This page is part of the Documentation Templates and Rules (v1.0.0: STU 1) based on FHIR R4. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions

Execution of CQL

Retrieval of patient FHIR resources to supply to CQL execution engine

The app SHOULD retrieve the FHIR resources specified in the dataRequirement section of a Library, it can then pass these resources to the Clinical Quality Language (CQL) engine. Using dataRequirement allows for a more declarative means of understanding the resource data needed from the EHR. For example, the below snippet is from a Library that contains a dataRequirement section. In this code snippet the resource data needed from the EHR is Condition.

"dataRequirement": [
    {
      "type": "Condition",
      "codeFilter": [
        {
          "path": "code",
          "valueSet": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1219.25"
        }
      ]
    },

For further guidance and details implementers are encouraged to reference the FHIR Clinical Guidelines IG - Library Resources section.

The app SHALL be provided with a token that allows it to access relevant information for the patient in question. Depending on user permissions, the app may not have access to all the data. The app developer should consider the possibility that access to some data may be restricted or prohibited(and access restrictions may happen silently (i.g., indistinguishable absent data). The app’s CQL execution engine SHOULD attempt to constrain queries as much as possible to reduce data transfer, however it MAY retrieve more data than is necessary (for example, if the CQL logic filters for medications meeting certain conditions. It is acceptable if the engine retrieves all medications for the patient, even if a more constrained query was possible).

As discussed in the Execution Results section below, it’s possible not every CQL statement will be executed (for example some questions may only be relevant given certain answers to prior questions). In order to reduce data transfers and increase overall speed, data MAY be fetched as needed. However, the app’s execution engine MAY be implemented using a different strategy (for example by doing bulk fetches before starting execution).

Engine Execution

The FHIR Library containing/referencing a CQL logic file can reference other needed CQL files (e.g., helper libraries) using the relatedArtifact field and a RelatedArtifact with a type of depends-on. The engine SHALL make available to the execution context all such referenced CQL libraries. If the Questionnaire has multiple cqf-library fields, then any valueExpression must specify the library name as well as the statement name as follows: "LibraryName".statementName.

It is likely that different versions of CQL will need to be created for different FHIR versions, as the same information could be in a different resource. The app will have access to the FHIR endpoint, it should check the version and then retrieve the package that has been created for the correct FHIR version.

Consideration must also be made regarding the CQL version.

Behavior when receiving malformed CQL

If the CQL is malformed (is not syntactically correct) in any way, the app’s execution engine SHALL NOT attempt any execution of the malformed CQL, the app SHALL log the error, and the user SHALL be notified with an appropriate on-screen message indicating that population did not occur and they SHALL be allowed to enter the information manually either now or at a later time. The app SHOULD log failures and ensure the maintainer of the CQL/Questionnaire package is notified.

In an effort to notify the appropriate party or maintainer that the CQL/Questionnaire is malformed, the app developer SHOULD use FHIR resource OperationOutcome. The details property of the OperationOutcome should use MSG_BAD_SYNTAX to indicate syntactical errors. The destination of the OperationOutcome should be the endpoint the malformed CQL/Questionnaire was retrieved from.

It is a CQL failure if the CQL cannot be executed by the app’s CQL engine in the SMART on FHIR app or in a capable EHR. The CQL author should take the capability of the app’s CQL engine into account when designing their CQL.

Behavior when encountering execution errors

If any errors are encountered during execution, the app’s engine SHALL NOT attempt any further execution, and the user SHALL be notified with an appropriate on-screen error message. The app SHALL log failures and ensure the maintainer of the CQL/Questionnaire package is notified. The user should have the option to complete the Questionnaire if possible, despite the error.

In an effort to notify the appropriate party or maintainer that the CQL/Questionnaire is malformed, the app developer SHOULD use FHIR resource OperationOutcome. The destination of the OperationOutcome should be the endpoint the malformed CQL/Questionnaire was retrieved from.

Note: A query for data that returns no results is never considered a failure.

Execution Results

The flow of execution of the CQL will be determined by the associated Questionnaire. The app will proceed through the Questionnaire, and for any question that is associated with the result of a CQL statement, that specific CQL statement will be executed. The app’s engine will use result caching so that each statement should be executed either zero or one time.