# EXM146 - Appropriate Testing for Children with Pharyngitis - Quality Measure Implementation Guide v2.0.0-ballot

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

 
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
* Metadata: Version
  * ?: 4.0.0
* Metadata: Identifier
  * ?: 146
* Metadata: Identifier
  * ?: urn:oid:2.16.840.1.113883.4.642.40.61.29.7
* Metadata: Effective Period
  * ?: 2018-01-01 through 2018-12-31
* Metadata: Approval Date
  * ?: 2016-01-01
* Metadata: Last Review Date
  * ?: 2016-09-01
* Metadata: Experimental
  * ?: true
* Metadata: Use Context
  * ?: Clinical Venue = EC
* Metadata: Jurisdiction
  * ?: 001 from[http://unstats.un.org/unsd/methods/m49/m49.htm](http://unstats.un.org/unsd/methods/m49/m49.htm)
* Metadata: Topic
  * ?: Health Quality Measure Document
* Metadata: Steward (Publisher)
  * ?: HL7 International / Clinical Quality Information
* Metadata: 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.
* Metadata: Purpose
  * ?: This measure has been developed to support improvement in clinical care.
* Metadata: 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.
* Metadata: 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].
* Metadata: Measure Basis
  * ?: Encounter
* Metadata: Measure Scoring
  * ?: Proportion
* Metadata: Improvement Notation
  * ?: Increased score indicates improvement
* Metadata: Measure Type
  * ?: process from[http://terminology.hl7.org/CodeSystem/measure-type](http://terminology.hl7.org/7.1.0/CodeSystem-measure-type.html)
* Metadata: 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).
* Metadata: 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)
* Metadata: Measure Group (Rate) (ID: primary)
* Metadata: Measure Logic
* Metadata: Primary Library
  * ?: [EXM146 - Example Proportion Measure Library](Library-EXM146.md)
* Metadata: Contents
  * ?: **[Population Criteria](#population-criteria)****[Logic Definitions](#definitions)****[Terminology](#terminology)****[Dependencies](#dependencies)****[Data Requirements](#data-requirements)****[Parameters](#parameters)**
* Metadata:  Population Criteria
* Metadata: Measure Group (Rate) (ID: primary)
* Metadata:  Logic Definitions
* Metadata: Logic Definition
  * ?: **Library Name:**EXM146
* Metadata:  ````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````
* Metadata: Logic Definition
  * ?: **Library Name:**EXM146
* Metadata:  ````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"````
* Metadata: Logic Definition
  * ?: **Library Name:**EXM146
* Metadata:  ````define "Pharyngitis": ([Condition: code in "Acute Pharyngitis"] union [Condition: code in "Acute Tonsillitis"]) Pharyngitis where Pharyngitis.clinicalStatus ~ Global.active and Pharyngitis.verificationStatus ~ Global.confirmed````
* Metadata: Logic Definition
  * ?: **Library Name:**EXM146
* Metadata:  ````define "Antibiotics": [MedicationRequest: medication in "Antibiotic Medications"] Prescription where Prescription.status = 'active' and Prescription.intent = 'order'````
* Metadata: Logic Definition
  * ?: **Library Name:**EXM146
* Metadata:  ````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)````
* Metadata: Logic Definition
  * ?: **Library Name:**EXM146
* Metadata:  ````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]````
* Metadata: Logic Definition
  * ?: **Library Name:**EXM146
* Metadata:  ````define "Numerator": "Strep Test Encounters"````
* Metadata: Logic Definition
  * ?: **Library Name:**EXM146
* Metadata:  ````define "Initial Population": "Pharyngitis Encounters With Antibiotics"````
* Metadata: Logic Definition
  * ?: **Library Name:**EXM146
* Metadata:  ````define "Denominator": "Initial Population"````
* Metadata: Logic Definition
  * ?: **Library Name:**EXM146
* Metadata:  ````define "Pharyngitis With Prior Antibiotics": "Pharyngitis" Pharyngitis with "Antibiotics" Antibiotics such that Antibiotics.authoredOn 30 days or less before Pharyngitis.onset````
* Metadata: Logic Definition
  * ?: **Library Name:**EXM146
