EXM124 - Cervical Cancer Screening - Quality Measure Implementation Guide (STU5) v5.0.0-ballot

This page is part of the Quality Measure STU2 for FHIR R4 Implementation Guide (v5.0.0-ballot: STU5 (v5.0.0) Ballot 1) based on FHIR (HL7® FHIR® Standard) R4. The current version which supersedes this version is 4.0.0. For a full list of available versions, see the Directory of published versions

Example Measure: EXM124 - Cervical Cancer Screening

Active as of 2022-02-22

Id: EXM124-FHIR

Download cql: EXM124-FHIR.cql

Url: EXM124 - Cervical Cancer Screening

Version: 5.0.0-ballot

Identifier:

value: 124

Identifier:

type:

value: http://example.org/fhir/us/cqfmeasures/Measure/EXM124-FHIR

Identifier:

type:

value: http://example.org/fhir/us/cqfmeasures/Measure/CMS124v7

Identifier:

type:

value: Cervical Cancer Screening

Identifier:

value: 309

Name: EXM124

Title: EXM124 - Cervical Cancer Screening

Status: active

Experimental: true

Scoring:

Proportion

Improvement Notation:

Increased score indicates improvement

Type:

process

Date: 2022-02-22

Publisher: HL7 International / Clinical Quality Information

Description:

Percentage of women 21-64 years of age who were screened for cervical cancer using either of the following criteria:

Women age 21-64 who had cervical cytology performed every 3 years
Women age 30-64 who had cervical cytology/human papillomavirus (HPV) co-testing performed every 5 years

Use Context:

code

value

program

Jurisdiction: US

Topic: 57024-2

Purpose:

Women 23-64 years of age with a visit during the measurement period

Guidance (Usage): To ensure the measure is only looking for a cervical cytology test only after a woman turns 21 years of age, the youngest age in the initial population is 23. Patient self-report for procedures as well as diagnostic studies should be recorded in 'Procedure, Performed' template or 'Diagnostic Study, Performed' template in QRDA-1. Include only cytology and HPV "co-testing"; in co-testing, both cytology and HPV tests are performed (i.e., the samples are collected and both tests are ordered, regardless of the cytology result) on the same date of service. Do not include reflex testing. In addition, if the medical record indicates the HPV test was performed only after determining the cytology result, this is considered reflex testing and does not meet criteria for the measure.

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

Population Criteria:

Initial Population:

Women 23-64 years of age with a visit during the measurement period

Numerator:

Women with one or more screenings for cervical cancer. Appropriate screenings are defined by any one of the following criteria: * Cervical cytology performed during the measurement period or the two years prior to the measurement period for women who are at least 21 years old at the time of the test * Cervical human papillomavirus (HPV) testing performed during the measurement period or the four years prior to the measurement period for women who are 30 years or older at the time of the test

Denominator:

Equals Initial Population

Denominator Exclusion:

Women who had a hysterectomy with no residual cervix or a congenital absence of cervix. Exclude patients who are in hospice care for any part of the measurement period. Exclude patients receiving palliative care during the measurement period.

Supplemental Data Guidance:

This measure collects supplemental data elements for Race, Ethnicity, Sex, and Payer

Supplemental Data Elements: SDE Ethnicity SDE Payer Race Sex

Libraries:

EXM124 - Cervical Cancer Screening Library

Related Artifact Dependencies: http://hl7.org/fhir/us/cqfmeasures/Library/SupplementalDataElements|2.0.000

http://fhir.org/guides/cqf/common/Library/FHIRHelpers|4.0.1

MAT Global Common Functions FHIR Library

http://hl7.org/fhir/us/cqfmeasures/Library/AdultOutpatientEncounters|2.0.000

http://hl7.org/fhir/us/cqfmeasures/Library/Hospice|2.0.000

http://snomed.info/sct|http://snomed.info/sct/731000124108/version/201709

Pap Test

HPV Test

Office Visit

Annual Wellness Visit

Preventive Care Services Established Office Visit, 18 and Up

Preventive Care Services Initial Office Visit, 18 and Up

Home Healthcare Services

Payer

Encounter Inpatient

Hospice Care Ambulatory

Hysterectomy with No Residual Cervix

Parameters:

name

use

min

max

type

Measurement Period

Period

SDE Sex

out

Coding

Numerator

out

boolean

Denominator

out

boolean

SDE Payer

out

Resource

Initial Population

out

boolean

SDE Ethnicity

out

Coding

Denominator Exclusion

out

boolean

SDE Race

out

Coding

DataRequirements:

