Quality Measure Implementation Guide
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## Measure: EXM146 - Appropriate Testing for Children with Pharyngitis (Experimental)

Official URL: http://hl7.org/fhir/uv/cqm/Measure/EXM146-FHIR | Version: 4.0.0 | Highlight text changes?
Standards status: Informative Active as of 2025-08-13 | Computable Name: EXM146
Other Identifiers: http://example.org/fhir/cqi/ecqm/Measure/Identifier/exm#146 (use: official, ), OID:2.16.840.1.113883.4.642.40.61.29.7
Usage: Clinical Venue: EC
Copyright/Legal: Physician Performance Measure (Measures) and related data specifications were developed by the National Committee for Quality Assurance (NCQA). The Measures are copyrighted but can be reproduced and distributed, without modification, for noncommercial purposes (eg, use by healthcare providers in connection with their practices). Commercial use is defined as the sale, licensing, or distribution of the Measures for commercial gain, or incorporation of the Measures into a product or service that is sold, licensed or distributed for commercial gain. Commercial use of the Measures requires a license agreement between the user and NCQA. NCQA is not responsible for any use of the Measures. (c) 2008 -2014 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 2004-2013 American Medical Association. LOINC(R) copyright 2004-2013 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2013 International Health Terminology Standards Development Organisation. ICD-10 copyright 2013 World Health Organization. All Rights Reserved.

Percentage of children 2-18 years of age who were diagnosed with pharyngitis, ordered an antibiotic and received a group A streptococcus (strep) test for the episode.

Metadata
Title | EXM146 - Appropriate Testing for Children with Pharyngitis
Version | 4.0.0
Identifier | 146
Identifier | urn:oid:2.16.840.1.113883.4.642.40.61.29.7
Effective Period | 2018-01-01 through 2018-12-31
Approval Date | 2016-01-01
Last Review Date | 2016-09-01
Experimental | true
Use Context | Clinical Venue = EC
Jurisdiction | 001 from http://unstats.un.org/unsd/methods/m49/m49.htm
Topic | Health Quality Measure Document
Steward (Publisher) | HL7 International / Clinical Quality Information
Description | Percentage of children 2-18 years of age who were diagnosed with pharyngitis, ordered an antibiotic and received a group A streptococcus (strep) test for the episode.
Purpose | This measure has been developed to support improvement in clinical care.
Copyright | Physician Performance Measure (Measures) and related data specifications were developed by the National Committee for Quality Assurance (NCQA). The Measures are copyrighted but can be reproduced and distributed, without modification, for noncommercial purposes (eg, use by healthcare providers in connection with their practices). Commercial use is defined as the sale, licensing, or distribution of the Measures for commercial gain, or incorporation of the Measures into a product or service that is sold, licensed or distributed for commercial gain. Commercial use of the Measures requires a license agreement between the user and NCQA. NCQA is not responsible for any use of the Measures. (c) 2008 -2014 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 2004-2013 American Medical Association. LOINC(R) copyright 2004-2013 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2013 International Health Terminology Standards Development Organisation. ICD-10 copyright 2013 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].
Measure Basis | Encounter
Measure Scoring | Proportion
Improvement Notation | Increased score indicates improvement
Measure Type | process from http://terminology.hl7.org/CodeSystem/measure-type
Rationale | Group A streptococcal bacterial infections and other infections that cause pharyngitis (which are most often viral) often produce the same signs and symptoms (IDSA 2002). The American Academy of Pediatrics, the Centers for Disease Control and Prevention, and the Infectious Diseases Society of America all recommend a diagnostic test for Strep A to improve diagnostic accuracy and avoid unnecessary antibiotic treatment (Linder et al. 2005). A study on antibiotic treatment of children with sore throat found that although only 15 to 36 percent of children with sore throat have Strep A pharyngitis, physicians prescribed antibiotics to 53 percent of children with a chief complaint of sore throat between 1995 and 2003 (Linder et al. 2005).