* Metadata:  ````define "Excluded Encounters": "Pharyngitis Encounters With Antibiotics" Encounters with "Pharyngitis With Prior Antibiotics" Pharyngitis such that Common."Includes Or Starts During"(Pharyngitis, Encounters)````
* Metadata: Logic Definition
  * ?: **Library Name:**EXM146
* Metadata:  ````define "Denominator Exclusions": "Excluded Encounters"````
* Metadata: Logic Definition
  * ?: **Library Name:**Common
* Metadata:  ````define function "Includes Or Starts During"(Condition Condition, Encounter Encounter): Interval[Condition.onset, Condition.abatement] includes Encounter.period or Condition.onset during Encounter.period````
* Metadata: Logic Definition
  * ?: **Library Name:**FHIRHelpers
* Metadata:  ````/* @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]````
* Metadata: Logic Definition
  * ?: **Library Name:**FHIRHelpers
* Metadata:  ````define function ToString(value EncounterStatus): value.value````
* Metadata: Logic Definition
  * ?: **Library Name:**FHIRHelpers
* Metadata:  ````/* @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 }````
* Metadata: Logic Definition
  * ?: **Library Name:**FHIRHelpers
* Metadata:  ````/* @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 }````
* Metadata: Logic Definition
  * ?: **Library Name:**FHIRHelpers
* Metadata:  ````define function ToDateTime(value dateTime): value.value````
* Metadata: Logic Definition
  * ?: **Library Name:**FHIRHelpers
* Metadata:  ````define function ToString(value MedicationRequestStatus): value.value````
* Metadata: Logic Definition
  * ?: **Library Name:**FHIRHelpers
* Metadata:  ````define function ToString(value MedicationRequestIntent): value.value````
* Metadata:  Terminology
* Metadata: Code System
  * ?: **Description**: Code system ConditionClinicalStatusCodes**Resource**:[Condition Clinical Status Codes](http://terminology.hl7.org/7.1.0/CodeSystem-condition-clinical.html)**Canonical URL**:http://terminology.hl7.org/CodeSystem/condition-clinical
* Metadata: Code System
  * ?: **Description**: Code system ConditionVerificationStatusCodes**Resource**:[ConditionVerificationStatus](http://terminology.hl7.org/7.1.0/CodeSystem-condition-ver-status.html)**Canonical URL**:http://terminology.hl7.org/CodeSystem/condition-ver-status
* Metadata: Value Set
  * ?: **Description**: Value set Ambulatory/ED Visit**Resource**:[Ambulatory/ED Visit](https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.464.1003.101.12.1061/expansion)**Canonical URL**:http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1061
* Metadata: Value Set
  * ?: **Description**: Value set Acute Pharyngitis**Resource**:[Acute Pharyngitis](https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.464.1003.102.12.1011/expansion)**Canonical URL**:http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.102.12.1011
* Metadata: Value Set
  * ?: **Description**: Value set Acute Tonsillitis**Resource**:[Acute Tonsillitis](https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.464.1003.102.12.1012/expansion)**Canonical URL**:http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.102.12.1012
* Metadata: Value Set
  * ?: **Description**: Value set Antibiotic Medications**Resource**:[Antibiotic Medications for Pharyngitis](https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.464.1003.196.12.1001/expansion)**Canonical URL**:http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.196.12.1001
* Metadata: Value Set
  * ?: **Description**: Value set Group A Streptococcus Test**Resource**:[Group A Streptococcus Test](https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.464.1003.198.12.1012/expansion)**Canonical URL**:http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1012
* Metadata: Direct Reference Code
  * ?: **Code**: active**System**:http://terminology.hl7.org/CodeSystem/condition-clinical
* Metadata: Direct Reference Code
  * ?: **Code**: confirmed**System**:http://terminology.hl7.org/CodeSystem/condition-ver-status
* Metadata:  Dependencies
* Metadata: Dependency
  * ?: **Description**: FHIR model information**Resource**:[http://hl7.org/fhir/uv/cql/Library/FHIR-ModelInfo|4.0.1](http://hl7.org/fhir/uv/cql/STU2/Library-FHIR-ModelInfo.html)**Canonical URL**:http://hl7.org/fhir/uv/cql/Library/FHIR-ModelInfo|4.0.1
