Quality Measure Implementation Guide (STU4)
4.0.0-ballot - ballot United States of America flag

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

Changes

This page details changes made in each version of the Quality Measure IG

STU4 Ballot for FHIR R4 (v4.0.0-ballot)

  • Applied: Add a pertinence extension(FHIR-37826)
  • Applied: Allow the fhirQueryPattern extension to be a superset of the data requirement(FHIR-39399)
  • Applied: Characterize text search capabilities for a terminology service and repository service(FHIR-37528)
  • Applied: Clarify guidance on SDE expression results(FHIR-38051)
  • Applied: Use new template-based publishing mechanism(FHIR-25694)
  • Applied: Update Cardinality for Composite Measure Profile’s Stratification Applies To Extension(FHIR-39353)
  • Applied: Clarify conformance related to patient-based CV measures(FHIR-39169)
  • Applied: Support batch searches(FHIR-37537)
  • Applied: Remove requirement related to code system order(FHIR-37681)
  • Applied: Support missing information for hosted content(FHIR-38827)
  • Applied: Provide guidance for hosted vs managed content(FHIR-38829)
  • Applied: Measure terminology service must mark profile tags(FHIR-38830)
  • Applied: PopulationBasis extension can be used on a population(FHIR-39311)
  • Applied: QUICK Reference(FHIR-37542)
  • Applied: Support keyword search for value sets(FHIR-37530)
  • Applied: Add requirements to support maintenance of a quality program(FHIR-37506)
  • Applied: Fix incorrect reference to text/cql.identifier(FHIR-38787)
  • Applied: Snippet and link mismatch related to Supplemental Data Elements(FHIR-37548)

STU3 Release for FHIR R4 (v3.0.0)

This release includes changes due to ballot reconciliation and connectathon testing. The following sections summarize the changes from the balloted version (v2.*0), followed by a detailed changes list of all changes applied.

Terminology Services Change Summary

Changes to the CQFMExecutableValueSet profile:
  • Changed the warning extension from cqfm-usageWarning to valueset-warning (base extension)
  • Changed the fixed value of the warning extension to discuss conformance only (moved guidance to the IG)
  • Changed expansion contains elements to require a version unless the parameters element has a system-version for the system
Changes to the CQFMQualityProgram profile:
  • Removed cqfm-activeOnly and cqfm-expansionUri extensions in favor of the more general cqfm-expansionParameters extension
Changes to the ValueSet/$expand operation:
  • Clarified semantics of the manifest parameter
  • Clarified semantics of the expansion parameter
  • Changed includePreview parameter to includeDraft
Changes to the Measure Terminology Service:
  • Added Expansion Rules to describe expected expansion behavior in the presence of a manifest
  • Recommended support for useContext search parameters
  • Recommended support for reference search parameters
Changes to align with FHIR publishing
  • Added support for the terminology model of a server’s capability statement
  • Added support for batch operations for $validate-code
  • Required support for activeOnly and displayLanguage in $validate-code
  • Required support for activeOnly, displayLanguage, limitedExpansion, and default-to-latest-version parameters in $expand
  • Recommended support for includeDesignation, designation, and paging parameters in $expand
Outstanding Questions
  • Search by URL should return all versions with that URL, otherwise there is no way to get the list of versions for a given value set URL
  • If searches return a SUBSETTED resource by default, should the server should allow the _summary=false parameter to request full resources?
  • Given the id of a ValueSet is the OID, how can I retrieve specific versions of a ValueSet?
  • How can I retrieve a list of available expansions for a given ValueSet URL?
  • Can I use a GET to invoke $expand with both the url and valueSetVersion parameters? (Connectathon testing resulted in an error)

