Quality Measure Implementation Guide (STU3 Ballot)
2.1.0 - ballot

Quality Measure Implementation Guide (STU3 Ballot), published by Clinical Quality Information WG. This is not an authorized publication; it is the continuous build for version 2.1.0). This version is based on the current content of https://github.com/HL7/cqf-measures/ and changes regularly. See the Directory of published versions

: Appropriate Testing for Children with Pharyngitis - XML Representation

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<Measure xmlns="http://hl7.org/fhir">
  <id value="measure-exm146-FHIR"/>
  <meta>
    <profile
             value="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/proportion-measure-cqfm"/>
    <profile
             value="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/computable-measure-cqfm"/>
  </meta>
  <text>
    <status value="extensions"/>
    <div xmlns="http://www.w3.org/1999/xhtml">
    <table class="grid dict">
        
        <tr>
            <th scope="row"><b>Id: </b></th>
            <td style="padding-left: 4px;">measure-exm146-FHIR</td>
        </tr>
        
        
        <tr>
            <th scope="row"><b>Url: </b></th>
            <td style="padding-left: 4px;">http://hl7.org/fhir/us/cqfmeasures/Measure/measure-exm146-FHIR</td>
        </tr>
        
        
        <tr>
            <th scope="row"><b>Version: </b></th>
            <td style="padding-left: 4px;">4.0.0</td>
        </tr>
        
        
        <tr>
            <th scope="row"><b>Identifier: </b></th>
            <td style="padding-left: 4px;">
                
                
                <p style="margin-bottom: 5px;">
                    <b>value: </b> <span>146</span>
                </p>
                
            </td>
        </tr>
        
        
        <tr>
            <th scope="row"><b>Name: </b></th>
            <td style="padding-left: 4px;">EXM146</td>
        </tr>
        
        
        <tr>
            <th scope="row"><b>Title: </b></th>
            <td style="padding-left: 4px;">Appropriate Testing for Children with Pharyngitis</td>
        </tr>
        
        
        
        <tr>
            <th scope="row"><b>Status: </b></th>
            <td style="padding-left: 4px;">active</td>
        </tr>
        
        
        <tr>
            <th scope="row"><b>Experimental: </b></th>
            <td style="padding-left: 4px;">true</td>
        </tr>
        
        
        <tr>
            <th scope="row"><b>Scoring: </b></th>
            <td style="padding-left: 4px;">
                
                    
                        
                        <p style="margin-bottom: 5px;">
                            <b>system: </b> <span>http://terminology.hl7.org/CodeSystem/measure-scoring</span>
                        </p>
                        
                        
                        <p style="margin-bottom: 5px;">
                            <b>code: </b> <span>proportion</span>
                        </p>
                        
                        
                        <p style="margin-bottom: 5px;">
                            <b>display: </b> <span>Proportion</span>
                        </p>
                        
                    
                
                
            </td>
        </tr>
        
        
        <tr>
            <th scope="row"><b>Improvement Notation: </b></th>
            <td style="padding-left: 4px;">
                
                    
                        
                        <p style="margin-bottom: 5px;">
                            <b>system: </b> <span>http://terminology.hl7.org/CodeSystem/measure-improvement-notation</span>
                        </p>
                        
                        
                        <p style="margin-bottom: 5px;">
                            <b>code: </b> <span>increase</span>
                        </p>
                        
                        
                        <p style="margin-bottom: 5px;">
                            <b>display: </b> <span>Increased score indicates improvement</span>
                        </p>
                        
                    
                
                
            </td>
        </tr>
        
        
        <tr>
            <th scope="row"><b>Type: </b></th>
            <td style="padding-left: 4px;">
                
                    
                        
                        <p style="margin-bottom: 5px;">
                            <b>system: </b> <span>http://terminology.hl7.org/CodeSystem/measure-type</span>
                        </p>
                        
                        
                        <p style="margin-bottom: 5px;">
                            <b>code: </b> <span>process</span>
                        </p>
                        
                        
                    
                
                
