Quality Measure Implementation Guide (STU4)
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Quality Measure Implementation Guide (STU4), published by Clinical Quality Information WG. This is not an authorized publication; it is the continuous build for version 4.0.0-ballot). This version is based on the current content of https://github.com/HL7/cqf-measures/ and changes regularly. See the Directory of published versions

Example Measure: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention

Draft as of 2022-02-22
Id: TSCComponent
Url: http://hl7.org/fhir/us/cqfmeasures/Measure/TSCComponent
Version: 0.0.001
Name: TSCComponent
Title: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
Status: draft
Experimental: true
Scoring:

Proportion

Improvement Notation:

increase

Type:

process

Date: 2022-02-22 11:37:04-0600
Publisher: Clinical Quality Information WG
Description:

This is an example only.

Populations:
GroupPopulationDescription
group-1
Initial Population
Denominator
Denominator Exception
Numerator
group-2
Initial Population
Denominator
Denominator Exception
Numerator
group-3
Initial Population
Denominator
Denominator Exception
Numerator
Supplemental Data:
expressionsystem
SDE Ethnicity http://terminology.hl7.org/CodeSystem/measure-data-usage
SDE Payer http://terminology.hl7.org/CodeSystem/measure-data-usage
SDE Race http://terminology.hl7.org/CodeSystem/measure-data-usage
SDE Sex http://terminology.hl7.org/CodeSystem/measure-data-usage
Jurisdiction: US
Effective Period: 2022-01-01..2022-12-31
Logic Definitions:
GroupScoringPopulation CriteriaExpression
group-1 Measure scoring:

Proportion

Initial Population
define "Initial Population":   exists ( ["Patient"] BirthDate         where Global."CalendarAgeInYearsAt" ( FHIRHelpers.ToDate ( BirthDate.birthDate ), start of "Measurement Period" ) >= 18     )       and ( Count("Office Based Visit During Measurement Period")>= 2           or exists "Preventive Visit During Measurement Period"       )
Denominator
define "Denominator 1":   "Initial Population"
Denominator Exception
define "Denominator Exceptions 1":   exists "Medical Reason for Not Screening for Tobacco Use"       or "Has Limited Life Expectancy"
Numerator
define "Numerator 1":   "Most Recent Tobacco Use Screening Indicates Tobacco Non User" is not null       or "Most Recent Tobacco Use Screening Indicates Tobacco User" is not null
group-2 Measure scoring:

Proportion

Initial Population
define "Initial Population":   exists ( ["Patient"] BirthDate         where Global."CalendarAgeInYearsAt" ( FHIRHelpers.ToDate ( BirthDate.birthDate ), start of "Measurement Period" ) >= 18     )       and ( Count("Office Based Visit During Measurement Period")>= 2           or exists "Preventive Visit During Measurement Period"       )
Denominator
define "Denominator 2":   "Initial Population"       and "Most Recent Tobacco Use Screening Indicates Tobacco User" is not null
Denominator Exception
define "Denominator Exceptions 2":   exists "Medical Reason for Not Counseling Tobacco User"       or exists "Medical Reason for Not Ordering Tobacco Cessation Pharmacotherapy"       or "Has Limited Life Expectancy"
Numerator
define "Numerator 2":   exists "Tobacco Cessation Counseling Given"       or exists "Tobacco Cessation Pharmacotherapy Ordered"
group-3 Measure scoring:

Proportion

Initial Population
define "Initial Population":   exists ( ["Patient"] BirthDate         where Global."CalendarAgeInYearsAt" ( FHIRHelpers.ToDate ( BirthDate.birthDate ), start of "Measurement Period" ) >= 18     )       and ( Count("Office Based Visit During Measurement Period")>= 2           or exists "Preventive Visit During Measurement Period"       )
Denominator
define "Denominator 3":   "Initial Population"
Denominator Exception
define "Denominator Exceptions 3":   exists "Medical Reason for Not Screening for Tobacco Use"       or exists "Medical Reason for Not Counseling Tobacco User"       or exists "Medical Reason for Not Ordering Tobacco Cessation Pharmacotherapy"       or "Has Limited Life Expectancy"
Numerator
define "Numerator 3":   "Most Recent Tobacco Use Screening Indicates Tobacco Non User" is not null       or ( "Most Recent Tobacco Use Screening Indicates Tobacco User" is not null           and ( exists "Tobacco Cessation Counseling Given"               or exists "Tobacco Cessation Pharmacotherapy Ordered"               //or exists "Active Pharmacotherapy for Tobacco Cessation"           )       )
Library NameNamesequence
TSCComponent Most Recent Tobacco Use Screening Indicates Tobacco Non User
define "Most Recent Tobacco Use Screening Indicates Tobacco Non User":   ( Last(["Observation": "Tobacco Use Screening"] TobaccoUseScreening         where Global."Normalize Interval"(TobaccoUseScreening.effective)overlaps "Measurement Period"         sort by start of Global."Normalize Interval"(effective)     )) MostRecentTobaccoUseScreening       where MostRecentTobaccoUseScreening.value in "Tobacco Non-User"