* Metadata: Dependency
  * ?: **Description**: Library FHIRHelpers**Resource**:[http://hl7.org/fhir/uv/cql/Library/FHIRHelpers|4.0.1](http://hl7.org/fhir/uv/cql/STU2/Library-FHIRHelpers.html)**Canonical URL**:http://hl7.org/fhir/uv/cql/Library/FHIRHelpers|4.0.1
* Metadata: Dependency
  * ?: **Description**: Library Global**Resource**:[MAT Global Common Functions FHIR Libraryversion: null5.0.000)](Library-MATGlobalCommonFunctions.md)**Canonical URL**:http://hl7.org/fhir/uv/cqm/Library/MATGlobalCommonFunctions|5.0.000
* Metadata: Dependency
  * ?: **Description**: Library Common**Resource**:[Common Libraryversion: null2.0.0)](Library-Common.md)**Canonical URL**:http://hl7.org/fhir/uv/cqm/Library/Common|2.0.0
* Metadata:  Data Requirements
* Metadata: Data Requirement
  * ?: **Type**: Patient**Profile(s)**:[Patient](http://hl7.org/fhir/R4/patient.html)
* Metadata: Data Requirement
  * ?: **Type**: Encounter**Profile(s)**:[Encounter](http://hl7.org/fhir/R4/encounter.html)**Must Support Elements**: type, period, status**Code Filter(s)**:**Path**: type**ValueSet**:[Ambulatory/ED Visit](https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.464.1003.101.12.1061/expansion)
* Metadata: Data Requirement
  * ?: **Type**: Condition**Profile(s)**:[Condition](http://hl7.org/fhir/R4/condition.html)**Must Support Elements**: code, clinicalStatus, verificationStatus, onset**Code Filter(s)**:**Path**: code**ValueSet**:[Acute Pharyngitis](https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.464.1003.102.12.1011/expansion)
* Metadata: Data Requirement
  * ?: **Type**: Condition**Profile(s)**:[Condition](http://hl7.org/fhir/R4/condition.html)**Must Support Elements**: code, clinicalStatus, verificationStatus, onset**Code Filter(s)**:**Path**: code**ValueSet**:[Acute Tonsillitis](https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.464.1003.102.12.1012/expansion)
* Metadata: Data Requirement
  * ?: **Type**: MedicationRequest**Profile(s)**:[MedicationRequest](http://hl7.org/fhir/R4/medicationrequest.html)**Must Support Elements**: medication, status, intent, authoredOn**Code Filter(s)**:**Path**: medication**ValueSet**:[Antibiotic Medications for Pharyngitis](https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.464.1003.196.12.1001/expansion)
* Metadata: Data Requirement
  * ?: **Type**: Observation**Profile(s)**:[Observation](http://hl7.org/fhir/R4/observation.html)**Must Support Elements**: code, value, effective**Code Filter(s)**:**Path**: code**ValueSet**:[Group A Streptococcus Test](https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.464.1003.198.12.1012/expansion)
* Metadata:  Parameters
* Metadata: 
  * ?: 
| | | | | |
| :--- | :--- | :--- | :--- | :--- |
| **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 |  |

* Metadata: Generated using version 0.5.4 of the sample-content-ig Liquid templates



## Resource Content

```json
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  "id" : "EXM146-FHIR",
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  "contained" : [{
    "resourceType" : "Library",
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      "valueCoding" : {
        "system" : "http://terminology.hl7.org/CodeSystem/condition-clinical",
        "code" : "active"
      }
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        "code" : "confirmed"
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        "url" : "name",
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        "url" : "name",
        "valueString" : "Strep Test Encounters"
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        "url" : "statement",
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        "url" : "name",
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        "url" : "statement",
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      },
      {
        "url" : "name",
        "valueString" : "Denominator Exclusions"
      },
      {
        "url" : "statement",