            </td>
        </tr>
        
        
        
        <tr>
            <th scope="row"><b>Date: </b></th>
            <td style="padding-left: 4px;">2021-04-03</td>
        </tr>
        
        
        <tr>
            <th scope="row"><b>Publisher: </b></th>
            <td style="padding-left: 4px;">Clinical Quality Information WG</td>
        </tr>
        
        
        <tr>
            <th scope="row"><b>Description: </b></th>
            <td style="padding-left: 4px;">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.</td>
        </tr>
        
        
        
        
        <tr>
            <th scope="row"><b>Parameters: </b></th>
            <td style="padding-left: 4px;">
                <table class="grid-dict">
                    <tr><th><b>name</b></th><th><b>use</b></th><th><b>min</b></th><th><b>max</b></th><th><b>type</b></th></tr>
                    
                    <tr>
                        <td>Measurement Period</td>
                        <td>in</td>
                        <td>0</td>
                        <td>1</td>
                        <td>Period</td>
                    </tr>
                    
                    <tr>
                        <td>Numerator</td>
                        <td>out</td>
                        <td>0</td>
                        <td>*</td>
                        <td>Encounter</td>
                    </tr>
                    
                    <tr>
                        <td>Strep Test Encounters</td>
                        <td>out</td>
                        <td>0</td>
                        <td>*</td>
                        <td>Encounter</td>
                    </tr>
                    
                    <tr>
                        <td>Pharyngitis Encounters With Antibiotics</td>
                        <td>out</td>
                        <td>0</td>
                        <td>*</td>
                        <td>Encounter</td>
                    </tr>
                    
                    <tr>
                        <td>Measurement Period Encounters</td>
                        <td>out</td>
                        <td>0</td>
                        <td>*</td>
                        <td>Encounter</td>
                    </tr>
                    
                    <tr>
                        <td>Is Between 2 and 17 Years of Age at Start of Measurement Period</td>
                        <td>out</td>
                        <td>0</td>
                        <td>1</td>
                        <td>boolean</td>
                    </tr>
                    
                    <tr>
                        <td>Pharyngitis</td>
                        <td>out</td>
                        <td>0</td>
                        <td>*</td>
                        <td>Condition</td>
                    </tr>
                    
                    <tr>
                        <td>Antibiotics</td>
                        <td>out</td>
                        <td>0</td>
                        <td>*</td>
                        <td>MedicationRequest</td>
                    </tr>
                    
                    <tr>
                        <td>Initial Population</td>
                        <td>out</td>
                        <td>0</td>
                        <td>*</td>
                        <td>Encounter</td>
                    </tr>
                    
                </table>
            </td>
        </tr>
        
        
        <tr>
          <th scope="row"><b>Data Requirements: </b></th>
          <td style="padding-left: 4px;">
                <table class="grid-dict">
                    <tr><th><b>type</b></th><th><b>path</b></th><th><b>valueSet or system</b></th><th><b>code</b></th></tr>
                    
                        <tr>
                            <td>Encounter</td>
                            <td>type</td>
                            
                                <td>http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1061</td>
                                <td></td>
                            
                            
                        </tr>
                    
                        <tr>
                            <td>Condition</td>
                            <td>code</td>
                            
                                <td>http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.102.12.1011</td>
                                <td></td>
                            
                            
                        </tr>
                    
                        <tr>
                            <td>Condition</td>
                            <td>code</td>
                            
                                <td>http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.102.12.1012</td>
                                <td></td>
                            
                            
                        </tr>
                    
                        <tr>
                            <td>MedicationRequest</td>
                            <td>medication</td>
                            
                                <td>http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.196.12.1001</td>
                                <td></td>
                            
                            
                        </tr>
                    
                        <tr>
                            <td>Observation</td>
                            <td>code</td>
                            
                                <td>http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1012</td>
                                <td></td>
                            
