": "http://hl7.org/fhir/us/cqfmeasures/Measure/measure-exm146-FHIR",
"display": "Appropriate Testing for Children with Pharyngitis"
}
The full example is available here:
Given the use of a version manifest as well as a program release, then the manifest parameter can be used
in the $expand operation to provide values for the relevant parameters:
[base]/ValueSet/chronic-liver-disease-legacy-example/$expand?manifest=http://hl7.org/fhir/us/cqfmeasures/Library/ecqm-update-2020
This is effectively an alternative mechanism for expressing the same value set and code system version specific expansion above,
and results in the same expansion, with the additional manifest parameter:
"expansion": {
"timestamp": "2021-02-05T08:57:00-06:00",
"parameter": [
{
"name": "valueSetVersion",
"valueString": "2020-05"
},
{
"name": "system-version",
"valueUri": "http://snomed.info/sct|http://snomed.info/sct/731000124108/version/20190901"
},
{
"name": "manifest",
"valueUri": "http://hl7.org/fhir/us/cqfmeasures/Library/ecqm-update-2020"
}
],
"contains": [
{
"system": "http://snomed.info/sct",
"code": "1116000",
"display": "Chronic aggressive type B viral hepatitis (disorder)"
},
{
"system": "http://snomed.info/sct",
"code": "10295004",
"display": "Chronic viral hepatitis (disorder)"
},
{
"system": "http://snomed.info/sct",
"inactive": true,
"code": "111370006",
"display": "Cirrhosis of liver not due to alcohol (disorder)"
}
]
}
Similarly, when using a release for the manifest parameter:
[base]/ValueSet/chronic-liver-disease-legacy-example/$expand?manifest=http://hl7.org/fhir/us/cqfmeasures/Library/ecqm-update-2020-05-07
This is effectively the same as providing the expansion parameter to the value set expand, and results in the expansion with the specified expansion identifier:
"expansion": {
"identifier": "eCQM%20Update%202020-05-07",
"timestamp": "2021-02-05T08:57:00-06:00",
"parameter": [
{
"name": "valueSetVersion",
"valueString": "2020-05"
},
{
"name": "system-version",
"valueUri": "http://snomed.info/sct|http://snomed.info/sct/731000124108/version/20190901"
},
{
"name": "manifest",
"valueUri": "http://hl7.org/fhir/us/cqfmeasures/Library/ecqm-update-2020-05-07"
}
],
"contains": [
{
"system": "http://snomed.info/sct",
"code": "1116000",
"display": "Chronic aggressive type B viral hepatitis (disorder)"
},
{
"system": "http://snomed.info/sct",
"code": "10295004",
"display": "Chronic viral hepatitis (disorder)"
},
{
"system": "http://snomed.info/sct",
"inactive": true,
"code": "111370006",
"display": "Cirrhosis of liver not due to alcohol (disorder)"
}
]
}
In addition to the use of the expansion parameter of the $expand operation, terminology services SHOULD support searching for a particular ValueSet expansion using the expansion search parameter:
[base]/ValueSet?url=http://hl7.org/fhir/us/cqfmeasures/ValueSet/chronic-liver-disease-legacy-example&expansion=eCQM%20Update%202020-05-07
The result of this search is the same as requesting an $expand with the expansion parameter.
The usage-user and usage-use search parameters can be used to search for valuesets that have been used in particular contexts and by particular users:
[base]/ValueSet?usage-user=CMS&usage-use=CMS124
IG © 2019+ Clinical Quality Information WG. Package hl7.fhir.us.cqfmeasures#2.1.0 based on FHIR 4.0.1. Generated 2021-04-13
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