Measure Representation Change Summary

Changes to the CQFMMeasure profile:
  • Required CQFMMeasure Library reference to be a CQFMLibrary
  • Relaxed scoring, type, and improvementNotation cardinality
Changes to the CQFMComputableMeasure profile:
  • Changed cardinality of group to 0..*
  • Changed the representation of effective data requirements on a measure to use a contained module definition library, rather than extensions in the measure
  • Added fhirQueryPattern extension to communicate FHIR queries
  • Added isSelective extension to dataRequirement
  • Added valueFilter extension to support additional filtering in dataRequirement
  • Added constraints to enforce scoring, populationBasis, and improvementNotation be specified at the root or all groups, but not both
  • Added constraints to enforce population criteria in groups based on the group scoring extension
  • Required Library to be a CQFMComputableLibrary and all expressions to be text/cql-expression or -identifier
Added CQFMExecutableMeasure
  • Required Library to be a CQFMExecutableLibrary and all expressions to be text/cql-identifier
Changes to measure repository service:
  • Removed the bundle-based packaging profiles in favor of artifact-based profiles to ensure artifact packaging can use paging when artifact packages contain a large number of components
  • Added support for advertising CQL version support
Changes to measure authoring:
  • Allowed any number of models to be referenced, rather than requiring one and only one reference to QICore
  • Recommended not disabling method invocation to allow fluent functions to be used
  • Added support for mixed-basis ratio measure
  • Added ability to associated stratifiers with specific populations
  • Added the ability to specify scoringUnit for a measure
  • Added composite scoring code