                            
                        </tr>
                    
                </table>
          </td>
        </tr>
        
        
        <tr>
          <th scope="row"><b>Direct Reference Codes: </b></th>
          <td style="padding-left: 4px;">
                <table class="grid-dict">
                    <tr><th><b>display</b></th><th><b>code</b></th><th><b>system</b></th></tr>
                    
                        <tr>
                            <td></td>
                            <td>active</td>
                            <td></td>
                        </tr>
                    
                        <tr>
                            <td></td>
                            <td>confirmed</td>
                            <td></td>
                        </tr>
                    
                </table>
          </td>
        </tr>
        
        
        
        <tr>
            <th scope="row"><b>Use Context: </b></th>
            <td style="padding-left: 4px;">
                <table class="grid-dict">
                    <tr><th><b>code</b></th><th><b>value</b></th></tr>
                    
                      <tr>
                        <td>program</td>
                        <td></td>
                      </tr>
                    
                </table>
            </td>
        </tr>
        
        
        <tr>
            <th scope="row"><b>Jurisdiction: </b></th>
            <td style="padding-left: 25px;">US</td>
        </tr>
        
        
        <tr>
            <th scope="row"><b>Topic: </b></th>
            <td style="padding-left: 25px;">57024-2</td>
        </tr>
        
        
        <tr>
            <th scope="row"><b>Purpose: </b></th>
            <td style="padding-left: 4px;">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).</td>
        </tr>
        
        
        
        <tr>
            <th scope="row"><b>Copyright: </b></th>
            <td style="padding-left: 25px;">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.</td>
        </tr>
        
        
        <tr>
            <th scope="row"><b>Disclaimer: </b></th>
            <td style="padding-left: 25px;">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].</td>
        </tr>
        
        
        <tr>
            <th scope="row"><b>Approval Date: </b></th>
            <td style="padding-left: 4px;">2016-01-01</td>
        </tr>
        
        
        <tr>
            <th scope="row"><b>Last Review Date: </b></th>
            <td style="padding-left: 4px;">2016-09-01</td>
        </tr>
        
        
        <tr>
            <th scope="row"><b>Effective Period: </b></th>
            <td style="padding-left: 4px;">2018-01-01..2018-12-31</td>
        </tr>
        
        
        <tr>
          <th scope="row"><b>Related Artifacts: </b></th>
          <td style="padding-left: 4px;">
            
            
            
            <p><b>Dependencies</b></p>
            <ul>
              
                <li>http://fhir.org/guides/cqf/common/Library/FHIRHelpers|4.0.1</li>
              
                <li>http://hl7.org/fhir/us/cqfmeasures/Library/MATGlobalCommonFunctions|5.0.000</li>
              
                <li>http://hl7.org/fhir/us/cqfmeasures/Library/Common|2.0.0</li>
              
                <li>http://terminology.hl7.org/CodeSystem/condition-clinical</li>
              
                <li>http://terminology.hl7.org/CodeSystem/condition-verification</li>
              
                <li>http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1061</li>
              
                <li>http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.102.12.1011</li>
              
                <li>http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.102.12.1012</li>
              
                <li>http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.196.12.1001</li>
              
                <li>http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1012</li>
              
            </ul>
            
            
            
            
            
          </td>
        </tr>
        
        
        
        
        
        <tr>
          <th scope="row"><b>Logic Definitions: </b></th>
          <td style="padding-left: 4px;">
            
                <table class="grid-dict">
                    <tr><th><b>Library Name</b></th><th><b>Name</b></th><th><b>sequence</b></th></tr>
                    <tr>
                        
                            <td>EXM146</td>
                        
                        
                            <td>Numerator</td>
                        
                        
                    </tr>
                </table>
                
                    <pre><code class="language-cql">define "Numerator":
   "Strep Test Encounters"</code></pre>
                
                <br/><br/>
            
                <table class="grid-dict">
                    <tr><th><b>Library Name</b></th><th><b>Name</b></th><th><b>sequence</b></th></tr>
                    <tr>
                        