Library NameNamesequence
TSCComponent Most Recent Tobacco Use Screening Indicates Tobacco User
define "Most Recent Tobacco Use Screening Indicates Tobacco User":   ( Last(["Observation": "Tobacco Use Screening"] TobaccoUseScreening         where Global."Normalize Interval"(TobaccoUseScreening.effective)overlaps "Measurement Period"         sort by start of Global."Normalize Interval"(effective)     )) MostRecentTobaccoUseScreening       where MostRecentTobaccoUseScreening.value in "Tobacco User"


Library NameNamesequence
TSCComponent Tobacco Cessation Counseling Given
// MedicationStatement is not available in R5, known publication issue //define "Active Pharmacotherapy for Tobacco Cessation": //  ["MedicationStatement": "Tobacco Use Cessation Pharmacotherapy"] TakingCessationPharmacotherapy //      where Global."Normalize Interval" ( TakingCessationPharmacotherapy.effective ) overlaps after "Measurement Period" //        and TakingCessationPharmacotherapy.status in { 'active', 'completed' } define "Tobacco Cessation Counseling Given":   ["Encounter": "Tobacco Use Cessation Counseling"] TobaccoCessationCounseling       where TobaccoCessationCounseling.period during "Measurement Period"         and TobaccoCessationCounseling.status = 'finished'


Library NameNamesequence
TSCComponent Tobacco Cessation Pharmacotherapy Ordered
define "Tobacco Cessation Pharmacotherapy Ordered":   ["MedicationRequest": "Tobacco Use Cessation Pharmacotherapy"] CessationPharmacotherapyOrdered       where CessationPharmacotherapyOrdered.authoredOn during "Measurement Period"         and CessationPharmacotherapyOrdered.status = 'active'


Library NameNamesequence
TSCComponent Numerator 3
define "Numerator 3":   "Most Recent Tobacco Use Screening Indicates Tobacco Non User" is not null       or ( "Most Recent Tobacco Use Screening Indicates Tobacco User" is not null           and ( exists "Tobacco Cessation Counseling Given"               or exists "Tobacco Cessation Pharmacotherapy Ordered"               //or exists "Active Pharmacotherapy for Tobacco Cessation"           )       )


Library NameNamesequence
TSCComponent Medical Reason for Not Screening for Tobacco Use
define "Medical Reason for Not Screening for Tobacco Use":   ["Observation": "Tobacco Use Screening"] NoTobaccoUseScreening       where NoTobaccoUseScreening.issued during "Measurement Period"         and "Not Done"(NoTobaccoUseScreening)         and "Not Done Reason in Medical Reason"(NoTobaccoUseScreening)         and NoTobaccoUseScreening.status = 'final'


Library NameNamesequence
TSCComponent Has Limited Life Expectancy
//or exists "Active Pharmacotherapy for Tobacco Cessation" define "Has Limited Life Expectancy":   exists ( ["Condition"] LimitedLifeExpectancy         where Global."Prevalence Period" ( LimitedLifeExpectancy ) overlaps after "Measurement Period"           and LimitedLifeExpectancy.clinicalStatus ~ ToConcept(Global."active")     )


Library NameNamesequence
TSCComponent Denominator Exceptions 1
define "Denominator Exceptions 1":   exists "Medical Reason for Not Screening for Tobacco Use"       or "Has Limited Life Expectancy"


Library NameNamesequence
TSCComponent Numerator 1
define "Numerator 1":   "Most Recent Tobacco Use Screening Indicates Tobacco Non User" is not null       or "Most Recent Tobacco Use Screening Indicates Tobacco User" is not null


Library NameNamesequence
TSCComponent Numerator 2
define "Numerator 2":   exists "Tobacco Cessation Counseling Given"       or exists "Tobacco Cessation Pharmacotherapy Ordered"


Library NameNamesequence
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 NameNamesequence
TSCComponent SDE Race
define "SDE Race":   SDE."SDE Race"


Library NameNamesequence
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 NameNamesequence
TSCComponent SDE Sex
define "SDE Sex":   SDE."SDE Sex"