Detailed Change Lists by Impact

Non-Compatible Changes
  • FHIR-36156: Required scoring, populationBasis, and improvementNotation to be specified at the root or on all groups, but not both
  • FHIR-33975: Changed executable value set to use the warning extension from the base specification
  • FHIR-33971: Restricted the use of the content element in a quality program
  • FHIR-33178: Required CQFMMeasure library reference to be a CQFMLibrary
  • FHIR-32748: Changed cardinality of group to 0..*
  • FHIR-32594: Changed the representation of expansion parameters to use a contained parameters resource rather than specific extensions per parameter
  • FHIR-32593: Changed the representation of effective data requirements on a measure to use a contained module definition library, rather than extensions in the measure
  • FHIR-30079: Removed the bundle-based packaging profiles in favor of artifact-based profiles to ensure that artifact packaging can use paging when artifact packages contain a large number of components
Compatible, Substantive Changes
  • FHIR-36304: Added CQFMExecutableMeasure profile to separate computable/executable concerns of a measure
  • FHIR-34290: Added capabilities to the measure terminology service to align with publishing terminology service capabilities
  • FHIR-33970: Added searching by useContext
  • FHIR-33968: Added searching for valuesets by artifacts that reference the value set
  • FHIR-33458: Added the fhirQueryPattern extension to support representing the FHIR query for a given data requirement
  • FHIR-33045: Added the ability to represent a mixed-basis population ratio measure (i.e. a ratio between encounters and procedures)
  • FHIR-32970: Relaxed conformance requirements on the use of QI Core from SHALL to SHOULD, to allow any FHIR IG(s) to be used for measure development
  • FHIR-32969: Added derivedFrom slice to support identifying previous versions of a measure
  • FHIR-32808: Added an invariant to ensure system-version is unambiguously communicated for all the codes in an expansion
  • FHIR-32686: Added an isSelective extension to support identifying “selective” data requirements (i.e. criteria that are positively indicative and likely to be selective of initial population membership)
  • FHIR-32675: Added the ability for a FHIR server to advertise the versions of CQL it supports
  • FHIR-32671: Added the ability to specify CQLOptions using a parameters resource
  • FHIR-32668: Added conformance expectations and guidance for specifying the version of CQL/ELM content in a library
  • FHIR-32372: Added a valueFilter extension to support representing additional filtering criteria in a data requirement
  • FHIR-32334: Added defaultValue extension to support representing default values for parameters
  • FHIR-32231: Updated measure narrative generation to display logic items in alphabetical order
  • FHIR-31921: Changed “preview” parameter in valueSet$expand operation to “includeDraft”
  • FHIR-31680: Added the ability to associated stratifiers with specific populations
  • FHIR-31624: Corrected all-or-none composite measure calculation formulas
  • FHIR-31409: Added quality domain and meaningful measure area to be specified for measures in a quality program
  • FHIR-30875: Added measure repository service capability statement and description
  • FHIR-30874: Added measure terminology service capability statement and description
  • FHIR-30873: Added support for composite measures both within and across FHIR Measure resources
  • FHIR-30770: Added a ModelDefinition profile to support the use of FHIR Library resources containing CQL ModelInfo content
  • FHIR-30763: Added composite code to the scoring code system
  • FHIR-30569: Added conformance requirements for the use of FHIR Library resources containing CQL content
  • FHIR-30506: Added the ability to specify the scoringUnit of a measure
  • FHIR-30395: Added slices for version-independent, version-specific, short-name, publisher, and endorser identifiers for measures
  • FHIR-30394: Added a ComputableMeasure profile to represent the formal computation aspects common to all quality measures, regardless of the scoring method
  • FHIR-28338: Added criteriaReference extension to the Ratio measure profile to support dual initial populations
  • FHIR-27878: Relaxed conformance requirements on stratifier criteria to allow the use of codes and paths to elements
  • FHIR-27795: Added inputParameters extension to support identifying the input parameters for a test case
  • FHIR-21107: Added conformance requirement to support composite measure representation
Non-substantive Changes
  • FHIR-34882: Added a data repository role to the quality reporting sequence diagram to make clear the separation between reporting capabilities and data repository capabilities
  • FHIR-34197: Changed guidance on the use of DisableMethodInvocation to ensure fluent functions can be used in quality measures going forward
  • FHIR-33992: Corrected broken hyperlink
  • FHIR-33967: Clarified behavior of expansions when expansion parameters are specified in both the expand operation and the manifest used
  • FHIR-33966: Clarified conformance requirements versus usage guidance in the executable value set profile
  • FHIR-33016: Added guidance on avoiding the use of direct reference codes for UCUM units
  • FHIR-32884: Corrected headings throughout
  • FHIR-32747: Corrected typographical error
  • FHIR-32746: Corrected typographical error
  • FHIR-32745: Corrected typographical error
  • FHIR-32744: Validated examples conform to expected profiles
  • FHIR-32742: Clarified documentation of the use of value sets during the authoring phase of the content management lifecycle
  • FHIR-32741: Corrected typographical error
  • FHIR-32740: Clarified that the measure repository services are represented with a focus on measures, but conceptually are broadly applicable to other types of knowledge artifacts
  • FHIR-32739: Clarified that the measure terminology service is represented with a focus on measures, but conceptually is broadly applicable to other types of knowledge artifacts
  • FHIR-32738: Added an introductory description for the quality reporting sequence diagram
  • FHIR-32737: Clarified quality program examples
  • FHIR-32736: Clarified quality program documentation
  • FHIR-32735: Clarified measure implementation as the focus of capabilities supported by this IG
  • FHIR-32734: Fixed typographical error
  • FHIR-32733: Clarified definition of a quality measure in the IG introduction
  • FHIR-32732: Clarified the metric development step in the quality improvement ecosystem discussion
  • FHIR-32731: Added registries as a stakeholder in the quality improvement ecosystem
  • FHIR-32730: Added internal quality improvement initiatives as a use case in the quality improvement ecosystem discussion
  • FHIR-32729: Clarified that payers are not primary developers of clinical guidelines
  • FHIR-32728: Clarified that improvement of clinical care is the focus of the quality improvement ecosystem
  • FHIR-32727: Clarified cyclic nature of the quality improvement ecosystem
  • FHIR-32726: Added internal quality improvement initiatives as a potential use case in the quality improvement ecosystem discussion
  • FHIR-32725: Highlighted the role of clinician judgement in the quality improvement ecosystem discussion
  • FHIR-32722: Added additional examples of stakeholders to the quality improvement ecosystem discussion
  • FHIR-32688: Noted that multiple versions of the same code system may be used in a single $expand
  • FHIR-32687: Clarified that expansion identifiers are server-specific
  • FHIR-32651: Added examples of expansions given the use of a manifest parameter
  • FHIR-32596: Added Must Support documentation
  • FHIR-32199: Corrected layout issue
  • FHIR-32079: Added discussion about referencing any FHIR type, as opposed to only FHIR types profiled by QI Core
  • FHIR-31942: Fixed a typographical error
  • FHIR-31941: Clarified description of Conformance Requirement 3.15
  • FHIR-31940: Fixed a typographical error
  • FHIR-31592: Clarified description of population criteria in the population scoring algorithm diagrams
  • FHIR-30764: Added trial-use note seeking feedback on the usefulness of a “Measure Source” metadata attribute
  • FHIR-30401: Added discussion of the use of Group resource to characterize attribution models, such as DaVinci Attribution (ATR)
  • FHIR-29649: Duplicate of 28239
  • FHIR-28303: Added mapping from V3 Aggregate Method to FHIR Aggregate Method
  • FHIR-28302: Added mapping from V3 Composite Measure Scoring to FHIR Composite Measure Scoring
  • FHIR-28301: Added mapping from V3 Measure Scoring to FHIR Measure Scoring
  • FHIR-28300: Added mapping from V3 Measure Types to FHIR Measure Types
  • FHIR-28290: Clarified the definition of population basis
  • FHIR-28288: Updated examples to use “citation” related artifact code, rather than “documentation” when they were citations of references
  • FHIR-28239: Corrected cardinality of CQFMMeasure.profile meta constraint
  • FHIR-28238: Corrected cardinality of CQFMLibrary.profile meta constraint
  • FHIR-28210: Corrected description of EXM146 as an encounter-based measure
  • FHIR-28206: Updated glossary terms
  • FHIR-26331: Corrected breadcrumbs display throughout the IG
  • FHIR-26329: Updated the IG to use the standard HL7 FHIR IG template