                            <td>EXM146</td>
                        
                        
                            <td>Strep Test Encounters</td>
                        
                        
                    </tr>
                </table>
                
                    <pre><code class="language-cql">// EndRegion: Denominator Exclusions

// Region: Denominator Exceptions

// None

// EndRegion: Denominator Exceptions

// Region: Numeratordefine "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]</code></pre>
                
                <br/><br/>
            
                <table class="grid-dict">
                    <tr><th><b>Library Name</b></th><th><b>Name</b></th><th><b>sequence</b></th></tr>
                    <tr>
                        
                            <td>EXM146</td>
                        
                        
                            <td>Pharyngitis Encounters With Antibiotics</td>
                        
                        
                    </tr>
                </table>
                
                    <pre><code class="language-cql">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)</code></pre>
                
                <br/><br/>
            
                <table class="grid-dict">
                    <tr><th><b>Library Name</b></th><th><b>Name</b></th><th><b>sequence</b></th></tr>
                    <tr>
                        
                            <td>EXM146</td>
                        
                        
                            <td>Measurement Period Encounters</td>
                        
                        
                    </tr>
                </table>
                
                    <pre><code class="language-cql">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"</code></pre>
                
                <br/><br/>
            
                <table class="grid-dict">
                    <tr><th><b>Library Name</b></th><th><b>Name</b></th><th><b>sequence</b></th></tr>
                    <tr>
                        
                            <td>EXM146</td>
                        
                        
                            <td>Is Between 2 and 17 Years of Age at Start of Measurement Period</td>
                        
                        
                    </tr>
                </table>
                
                    <pre><code class="language-cql">// Region: Initial Populationdefine "Is Between 2 and 17 Years of Age at Start of Measurement Period":
   AgeInYearsAt(start of "Measurement Period") &gt;= 2
      and AgeInYearsAt(start of "Measurement Period") &lt;= 17</code></pre>
                
                <br/><br/>
            
                <table class="grid-dict">
                    <tr><th><b>Library Name</b></th><th><b>Name</b></th><th><b>sequence</b></th></tr>
                    <tr>
                        
                            <td>EXM146</td>
                        
                        
                            <td>Pharyngitis</td>
                        
                        
                    </tr>
                </table>
                
                    <pre><code class="language-cql">define "Pharyngitis":
   ([Condition: code in "Acute Pharyngitis"]
     union [Condition: code in "Acute Tonsillitis"]) Pharyngitis
     where Pharyngitis.clinicalStatus ~ Global.active
       and Pharyngitis.verificationStatus ~ Global.confirmed</code></pre>
                
                <br/><br/>
            
                <table class="grid-dict">
                    <tr><th><b>Library Name</b></th><th><b>Name</b></th><th><b>sequence</b></th></tr>
                    <tr>
                        
                            <td>EXM146</td>
                        
                        
                            <td>Antibiotics</td>
                        
                        
                    </tr>
                </table>
                
                    <pre><code class="language-cql">define "Antibiotics":
   [MedicationRequest: medication in "Antibiotic Medications"] Prescription
     where Prescription.status = 'active'
       and Prescription.intent = 'order'</code></pre>
                
                <br/><br/>
            
                <table class="grid-dict">
                    <tr><th><b>Library Name</b></th><th><b>Name</b></th><th><b>sequence</b></th></tr>
                    <tr>
                        
                            <td>EXM146</td>
                        
                        
                            <td>Initial Population</td>
                        
                        
                    </tr>
                </table>
                
                    <pre><code class="language-cql">define "Initial Population":
   "Pharyngitis Encounters With Antibiotics"</code></pre>
                