        "valueString" : "define \"Denominator Exclusions\":\n  \"Excluded Encounters\""
      },
      {
        "url" : "displaySequence",
        "valueInteger" : 11
      }],
      "url" : "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
    },
    {
      "extension" : [{
        "url" : "libraryName",
        "valueString" : "FHIRHelpers"
      },
      {
        "url" : "name",
        "valueString" : "ToInterval"
      },
      {
        "url" : "statement",
        "valueString" : "/*\n@description: Converts the given [Period](https://hl7.org/fhir/datatypes.html#Period)\nvalue to a CQL DateTime Interval\n@comment: If the start value of the given period is unspecified, the starting\nboundary of the resulting interval will be open (meaning the start of the interval\nis unknown, as opposed to interpreted as the beginning of time).\n*/\ndefine function ToInterval(period FHIR.Period):\n    if period is null then\n        null\n    else\n        if period.\"start\" is null then\n            Interval(period.\"start\".value, period.\"end\".value]\n        else\n            Interval[period.\"start\".value, period.\"end\".value]"
      },
      {
        "url" : "displaySequence",
        "valueInteger" : 12
      }],
      "url" : "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
    },
    {
      "extension" : [{
        "url" : "libraryName",
        "valueString" : "FHIRHelpers"
      },
      {
        "url" : "name",
        "valueString" : "ToString"
      },
      {
        "url" : "statement",
        "valueString" : "define function ToString(value EncounterStatus): value.value"
      },
      {
        "url" : "displaySequence",
        "valueInteger" : 13
      }],
      "url" : "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
    },
    {
      "extension" : [{
        "url" : "libraryName",
        "valueString" : "FHIRHelpers"
      },
      {
        "url" : "name",
        "valueString" : "ToConcept"
      },
      {
        "url" : "statement",
        "valueString" : "/*\n@description: Converts the given FHIR [CodeableConcept](https://hl7.org/fhir/datatypes.html#CodeableConcept) value to a CQL Concept.\n*/\ndefine function ToConcept(concept FHIR.CodeableConcept):\n    if concept is null then\n        null\n    else\n        System.Concept {\n            codes: concept.coding C return ToCode(C),\n            display: concept.text.value\n        }"
      },
      {
        "url" : "displaySequence",
        "valueInteger" : 14
      }],
      "url" : "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
    },
    {
      "extension" : [{
        "url" : "libraryName",
        "valueString" : "FHIRHelpers"
      },
      {
        "url" : "name",
        "valueString" : "ToCode"
      },
      {
        "url" : "statement",
        "valueString" : "/*\n@description: Converts the given FHIR [Coding](https://hl7.org/fhir/datatypes.html#Coding) value to a CQL Code.\n*/\ndefine function ToCode(coding FHIR.Coding):\n    if coding is null then\n        null\n    else\n        System.Code {\n          code: coding.code.value,\n          system: coding.system.value,\n          version: coding.version.value,\n          display: coding.display.value\n        }"
      },
      {
        "url" : "displaySequence",
        "valueInteger" : 15
      }],
      "url" : "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
    },
    {
      "extension" : [{
        "url" : "libraryName",
        "valueString" : "Common"
      },
      {
        "url" : "name",
        "valueString" : "Includes Or Starts During"
      },
      {
        "url" : "statement",
        "valueString" : "define function\n   \"Includes Or Starts During\"(Condition Condition, Encounter Encounter):\n      Interval[Condition.onset, Condition.abatement] includes Encounter.period\n         or Condition.onset during Encounter.period"
      },
      {
        "url" : "displaySequence",
        "valueInteger" : 16
      }],
      "url" : "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
    },
    {
      "extension" : [{
        "url" : "libraryName",