Clinical Recommendation Statement | Institute for Clinical Systems Improvement (ICSI) (2007) Reduce unnecessary use of antibiotics. Antibiotic treatment should be reserved for a bacterial illness. Diagnosis of group A beta streptococcal Pharyngitis should be made by laboratory testing rather than clinically. Infectious Disease Society of America (Bisno et al. 2002) The signs and symptoms of group A streptococcal and other (most frequently viral) pharyngitides overlap broadly. Therefore, unless the physician is able with confidence to exclude the diagnosis of streptococcal pharyngitis on epidemiological and clinical grounds alone, a laboratory test should be done to determine whether group A streptococci are present in the pharynx. With the exception of very rare infections by certain other pharyngeal bacterial pathogens (eg, Corynebacterium diphtheriae and Neisseria gonorrhoeae), antimicrobial therapy is of no proven benefit as treatment for acute pharyngitis due to bacteria other than group A streptococci. Therefore, it is extremely important that physicians exclude the diagnosis of group A streptococcal pharyngitis to prevent inappropriate administration of antimicrobials to large numbers of patients with pharyngitis. Michigan Quality Improvement Consortium (2007) Probability of group A beta hemolytic streptococci (GABHS): Low; Testing: None; Treatment: Symptomatic treatment only. Avoid antibiotics. Probability of GABHS: Intermediate or High; Testing: Throat Culture (TC) OR Rapid Screen; Treatment: If TC is positive, use antibiotics. If TC is negative, use symptomatic treatment only. Avoid antibiotics. If treatment is started and culture result is negative, stop antibiotics. If Rapid Screen is positive, use antibiotics. If Rapid Screen is negative, culture (Culture is optional for age 16 and over) and only use antibiotics if throat culture is positive. (Michigan, 2007)
Measure Group (Rate) (ID: primary)
Measure Logic
Primary Library | EXM146 - Example Proportion Measure Library
Contents | Population Criteria Logic Definitions Terminology Dependencies Data Requirements Parameters
Population Criteria
Measure Group (Rate) (ID: primary)
Logic Definitions
Logic Definition | Library Name: EXM146
    define "Is Between 2 and 17 Years of Age at Start of Measurement Period":
       AgeInYearsAt(start of "Measurement Period") >= 2
          and AgeInYearsAt(start of "Measurement Period") <= 17
Logic Definition | Library Name: EXM146
    define "Measurement Period Encounters":
       [Encounter: "Ambulatory/ED Visit"] Encounter
          where Encounter.period during "Measurement Period"
            and Encounter.status = 'finished'
            and "Is Between 2 and 17 Years of Age at Start of Measurement Period"
Logic Definition | Library Name: EXM146
    define "Pharyngitis":
       ([Condition: code in "Acute Pharyngitis"]
         union [Condition: code in "Acute Tonsillitis"]) Pharyngitis
         where Pharyngitis.clinicalStatus ~ Global.active
           and Pharyngitis.verificationStatus ~ Global.confirmed
Logic Definition | Library Name: EXM146
    define "Antibiotics":
       [MedicationRequest: medication in "Antibiotic Medications"] Prescription
         where Prescription.status = 'active'
           and Prescription.intent = 'order'
Logic Definition | Library Name: EXM146
    define "Pharyngitis Encounters With Antibiotics":
       "Measurement Period Encounters" Encounters
          with "Pharyngitis" Pharyngitis such that
             Common."Includes Or Starts During"(Pharyngitis, Encounters)
          with "Antibiotics" Antibiotics such that Antibiotics.authoredOn
             3 days or less after FHIRHelpers.ToInterval(Encounters.period)
Logic Definition | Library Name: EXM146
    define "Strep Test Encounters":
       "Pharyngitis Encounters With Antibiotics" Encounters
          with [Observation: code in "Group A Streptococcus Test"] Tests
             such that Tests.value is not null
                and Tests.effective starts during
                   Interval[start of FHIRHelpers.ToInterval(Encounters.period) - 3 days,
                     end of FHIRHelpers.ToInterval(Encounters.period) + 3 days]
Logic Definition | Library Name: EXM146
    define "Numerator":
       "Strep Test Encounters"
Logic Definition | Library Name: EXM146
    define "Initial Population":
       "Pharyngitis Encounters With Antibiotics"
Logic Definition | Library Name: EXM146
    define "Denominator":
       "Initial Population"
Logic Definition | Library Name: EXM146
    define "Pharyngitis With Prior Antibiotics":
       "Pharyngitis" Pharyngitis
          with "Antibiotics" Antibiotics such that
             Antibiotics.authoredOn 30 days or less before Pharyngitis.onset
Logic Definition | Library Name: EXM146
    define "Excluded Encounters":
       "Pharyngitis Encounters With Antibiotics" Encounters
          with "Pharyngitis With Prior Antibiotics" Pharyngitis such that
             Common."Includes Or Starts During"(Pharyngitis, Encounters)
Logic Definition | Library Name: EXM146
    define "Denominator Exclusions":
      "Excluded Encounters"
Logic Definition | Library Name: Common
    define function
       "Includes Or Starts During"(Condition Condition, Encounter Encounter):
          Interval[Condition.onset, Condition.abatement] includes Encounter.period
             or Condition.onset during Encounter.period
Logic Definition | Library Name: FHIRHelpers
    /*
    @description: Converts the given [Period](https://hl7.org/fhir/datatypes.html#Period)
    value to a CQL DateTime Interval
    @comment: If the start value of the given period is unspecified, the starting
    boundary of the resulting interval will be open (meaning the start of the interval
    is unknown, as opposed to interpreted as the beginning of time).