                <br/><br/>
            
          </td>
        </tr>
        
    </table>
</div>
  </text>
  <extension
             url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-populationBasis">
    <valueCode value="Encounter"/>
  </extension>
  <extension
             url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-parameter">
    <valueParameterDefinition>
      <name value="Measurement Period"/>
      <use value="in"/>
      <min value="0"/>
      <max value="1"/>
      <type value="Period"/>
    </valueParameterDefinition>
  </extension>
  <extension
             url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-parameter">
    <valueParameterDefinition>
      <name value="Numerator"/>
      <use value="out"/>
      <min value="0"/>
      <max value="*"/>
      <type value="Encounter"/>
    </valueParameterDefinition>
  </extension>
  <extension
             url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-parameter">
    <valueParameterDefinition>
      <name value="Strep Test Encounters"/>
      <use value="out"/>
      <min value="0"/>
      <max value="*"/>
      <type value="Encounter"/>
    </valueParameterDefinition>
  </extension>
  <extension
             url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-parameter">
    <valueParameterDefinition>
      <name value="Pharyngitis Encounters With Antibiotics"/>
      <use value="out"/>
      <min value="0"/>
      <max value="*"/>
      <type value="Encounter"/>
    </valueParameterDefinition>
  </extension>
  <extension
             url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-parameter">
    <valueParameterDefinition>
      <name value="Measurement Period Encounters"/>
      <use value="out"/>
      <min value="0"/>
      <max value="*"/>
      <type value="Encounter"/>
    </valueParameterDefinition>
  </extension>
  <extension
             url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-parameter">
    <valueParameterDefinition>
      <name
            value="Is Between 2 and 17 Years of Age at Start of Measurement Period"/>
      <use value="out"/>
      <min value="0"/>
      <max value="1"/>
      <type value="boolean"/>
    </valueParameterDefinition>
  </extension>
  <extension
             url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-parameter">
    <valueParameterDefinition>
      <name value="Pharyngitis"/>
      <use value="out"/>
      <min value="0"/>
      <max value="*"/>
      <type value="Condition"/>
    </valueParameterDefinition>
  </extension>
  <extension
             url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-parameter">
    <valueParameterDefinition>
      <name value="Antibiotics"/>
      <use value="out"/>
      <min value="0"/>
      <max value="*"/>
      <type value="MedicationRequest"/>
    </valueParameterDefinition>
  </extension>
  <extension
             url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-parameter">
    <valueParameterDefinition>
      <name value="Initial Population"/>
      <use value="out"/>
      <min value="0"/>
      <max value="*"/>
      <type value="Encounter"/>
    </valueParameterDefinition>
  </extension>
  <extension
             url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-dataRequirement">
    <valueDataRequirement>
      <type value="Encounter"/>
      <profile value="http://hl7.org/fhir/StructureDefinition/Encounter"/>
      <codeFilter>
        <path value="type"/>
        <valueSet
                  value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1061"/>
      </codeFilter>
    </valueDataRequirement>
  </extension>
  <extension
             url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-dataRequirement">
    <valueDataRequirement>
      <type value="Condition"/>
      <profile value="http://hl7.org/fhir/StructureDefinition/Condition"/>
      <codeFilter>
        <path value="code"/>
        <valueSet
                  value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.102.12.1011"/>
      </codeFilter>
    </valueDataRequirement>
  </extension>
  <extension
             url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-dataRequirement">
    <valueDataRequirement>
      <type value="Condition"/>
      <profile value="http://hl7.org/fhir/StructureDefinition/Condition"/>
      <codeFilter>
        <path value="code"/>
        <valueSet
                  value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.102.12.1012"/>
      </codeFilter>
    </valueDataRequirement>
  </extension>
  <extension
             url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-dataRequirement">
    <valueDataRequirement>
      <type value="MedicationRequest"/>
      <profile value="http://hl7.org/fhir/StructureDefinition/MedicationRequest"/>
      <codeFilter>
        <path value="medication"/>
        <valueSet
                  value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.196.12.1001"/>
      </codeFilter>
    </valueDataRequirement>
  </extension>
  <extension
             url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-dataRequirement">
    <valueDataRequirement>
      <type value="Observation"/>
      <profile value="http://hl7.org/fhir/StructureDefinition/Observation"/>
      <codeFilter>
        <path value="code"/>
        <valueSet
                  value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1012"/>
      </codeFilter>
    </valueDataRequirement>
  </extension>
  <extension
             url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-directReferenceCode">
    <valueCoding>
      <system value="http://terminology.hl7.org/CodeSystem/condition-clinical"/>
      <code value="active"/>
    </valueCoding>
  </extension>
  <extension
             url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-directReferenceCode">
    <valueCoding>
      <system value="http://terminology.hl7.org/CodeSystem/condition-ver-status"/>
      <code value="confirmed"/>
    </valueCoding>
  </extension>
  <extension
             url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
    <extension url="libraryName">
      <valueString value="EXM146"/>
    </extension>
    <extension url="name">
      <valueString value="Numerator"/>
    </extension>
    <extension url="statement">
      <valueString
                   value="define &quot;Numerator&quot;:
   &quot;Strep Test Encounters&quot;"/>
    </extension>
    <extension url="displaySequence">
      <valueInteger value="0"/>
    </extension>
  </extension>
  <extension
             url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
    <extension url="libraryName">
      <valueString value="EXM146"/>
    </extension>
    <extension url="name">
      <valueString value="Strep Test Encounters"/>
    </extension>
    <extension url="statement">
      <valueString
                   value="// EndRegion: Denominator Exclusions