        "valueString" : "FHIRHelpers"
      },
      {
        "url" : "name",
        "valueString" : "ToDateTime"
      },
      {
        "url" : "statement",
        "valueString" : "define function ToDateTime(value dateTime): value.value"
      },
      {
        "url" : "displaySequence",
        "valueInteger" : 17
      }],
      "url" : "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
    },
    {
      "extension" : [{
        "url" : "libraryName",
        "valueString" : "FHIRHelpers"
      },
      {
        "url" : "name",
        "valueString" : "ToString"
      },
      {
        "url" : "statement",
        "valueString" : "define function ToString(value MedicationRequestStatus): value.value"
      },
      {
        "url" : "displaySequence",
        "valueInteger" : 18
      }],
      "url" : "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
    },
    {
      "extension" : [{
        "url" : "libraryName",
        "valueString" : "FHIRHelpers"
      },
      {
        "url" : "name",
        "valueString" : "ToString"
      },
      {
        "url" : "statement",
        "valueString" : "define function ToString(value MedicationRequestIntent): value.value"
      },
      {
        "url" : "displaySequence",
        "valueInteger" : 19
      }],
      "url" : "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
    }],
    "name" : "EffectiveDataRequirements",
    "status" : "active",
    "type" : {
      "coding" : [{
        "system" : "http://terminology.hl7.org/CodeSystem/library-type",
        "code" : "module-definition"
      }]
    },
    "relatedArtifact" : [{
      "type" : "depends-on",
      "display" : "FHIR model information",
      "resource" : "http://hl7.org/fhir/uv/cql/Library/FHIR-ModelInfo|4.0.1"
    },
    {
      "type" : "depends-on",
      "display" : "Library FHIRHelpers",
      "resource" : "http://hl7.org/fhir/uv/cql/Library/FHIRHelpers|4.0.1"
    },
    {
      "type" : "depends-on",
      "display" : "Library Global",
      "resource" : "http://hl7.org/fhir/uv/cqm/Library/MATGlobalCommonFunctions|5.0.000"
    },
    {
      "type" : "depends-on",
      "display" : "Library Common",
      "resource" : "http://hl7.org/fhir/uv/cqm/Library/Common|2.0.0"
    },
    {
      "type" : "depends-on",
      "display" : "Code system ConditionClinicalStatusCodes",
      "resource" : "http://terminology.hl7.org/CodeSystem/condition-clinical"
    },
    {
      "type" : "depends-on",
      "display" : "Code system ConditionVerificationStatusCodes",
      "resource" : "http://terminology.hl7.org/CodeSystem/condition-ver-status"
    },
    {
      "type" : "depends-on",
      "display" : "Value set Ambulatory/ED Visit",
      "resource" : "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1061"
    },
    {
      "type" : "depends-on",
      "display" : "Value set Acute Pharyngitis",
      "resource" : "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.102.12.1011"
    },
    {
      "type" : "depends-on",
      "display" : "Value set Acute Tonsillitis",
      "resource" : "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.102.12.1012"
    },
    {
      "type" : "depends-on",
      "display" : "Value set Antibiotic Medications",
      "resource" : "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.196.12.1001"
    },
    {
      "type" : "depends-on",
      "display" : "Value set Group A Streptococcus Test",
      "resource" : "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1012"
    }],
    "parameter" : [{
      "name" : "Measurement Period",
      "use" : "in",
      "min" : 0,
      "max" : "1",
      "type" : "Period"
    },
    {
      "name" : "Numerator",
      "use" : "out",
      "min" : 0,
      "max" : "*",
      "type" : "Encounter"
    },
    {
      "name" : "Denominator",
      "use" : "out",
      "min" : 0,
      "max" : "*",
      "type" : "Encounter"
    },
    {
      "name" : "Initial Population",
      "use" : "out",
      "min" : 0,
      "max" : "*",
      "type" : "Encounter"
    },
    {
      "name" : "Denominator Exclusions",