Library NameNamesequence
TSCComponent Office Based Visit During Measurement Period
define "Office Based Visit During Measurement Period":   ( ["Encounter": "Health behavior intervention, individual, face-to-face; initial 30 minutes"]       union ["Encounter": "Health behavior assessment, or re-assessment (ie, health-focused clinical interview, behavioral observations, clinical decision making)"]       union ["Encounter": "Home Healthcare Services"]       union ["Encounter": "Occupational Therapy Evaluation"]       union ["Encounter": "Office Visit"]       union ["Encounter": "Ophthalmological Services"]       union ["Encounter": "Physical Therapy Evaluation"]       union ["Encounter": "Psych Visit - Diagnostic Evaluation"]       union ["Encounter": "Psych Visit - Psychotherapy"]       union ["Encounter": "Psychoanalysis"]       union ["Encounter": "Speech and Hearing Evaluation"] ) OfficeBasedEncounter       where OfficeBasedEncounter.period during "Measurement Period"         and OfficeBasedEncounter.status = 'finished'


Library NameNamesequence
TSCComponent Preventive Visit During Measurement Period
define "Preventive Visit During Measurement Period":   ( ["Encounter": "Annual Wellness Visit"]       union ["Encounter": "Preventive Care Services - Established Office Visit, 18 and Up"]       union ["Encounter": "Preventive Care Services - Group Counseling"]       union ["Encounter": "Preventive Care Services - Other"]       union ["Encounter": "Preventive Care Services-Individual Counseling"]       union ["Encounter": "Preventive Care Services-Initial Office Visit, 18 and Up"] ) PreventiveEncounter       where PreventiveEncounter.period during "Measurement Period"         and PreventiveEncounter.status = 'finished'


Library NameNamesequence
TSCComponent Initial Population
define "Initial Population":   exists ( ["Patient"] BirthDate         where Global."CalendarAgeInYearsAt" ( FHIRHelpers.ToDate ( BirthDate.birthDate ), start of "Measurement Period" ) >= 18     )       and ( Count("Office Based Visit During Measurement Period")>= 2           or exists "Preventive Visit During Measurement Period"       )


Library NameNamesequence
TSCComponent Denominator 3
define "Denominator 3":   "Initial Population"


Library NameNamesequence
TSCComponent Denominator 2
define "Denominator 2":   "Initial Population"       and "Most Recent Tobacco Use Screening Indicates Tobacco User" is not null


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


Library NameNamesequence
TSCComponent SDE Payer
define "SDE Payer":   SDE."SDE Payer"


Library NameNamesequence
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 NameNamesequence
TSCComponent SDE Ethnicity
define "SDE Ethnicity":   SDE."SDE Ethnicity"


Library NameNamesequence
TSCComponent Medical Reason for Not Counseling Tobacco User
define "Medical Reason for Not Counseling Tobacco User":   ["Procedure": "Tobacco Use Cessation Counseling"] NoTobaccoCessationCounseling       where Global."Normalize Interval" ( NoTobaccoCessationCounseling.performed ) starts during "Measurement Period"         and ( ( NoTobaccoCessationCounseling.status = 'not-done'               and NoTobaccoCessationCounseling.statusReason in "Medical Reason"           )             or ( "Not Done"(NoTobaccoCessationCounseling)                 and "Not Done Reason in Medical Reason"(NoTobaccoCessationCounseling)             )         )


Library NameNamesequence
TSCComponent Medical Reason for Not Ordering Tobacco Cessation Pharmacotherapy
define "Medical Reason for Not Ordering Tobacco Cessation Pharmacotherapy":   ["MedicationRequest": "Tobacco Use Cessation Pharmacotherapy"] NoCessationPharmacotherapyOrdered       where NoCessationPharmacotherapyOrdered.authoredOn during "Measurement Period"         and NoCessationPharmacotherapyOrdered.status = 'completed'         and ( ( "Not Done"(NoCessationPharmacotherapyOrdered)               and "Not Done Reason in Medical Reason"(NoCessationPharmacotherapyOrdered)           )             or ( NoCessationPharmacotherapyOrdered.doNotPerform = true                 and NoCessationPharmacotherapyOrdered.statusReason in "Medical Reason"             )         )


Library NameNamesequence
TSCComponent Denominator Exceptions 2
define "Denominator Exceptions 2":   exists "Medical Reason for Not Counseling Tobacco User"       or exists "Medical Reason for Not Ordering Tobacco Cessation Pharmacotherapy"       or "Has Limited Life Expectancy"


Library NameNamesequence
TSCComponent Denominator Exceptions 3
define "Denominator Exceptions 3":   exists "Medical Reason for Not Screening for Tobacco Use"       or exists "Medical Reason for Not Counseling Tobacco User"       or exists "Medical Reason for Not Ordering Tobacco Cessation Pharmacotherapy"       or "Has Limited Life Expectancy"


Library NameNamesequence
TSCComponent Denominator 1
define "Denominator 1":   "Initial Population"


Contained resources