Quality Measure Implementation Guide (STU5)
5.0.0-ballot - ballot United States of America flag

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: EXM125 - Breast Cancer Screening

Active as of 2022-02-22
Id: EXM125-FHIR
Download cql: EXM125-FHIR.cql
Url: EXM125 - Breast Cancer Screening
Version: 5.0.0-ballot
Identifier:

value: 125

Identifier:

value: 112

Name: EXM125
Title: EXM125 - Breast 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 50-74 years of age who had a mammogram to screen for breast cancer
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
Supplemental Data Elements: SDE Ethnicity SDE Payer SDE Race SDE Sex
Libraries:
EXM125 - Breast 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
  • Condition Clinical Status Codes
  • Mammography
  • 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
  • Unilateral Mastectomy
  • Status Post Right Mastectomy
  • Unilateral Mastectomy, Unspecified Laterality
  • Right
  • Status Post Left Mastectomy
  • Left
  • History of bilateral mastectomy
  • Bilateral Mastectomy
    		•
    Parameters:
    nameuseminmaxtype
    Measurement Period in 0 1 Period
    SDE Sex out 0 1 Coding
    Numerator out 0 1 boolean
    Denominator out 0 1 boolean
    SDE Payer out 0 * Resource
    Initial Population out 0 1 boolean
    SDE Ethnicity out 0 * Coding
    Denominator Exclusion out 0 1 boolean
    SDE Race out 0 * Coding
    DataRequirements:
    TypeMust SupportValueset NameValueset
    Coverage period type Payer Payer
    Patient extension value url
    Condition code clinicalStatus Status Post Right Mastectomy Status Post Right Mastectomy
    Condition code clinicalStatus Status Post Left Mastectomy Status Post Left Mastectomy
    Condition bodySite code clinicalStatus Unilateral Mastectomy, Unspecified Laterality Unilateral Mastectomy, Unspecified Laterality
    Condition code clinicalStatus onset History of bilateral mastectomy History of bilateral mastectomy
    Procedure code performed status Bilateral Mastectomy Bilateral Mastectomy
    Procedure code performed status Unilateral Mastectomy Unilateral Mastectomy
    Procedure code performed status Hospice care ambulatory Hospice Care Ambulatory
    Encounter type Office Visit Office Visit
    Encounter type Annual Wellness Visit 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 Home Healthcare Services
    Encounter period hospitalization hospitalization.dischargeDisposition type status Encounter Inpatient Encounter Inpatient
    ServiceRequest code authoredOn intent Hospice care ambulatory Hospice Care Ambulatory
    DiagnosticReport effective code status Mammography Mammography
    Direct Reference Codes:
    displaycodesystem
    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)
    active Condition Clinical Status Codes
    Logic Definitions:
    GroupScoringPopulation CriteriaExpression
    Measure scoring:

    Proportion

    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"
    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' }
		)
    Denominator 
    define "Denominator":
		"Initial Population"
    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 NameName
    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 NameName
    EXM125-FHIR SDE Sex 
    define "SDE Sex":
  SDE."SDE Sex"
    Library NameName
    EXM125-FHIR 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 NameName
    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 NameName
    EXM125-FHIR 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 NameName
    EXM125-FHIR Denominator 
    define "Denominator":
		"Initial Population"
    Library NameName
    SupplementalDataElements SDE Payer 
    define "SDE Payer":
  [Coverage: type in "Payer"] Payer
        return {
          code: Payer.type,
          period: Payer.period
        }
    Library NameName
    EXM125-FHIR SDE Payer 
    define "SDE Payer":
  SDE."SDE Payer"
    Library NameName
    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 NameName
    EXM125-FHIR SDE Ethnicity 
    define "SDE Ethnicity":
  SDE."SDE Ethnicity"
    Library NameName
    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 NameName
    EXM125-FHIR 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 NameName
    EXM125-FHIR 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 NameName
    EXM125-FHIR 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 NameName
    EXM125-FHIR 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 NameName
    EXM125-FHIR 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 NameName
    EXM125-FHIR 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 NameName
    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 NameName
    EXM125-FHIR SDE Race 
    define "SDE Race":
  SDE."SDE Race"

    Contained resources