      "use" : "out",
      "min" : 0,
      "max" : "*",
      "type" : "Encounter"
    }],
    "dataRequirement" : [{
      "type" : "Patient",
      "profile" : ["http://hl7.org/fhir/StructureDefinition/Patient"]
    },
    {
      "type" : "Encounter",
      "profile" : ["http://hl7.org/fhir/StructureDefinition/Encounter"],
      "mustSupport" : ["type", "period", "status"],
      "codeFilter" : [{
        "path" : "type",
        "valueSet" : "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1061"
      }]
    },
    {
      "type" : "Condition",
      "profile" : ["http://hl7.org/fhir/StructureDefinition/Condition"],
      "mustSupport" : ["code", "clinicalStatus", "verificationStatus", "onset"],
      "codeFilter" : [{
        "path" : "code",
        "valueSet" : "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.102.12.1011"
      }]
    },
    {
      "type" : "Condition",
      "profile" : ["http://hl7.org/fhir/StructureDefinition/Condition"],
      "mustSupport" : ["code", "clinicalStatus", "verificationStatus", "onset"],
      "codeFilter" : [{
        "path" : "code",
        "valueSet" : "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.102.12.1012"
      }]
    },
    {
      "type" : "MedicationRequest",
      "profile" : ["http://hl7.org/fhir/StructureDefinition/MedicationRequest"],
      "mustSupport" : ["medication", "status", "intent", "authoredOn"],
      "codeFilter" : [{
        "path" : "medication",
        "valueSet" : "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.196.12.1001"
      }]
    },
    {
      "type" : "Observation",
      "profile" : ["http://hl7.org/fhir/StructureDefinition/Observation"],
      "mustSupport" : ["code", "value", "effective"],
      "codeFilter" : [{
        "path" : "code",
        "valueSet" : "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1012"
      }]
    }]
  }],
  "extension" : [{
    "url" : "http://hl7.org/fhir/uv/cqm/StructureDefinition/cqm-populationBasis",
    "valueCode" : "Encounter"
  },
  {
    "url" : "http://hl7.org/fhir/uv/crmi/StructureDefinition/crmi-softwaresystem",
    "valueReference" : {
      "reference" : "Device/software-system-example"
    }
  },
  {
    "url" : "http://hl7.org/fhir/uv/crmi/StructureDefinition/crmi-effectiveDataRequirements",
    "valueCanonical" : "#effective-data-requirements"
  }],
  "url" : "http://hl7.org/fhir/uv/cqm/Measure/EXM146-FHIR",
  "identifier" : [{
    "use" : "official",
    "system" : "http://example.org/fhir/cqi/ecqm/Measure/Identifier/exm",
    "value" : "146"
  },
  {
    "system" : "urn:ietf:rfc:3986",
    "value" : "urn:oid:2.16.840.1.113883.4.642.40.61.29.7"
  }],
  "version" : "4.0.0",
  "name" : "EXM146",
  "title" : "EXM146 - Appropriate Testing for Children with Pharyngitis",
  "status" : "active",
  "experimental" : true,
  "date" : "2025-08-13",
  "publisher" : "HL7 International / Clinical Quality Information",
  "contact" : [{
    "telecom" : [{
      "system" : "url",
      "value" : "http://www.hl7.org/Special/committees/cqi"
    }]
  }],
  "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.",
  "useContext" : [{
    "code" : {
      "system" : "http://terminology.hl7.org/CodeSystem/usage-context-type",
      "code" : "venue",
      "display" : "Clinical Venue"
    },
    "valueCodeableConcept" : {
      "coding" : [{
        "system" : "http://hl7.org/fhir/uv/cqm/CodeSystem/intended-venue-codes",
        "code" : "ec",
        "display" : "EC"
      }]
    }
  }],
  "jurisdiction" : [{
    "coding" : [{
      "system" : "http://unstats.un.org/unsd/methods/m49/m49.htm",
      "code" : "001"
    }]
  }],
  "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). \r\nThe 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. \r\n(c) 2008 -2014 National Committee for Quality Assurance. All Rights Reserved. \r\nLimited 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.\r\nCPT(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.",
  "approvalDate" : "2016-01-01",
  "lastReviewDate" : "2016-09-01",
  "effectivePeriod" : {
    "start" : "2018-01-01",
    "end" : "2018-12-31"