// Region: Denominator Exceptions

// None

// EndRegion: Denominator Exceptions

// Region: Numeratordefine &quot;Strep Test Encounters&quot;:
   &quot;Pharyngitis Encounters With Antibiotics&quot; Encounters
      with [Observation: code in &quot;Group A Streptococcus Test&quot;] 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]"/>
    </extension>
    <extension url="displaySequence">
      <valueInteger value="1"/>
    </extension>
  </extension>
  <extension
             url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
    <extension url="libraryName">
      <valueString value="EXM146"/>
    </extension>
    <extension url="name">
      <valueString value="Pharyngitis Encounters With Antibiotics"/>
    </extension>
    <extension url="statement">
      <valueString
                   value="define &quot;Pharyngitis Encounters With Antibiotics&quot;:
   &quot;Measurement Period Encounters&quot; Encounters
      with &quot;Pharyngitis&quot; Pharyngitis such that
         Common.&quot;Includes Or Starts During&quot;(Pharyngitis, Encounters)
      with &quot;Antibiotics&quot; Antibiotics such that Antibiotics.authoredOn
         3 days or less after FHIRHelpers.ToInterval(Encounters.period)"/>
    </extension>
    <extension url="displaySequence">
      <valueInteger value="2"/>
    </extension>
  </extension>
  <extension
             url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
    <extension url="libraryName">
      <valueString value="EXM146"/>
    </extension>
    <extension url="name">
      <valueString value="Measurement Period Encounters"/>
    </extension>
    <extension url="statement">
      <valueString
                   value="define &quot;Measurement Period Encounters&quot;:
   [Encounter: &quot;Ambulatory/ED Visit&quot;] Encounter
      where Encounter.period during &quot;Measurement Period&quot;
        and Encounter.status = &#39;finished&#39;
        and &quot;Is Between 2 and 17 Years of Age at Start of Measurement Period&quot;"/>
    </extension>
    <extension url="displaySequence">
      <valueInteger value="3"/>
    </extension>
  </extension>
  <extension
             url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
    <extension url="libraryName">
      <valueString value="EXM146"/>
    </extension>
    <extension url="name">
      <valueString
                   value="Is Between 2 and 17 Years of Age at Start of Measurement Period"/>
    </extension>
    <extension url="statement">
      <valueString
                   value="// Region: Initial Populationdefine &quot;Is Between 2 and 17 Years of Age at Start of Measurement Period&quot;:
   AgeInYearsAt(start of &quot;Measurement Period&quot;) &gt;= 2
      and AgeInYearsAt(start of &quot;Measurement Period&quot;) &lt;= 17"/>
    </extension>
    <extension url="displaySequence">
      <valueInteger value="4"/>
    </extension>
  </extension>
  <extension
             url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
    <extension url="libraryName">
      <valueString value="EXM146"/>
    </extension>
    <extension url="name">
      <valueString value="Pharyngitis"/>
    </extension>
    <extension url="statement">
      <valueString
                   value="define &quot;Pharyngitis&quot;:
   ([Condition: code in &quot;Acute Pharyngitis&quot;]
     union [Condition: code in &quot;Acute Tonsillitis&quot;]) Pharyngitis
     where Pharyngitis.clinicalStatus ~ Global.active
       and Pharyngitis.verificationStatus ~ Global.confirmed"/>
    </extension>
    <extension url="displaySequence">
      <valueInteger value="5"/>
    </extension>
  </extension>
  <extension
             url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
    <extension url="libraryName">
      <valueString value="EXM146"/>
    </extension>
    <extension url="name">
      <valueString value="Antibiotics"/>
    </extension>