Type

Must Support

Valueset Name

Valueset

Coverage

period type

Payer

Patient

extension value url

Encounter

type

Office Visit

Encounter

type

Annual Wellness Visit

Encounter

type

Preventive Care Services - Established Office Visit, 18 and Up

Preventive Care Services Established Office Visit, 18 and Up

Encounter

type

Preventive Care Services-Initial Office Visit, 18 and Up

Preventive Care Services Initial Office Visit, 18 and Up

Encounter

type

Home Healthcare Services

Encounter

period hospitalization hospitalization.dischargeDisposition type status

Encounter Inpatient

ServiceRequest

code authoredOn intent

Hospice care ambulatory

Hospice Care Ambulatory

Procedure

code performed status

Hospice care ambulatory

Hospice Care Ambulatory

Procedure

code performed status

Hysterectomy with No Residual Cervix

Condition

code onset

Observation

effective code value status

Pap Test

Observation

effective code value status

HPV Test

Direct Reference Codes:

display

code

system

Discharge to home for hospice care (procedure)

428361000124107

SNOMED CT (all versions)

Discharge to healthcare facility for hospice care (procedure)

428371000124100

SNOMED CT (all versions)

Congenital absence of cervix (disorder)

37687000

SNOMED CT (all versions)

Logic Definitions:

Group Scoring Population Criteria Expression

Measure scoring:

Proportion

Initial Population

define "Initial Population":
	Patient.gender = 'female'
		and Global."CalendarAgeInYearsAt"(FHIRHelpers.ToDate(Patient.birthDate), start of "Measurement Period") in Interval[23, 64]
		and exists AdultOutpatientEncounters."Qualifying Encounters"

Numerator

//    and NoCervixBirth.clinicalStatus ~ ToConcept(Global."active") because this is an excluion, all statuses are acceptable
define "Numerator":
	exists "Cervical Cytology Within 3 Years"
		or exists "HPV Test Within 5 Years for Women Age 30 and Older"

Denominator

define "Denominator":
	"Initial Population"

Denominator Exclusion

define "Denominator Exclusion":
	Hospice."Has Hospice"
		or exists "Absence of Cervix"

Library Name Name

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 Name Name

EXM124-FHIR SDE Sex

define "SDE Sex":
  SDE."SDE Sex"

Library Name Name

EXM124-FHIR Cervical Cytology Within 3 Years

define "Cervical Cytology Within 3 Years":
	[Observation: "Pap Test"] CervicalCytology
		where CervicalCytology.value is not null
			and CervicalCytology.status in { 'final', 'amended', 'corrected', 'preliminary' }
		  and Global."Normalize Interval"(CervicalCytology.effective) ends 3 years or less on or before end of "Measurement Period"

Library Name Name

EXM124-FHIR HPV Test Within 5 Years for Women Age 30 and Older

define "HPV Test Within 5 Years for Women Age 30 and Older":
	[Observation: "HPV Test"] HPVTest
      where HPVTest.value is not null
        and HPVTest.status in { 'final', 'amended', 'corrected', 'preliminary' }
        and  Global."CalendarAgeInYearsAt"(FHIRHelpers.ToDate(Patient.birthDate), start of Global."Normalize Interval"(HPVTest.effective))>= 30
        and Global."Normalize Interval"(HPVTest.effective) ends 5 years or less on or before end of "Measurement Period"

Library Name Name

EXM124-FHIR Numerator

//    and NoCervixBirth.clinicalStatus ~ ToConcept(Global."active") because this is an excluion, all statuses are acceptable
define "Numerator":
	exists "Cervical Cytology Within 3 Years"
		or exists "HPV Test Within 5 Years for Women Age 30 and Older"

Library Name Name

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 Name Name

EXM124-FHIR Initial Population

define "Initial Population":
	Patient.gender = 'female'
		and Global."CalendarAgeInYearsAt"(FHIRHelpers.ToDate(Patient.birthDate), start of "Measurement Period") in Interval[23, 64]
		and exists AdultOutpatientEncounters."Qualifying Encounters"

Library Name Name

EXM124-FHIR Denominator

define "Denominator":
	"Initial Population"

Library Name Name

SupplementalDataElements SDE Payer

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

Library Name Name

EXM124-FHIR SDE Payer

define "SDE Payer":
  SDE."SDE Payer"

Library Name Name

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 Name Name

EXM124-FHIR SDE Ethnicity

define "SDE Ethnicity":
  SDE."SDE Ethnicity"

Library Name Name

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 Name Name

EXM124-FHIR Absence of Cervix

define "Absence of Cervix":
  ([Procedure: "Hysterectomy with No Residual Cervix"] NoCervixProcedure
   where Global."Normalize Interval"(NoCervixProcedure.performed) ends on or before end of "Measurement Period"
     and NoCervixProcedure.status = 'completed'
     )
  union [Condition : "Congenital absence of cervix (disorder)"] NoCervixBirth
		where Global."Normalize Interval"(NoCervixBirth.onset) starts on or before end of "Measurement Period"

Library Name Name

EXM124-FHIR Denominator Exclusion

define "Denominator Exclusion":
	Hospice."Has Hospice"
		or exists "Absence of Cervix"

Library Name Name

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

Library Name Name

EXM124-FHIR SDE Race

define "SDE Race":
  SDE."SDE Race"

Contained resources

EffectiveDataRequirements