STU3 Ballot for FHIR R4 (v2.*0)

This ballot release introduces support for composite measures, and adds descriptions of a Measure Terminology Service and a Measure Repository in support of authoring, distributing, and evaluating quality measures.

  • Applied:conformance requirement 1 does not mention composite measures. Should it? (FHIR-21107)
  • Applied:Need to clarify how measure evaluation parameters are specified in a test case (FHIR-27795)
  • Applied:Permit stratifier expression to have any type (Conformance requirement 15) (FHIR-27878)
  • Applied:Glossary population criteria entries are inconsistent with population code system (FHIR-28206)
  • Applied:Example measure 146 is incorrectly described as “patient-based” (FHIR-28210)
  • Applied:CQFM Library has incorrect cardinality for profile constraint (FHIR-28238)
  • Applied:CQFMMeasure profile has incorrect cardinality for profile constraint (FHIR-28239)
  • Applied:Possible issue with related artifact example (FHIR-28288)
  • Applied:PopulationBasis definition (FHIR-28290)
  • Applied:Measure Type valueset needs a concept map to the V3 codes (FHIR-28300)
  • Applied:Measure scoring value set needs a concept map from V3 (FHIR-28301)
  • Applied:Composite Measure Scoring needs a mapping to V3 concepts (FHIR-28302)
  • Applied:Aggregate method needs a mapping to HL7 V3 concepts (FHIR-28303)
  • Applied:Ratio measure profile (FHIR-28338)
  • Applied:Cardinality of Measure.meta.profile (FHIR-29649)
  • Applied:Issues with Packaging and Bundle profiles (FHIR-30079)
  • Applied:Define a computable measure profile (FHIR-30394)
  • Applied:Add identifier slices for shortname, publisher, and endorser (FHIR-30395)
  • Applied:Add attribution model identifier to quality program (FHIR-30401)
  • Applied:Support specification of scoringUnit (FHIR-30506)
  • Applied:Conformance requirements for CQL Library resource usage (FHIR-30569)
  • Resolved - No Change Required:Support authoring concerns for inactive value set codes (FHIR-30573)
  • Resolved - Change Required:Move the “composite” code from Measure Type to Measure Scoring (FHIR-30763)
  • Resolved - Change Required:Allow the specification of “intended data source” (FHIR-30764)
  • Applied:Add a profile for FHIR Model Info Library (FHIR-30770)
  • Applied:Add composite measure support and profiles (FHIR-30873)
  • Applied:Support measure terminology service (FHIR-30874)
  • Applied:Create measure repository service (FHIR-30875)
  • Applied:Support specifying quality domain and meaningful measure area in quality programs (FHIR-31409)
  • Applied:Modify diagram text to “Population Relationships” Figures 3.2, 3.3, 3.4, 3.5 (FHIR-31592)
  • Applied:All-or-nothing scoring should use “implies” (FHIR-31624)

STU2 Release for FHIR R4 (v2.0.0)

This release includes changes applied as a result of ballot feedback as well as connectathon testing.