    <extension url="statement">
      <valueString
                   value="define &quot;Antibiotics&quot;:
   [MedicationRequest: medication in &quot;Antibiotic Medications&quot;] Prescription
     where Prescription.status = &#39;active&#39;
       and Prescription.intent = &#39;order&#39;"/>
    </extension>
    <extension url="displaySequence">
      <valueInteger value="6"/>
    </extension>
  </extension>
  <extension
             url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
    <extension url="libraryName">
      <valueString value="EXM146"/>
    </extension>
    <extension url="name">
      <valueString value="Initial Population"/>
    </extension>
    <extension url="statement">
      <valueString
                   value="define &quot;Initial Population&quot;:
   &quot;Pharyngitis Encounters With Antibiotics&quot;"/>
    </extension>
    <extension url="displaySequence">
      <valueInteger value="7"/>
    </extension>
  </extension>
  <url value="http://hl7.org/fhir/us/cqfmeasures/Measure/measure-exm146-FHIR"/>
  <identifier>
    <use value="official"/>
    <system value="http://example.org/fhir/cqi/ecqm/Measure/Identifier/exm"/>
    <value value="146"/>
  </identifier>
  <version value="4.0.0"/>
  <name value="EXM146"/>
  <title value="Appropriate Testing for Children with Pharyngitis"/>
  <status value="active"/>
  <experimental value="true"/>
  <date value="2021-04-03"/>
  <publisher value="Clinical Quality Information WG"/>
  <contact>
    <telecom>
      <system value="url"/>
      <value value="http://www.hl7.org/Special/committees/cqi/index.cfm"/>
    </telecom>
  </contact>
  <description
               value="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 value="http://terminology.hl7.org/CodeSystem/usage-context-type"/>
      <code value="program"/>
    </code>
    <valueCodeableConcept>
      <coding>
        <system
                value="http://hl7.org/fhir/us/cqfmeasures/CodeSystem/quality-programs"/>
        <code value="ep-ec"/>
        <display value="EP/EC"/>
      </coding>
    </valueCodeableConcept>
  </useContext>
  <jurisdiction>
    <coding>
      <system value="urn:iso:std:iso:3166"/>
      <code value="US"/>
    </coding>
  </jurisdiction>
  <purpose
           value="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)."/>
  <copyright
             value="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."/>
  <approvalDate value="2016-01-01"/>
  <lastReviewDate value="2016-09-01"/>
  <effectivePeriod>
    <start value="2018-01-01"/>
    <end value="2018-12-31"/>
  </effectivePeriod>
  <topic>
    <coding>
      <system value="http://loinc.org"/>
      <code value="57024-2"/>
      <display value="Health Quality Measure Document"/>
    </coding>
  </topic>
  <relatedArtifact>
    <type value="depends-on"/>
    <display value="Library FHIRHelpers"/>
    <resource
              value="http://fhir.org/guides/cqf/common/Library/FHIRHelpers|4.0.1"/>
  </relatedArtifact>
  <relatedArtifact>
    <type value="depends-on"/>
    <display value="Library Global"/>
    <resource
              value="http://hl7.org/fhir/us/cqfmeasures/Library/MATGlobalCommonFunctions|5.0.000"/>
  </relatedArtifact>
  <relatedArtifact>
    <type value="depends-on"/>
    <display value="Library Common"/>
    <resource value="http://hl7.org/fhir/us/cqfmeasures/Library/Common|2.0.0"/>
  </relatedArtifact>
  <relatedArtifact>
    <type value="depends-on"/>
    <display value="Code system ConditionClinicalStatusCodes"/>
    <resource value="http://terminology.hl7.org/CodeSystem/condition-clinical"/>
  </relatedArtifact>
  <relatedArtifact>
    <type value="depends-on"/>
    <display value="Code system ConditionVerificationStatusCodes"/>
    <resource
              value="http://terminology.hl7.org/CodeSystem/condition-verification"/>
  </relatedArtifact>
  <relatedArtifact>
    <type value="depends-on"/>