    */
    define function ToInterval(period FHIR.Period):
        if period is null then
            null
        else
            if period."start" is null then
                Interval(period."start".value, period."end".value]
            else
                Interval[period."start".value, period."end".value]
Logic Definition | Library Name: FHIRHelpers
    define function ToString(value EncounterStatus): value.value
Logic Definition | Library Name: FHIRHelpers
    /*
    @description: Converts the given FHIR [CodeableConcept](https://hl7.org/fhir/datatypes.html#CodeableConcept) value to a CQL Concept.
    */
    define function ToConcept(concept FHIR.CodeableConcept):
        if concept is null then
            null
        else
            System.Concept {
                codes: concept.coding C return ToCode(C),
                display: concept.text.value
            }
Logic Definition | Library Name: FHIRHelpers
    /*
    @description: Converts the given FHIR [Coding](https://hl7.org/fhir/datatypes.html#Coding) value to a CQL Code.
    */
    define function ToCode(coding FHIR.Coding):
        if coding is null then
            null
        else
            System.Code {
              code: coding.code.value,
              system: coding.system.value,
              version: coding.version.value,
              display: coding.display.value
            }
Logic Definition | Library Name: FHIRHelpers
    define function ToDateTime(value dateTime): value.value
Logic Definition | Library Name: FHIRHelpers
    define function ToString(value MedicationRequestStatus): value.value
Logic Definition | Library Name: FHIRHelpers
    define function ToString(value MedicationRequestIntent): value.value
Terminology
Code System | Description: Code system ConditionClinicalStatusCodes Resource: Condition Clinical Status Codes Canonical URL: `http://terminology.hl7.org/CodeSystem/condition-clinical`
Code System | Description: Code system ConditionVerificationStatusCodes Resource: ConditionVerificationStatus Canonical URL: `http://terminology.hl7.org/CodeSystem/condition-ver-status`
Value Set | Description: Value set Ambulatory/ED Visit Resource: Ambulatory/ED Visit Canonical URL: `http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1061`
Value Set | Description: Value set Acute Pharyngitis Resource: Acute Pharyngitis Canonical URL: `http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.102.12.1011`
Value Set | Description: Value set Acute Tonsillitis Resource: Acute Tonsillitis Canonical URL: `http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.102.12.1012`
Value Set | Description: Value set Antibiotic Medications Resource: Antibiotic Medications for Pharyngitis Canonical URL: `http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.196.12.1001`
Value Set | Description: Value set Group A Streptococcus Test Resource: Group A Streptococcus Test Canonical URL: `http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1012`
Direct Reference Code | Code: active System: `http://terminology.hl7.org/CodeSystem/condition-clinical`
Direct Reference Code | Code: confirmed System: `http://terminology.hl7.org/CodeSystem/condition-ver-status`
Dependencies
Dependency | Description: FHIR model information Resource: http://hl7.org/fhir/uv/cql/Library/FHIR-ModelInfo|4.0.1 Canonical URL: `http://hl7.org/fhir/uv/cql/Library/FHIR-ModelInfo|4.0.1`
Dependency | Description: Library FHIRHelpers Resource: http://hl7.org/fhir/uv/cql/Library/FHIRHelpers|4.0.1 Canonical URL: `http://hl7.org/fhir/uv/cql/Library/FHIRHelpers|4.0.1`
Dependency | Description: Library Global Resource: MAT Global Common Functions FHIR Libraryversion: null5.0.000) Canonical URL: `http://hl7.org/fhir/uv/cqm/Library/MATGlobalCommonFunctions|5.0.000`
Dependency | Description: Library Common Resource: Common Libraryversion: null2.0.0) Canonical URL: `http://hl7.org/fhir/uv/cqm/Library/Common|2.0.0`
Data Requirements
Data Requirement | Type: Patient Profile(s): Patient
Data Requirement | Type: Encounter Profile(s): Encounter Must Support Elements: type, period, status Code Filter(s): Path: type ValueSet: Ambulatory/ED Visit
Data Requirement | Type: Condition Profile(s): Condition Must Support Elements: code, clinicalStatus, verificationStatus, onset Code Filter(s): Path: code ValueSet: Acute Pharyngitis
Data Requirement | Type: Condition Profile(s): Condition Must Support Elements: code, clinicalStatus, verificationStatus, onset Code Filter(s): Path: code ValueSet: Acute Tonsillitis
Data Requirement | Type: MedicationRequest Profile(s): MedicationRequest Must Support Elements: medication, status, intent, authoredOn Code Filter(s): Path: medication ValueSet: Antibiotic Medications for Pharyngitis
Data Requirement | Type: Observation Profile(s): Observation Must Support Elements: code, value, effective Code Filter(s): Path: code ValueSet: Group A Streptococcus Test
Parameters
Name | Use | Card. | Type | Documentation
Measurement Period | In | 0..1 | Period |
Numerator | Out | 0..* | Encounter |
Denominator | Out | 0..* | Encounter |
Initial Population | Out | 0..* | Encounter |
Denominator Exclusions | Out | 0..* | Encounter |
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