Non-compatible

  • FHIR-26534 - Use of text/cql.identifier media type for CQL expression references
  • FHIR-21994 - Use of namespaces with CQL libraries
  • FHIR-25285 - Changed definition term extension to preserve association of term and definition
  • FHIR-21998 - Disallowed stratification of ratio measures
  • FHIR-21996 - Required use of called clause for included libraries

Compatible, Substantive

  • Corrections to proportion, ratio, and continuous-variable measure profiles
  • Added profile layering for shareable, computable, publishable, and executable capabilities
  • Added profiles and guidance for packaging, distribution, and testing
  • Clarified risk adjustment conformance requirements
  • Added support for identifying packaging, testing, and authoring tooling
  • Library and measure resources require narrative and profile declarations
  • Added publicationStatus and publicationDate extensions for relatedArtifact
  • Clarified calculation flow diagrams for all measure types
  • Clarified relationship of FHIR terminology to V3 measure terminology
  • Added support for defining and referencing measure programs

Non-substantive

  • Numerous clarifications and corrections throughout

STU2 Ballot for FHIR R4 (v**0)

This ballot is a minimal update to the STU1 ballot to address the following items:

  • Updated to use FHIR R4
  • Added artifact packaging guidance and conformance requirements

STU1 Release for FHIR STU3 (v*0.0)

  • Clarifications and fixes throughout

Compatible, substantive

  • 21181 *.1 relationships
  • 21684 Risk adjustment naming conventions? - QM #15
  • 21156 Clarify where the risk adjustment variables are stored in the fhir document.
  • 21155 Inconsistent conformance requirements (16 and 17).
  • 21986 Denominator exceptions in differential table? - QM #136
  • 21988 Supporting measurement period without specifying year? - QM #137
  • 21145 conformance requirement 13 states that a continuous variable measure SHALL have a criteriaReference extension but the profile has this extension as 0..1 rather than . Should the profile have *.1?
  • 21187 consider for all slices that are not “measure observation” to make cqfm-criteriaReference and cqfm-aggregateMethod 0..0
  • 21183 initial population slice for proportion measure is .2. Should be *. (*.2 is for ratio measure).
  • 21192 EXM55 library references
  • 21178 Does it make sense for the profile itself to specify usage for criteriaReference and aggregateMethod (measure observations)
  • 21191 consider slicing content and including the required contentType (text/cql) and optional ones (application/elm+xml, application/elm+json)
  • 21984 Require use of specific model? - QM #135
  • 21158 Should this be a conformance requirement?
  • 21188 consider making cqfm-criteriaReference and cqfm-aggregateMethod *.1 for “measure observation” slice.
  • 21186 measure population exclusion slice should be 0..* population.code for this slice should still be required (*.1)
  • 21182 should population.identifier, supplementalData.identifier and stratification.identifier be required?
  • 21185 missing denominator exception slice
  • 21173 This statement uses SHOULD NOT language but the conformance requirement is SHALL NOT. Recommend rewording for clarity.
  • 21146 should conformance requirement 13 require an aggregateMethod extension on the measure observation criteria? It currently does not.

Non-compatible

  • 21998 Restrict stratification of ratio measure - QM #142
  • 21994 Library namespace guidance - QM #140
  • 21056 Disallow the use of strings for membership testing in value sets and code systems
  • 21996 Library alias guidance - QM #141

STU1 Ballot for FHIR STU3 (v0.*0)

STU1 Ballot for FHIR STU3 Version