    <display value="Value set Ambulatory/ED Visit"/>
    <resource
              value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1061"/>
  </relatedArtifact>
  <relatedArtifact>
    <type value="depends-on"/>
    <display value="Value set Acute Pharyngitis"/>
    <resource
              value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.102.12.1011"/>
  </relatedArtifact>
  <relatedArtifact>
    <type value="depends-on"/>
    <display value="Value set Acute Tonsillitis"/>
    <resource
              value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.102.12.1012"/>
  </relatedArtifact>
  <relatedArtifact>
    <type value="depends-on"/>
    <display value="Value set Antibiotic Medications"/>
    <resource
              value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.196.12.1001"/>
  </relatedArtifact>
  <relatedArtifact>
    <type value="depends-on"/>
    <display value="Value set Group A Streptococcus Test"/>
    <resource
              value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1012"/>
  </relatedArtifact>
  <library value="http://hl7.org/fhir/us/cqfmeasures/Library/EXM146"/>
  <disclaimer
              value="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 &quot;AS IS&quot; 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]."/>
  <scoring>
    <coding>
      <system value="http://terminology.hl7.org/CodeSystem/measure-scoring"/>
      <code value="proportion"/>
      <display value="Proportion"/>
    </coding>
  </scoring>
  <type>
    <coding>
      <system value="http://terminology.hl7.org/CodeSystem/measure-type"/>
      <code value="process"/>
    </coding>
  </type>
  <rationale
             value="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
                                   value="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)"/>
  <improvementNotation>
    <coding>
      <system
              value="http://terminology.hl7.org/CodeSystem/measure-improvement-notation"/>
      <code value="increase"/>
      <display value="Increased score indicates improvement"/>
    </coding>
  </improvementNotation>
  <guidance
            value="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>
    <population>
      <code>
        <coding>
          <system
                  value="http://terminology.hl7.org/CodeSystem/measure-population"/>
          <code value="initial-population"/>
          <display value="Initial Population"/>
        </coding>
      </code>
      <criteria>
        <language value="text/cql.identifier"/>
        <expression value="Initial Population"/>
      </criteria>
    </population>
    <population>
      <code>
        <coding>
          <system
                  value="http://terminology.hl7.org/CodeSystem/measure-population"/>
          <code value="numerator"/>
          <display value="Numerator"/>
        </coding>
      </code>
      <criteria>
        <language value="text/cql.identifier"/>
        <expression value="Numerator"/>
      </criteria>
    </population>
    <population>
      <code>
        <coding>
          <system
                  value="http://terminology.hl7.org/CodeSystem/measure-population"/>
          <code value="denominator"/>
          <display value="Denominator"/>
        </coding>
      </code>
      <criteria>
        <language value="text/cql.identifier"/>
        <expression value="Denominator"/>
      </criteria>
    </population>
    <population>
      <code>
        <coding>
          <system
                  value="http://terminology.hl7.org/CodeSystem/measure-population"/>
          <code value="denominator-exclusion"/>
          <display value="Denominator Exclusion"/>
        </coding>
      </code>
      <criteria>
        <language value="text/cql.identifier"/>
        <expression value="Denominator Exclusion"/>
      </criteria>
    </population>
  </group>
</Measure>