  },
  "topic" : [{
    "coding" : [{
      "system" : "http://loinc.org",
      "code" : "57024-2",
      "display" : "Health Quality Measure Document"
    }]
  }],
  "library" : ["http://hl7.org/fhir/uv/cqm/Library/EXM146"],
  "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. \n Due to technical limitations, registered trademarks are indicated by (R) or [R] and unregistered trademarks are indicated by (TM) or [TM].",
  "scoring" : {
    "coding" : [{
      "system" : "http://terminology.hl7.org/CodeSystem/measure-scoring",
      "code" : "proportion",
      "display" : "Proportion"
    }]
  },
  "type" : [{
    "coding" : [{
      "system" : "http://terminology.hl7.org/CodeSystem/measure-type",
      "code" : "process"
    }]
  }],
  "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).",
  "clinicalRecommendationStatement" : "Institute for Clinical Systems Improvement (ICSI) (2007) \n 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. \nInfectious Disease Society of America (Bisno et al. 2002) \nThe 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. \nWith 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. \nMichigan Quality Improvement Consortium (2007)\nProbability 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)",
  "improvementNotation" : {
    "coding" : [{
      "system" : "http://terminology.hl7.org/CodeSystem/measure-improvement-notation",
      "code" : "increase",
      "display" : "Increased score indicates improvement"
    }]
  },
  "guidance" : "This is an episode of care measure that examines all eligible episodes for the patient during the measurement period. If the patient has more than one episode, include all episodes in the measure.",
  "group" : [{
    "id" : "group-1",
    "extension" : [{
      "url" : "http://hl7.org/fhir/5.0/StructureDefinition/extension-Measure.group.linkId",
      "valueString" : "primary"
    }],
    "population" : [{
      "extension" : [{
        "url" : "http://hl7.org/fhir/5.0/StructureDefinition/extension-Measure.group.population.linkId",
        "valueString" : "primary-exm146-initial-population"
      }],
      "code" : {
        "coding" : [{
          "system" : "http://terminology.hl7.org/CodeSystem/measure-population",
          "code" : "initial-population",
          "display" : "Initial Population"
        }]
      },
      "criteria" : {
        "language" : "text/cql-identifier",
        "expression" : "Initial Population"
      }
    },
    {
      "extension" : [{
        "url" : "http://hl7.org/fhir/5.0/StructureDefinition/extension-Measure.group.population.linkId",
        "valueString" : "primary-exm146-numerator"
      }],
      "code" : {
        "coding" : [{
          "system" : "http://terminology.hl7.org/CodeSystem/measure-population",
          "code" : "numerator",
          "display" : "Numerator"
        }]
      },
      "criteria" : {
        "language" : "text/cql-identifier",
        "expression" : "Numerator"
      }
    },
    {
      "extension" : [{
        "url" : "http://hl7.org/fhir/5.0/StructureDefinition/extension-Measure.group.population.linkId",
        "valueString" : "primary-exm146-denominator"
      }],
      "code" : {
        "coding" : [{
          "system" : "http://terminology.hl7.org/CodeSystem/measure-population",
          "code" : "denominator",
          "display" : "Denominator"
        }]
      },
      "criteria" : {
        "language" : "text/cql-identifier",
        "expression" : "Denominator"
      }
    },
    {
      "extension" : [{
        "url" : "http://hl7.org/fhir/5.0/StructureDefinition/extension-Measure.group.population.linkId",
        "valueString" : "primary-exm146-denominator-exclusion"
      }],
      "code" : {
        "coding" : [{
          "system" : "http://terminology.hl7.org/CodeSystem/measure-population",
          "code" : "denominator-exclusion",
          "display" : "Denominator Exclusion"
        }]
      },
      "criteria" : {
        "language" : "text/cql-identifier",
        "expression" : "Denominator Exclusions"
      }
    }]
  }]
}

```
