Metadata
Title EXM108 - Venous Thromboembolism Prophylaxis
Version 8.2.000
Identifier 108
Identifier urn:oid:2.16.840.1.113883.4.642.40.61.29.3
Effective Period 2018-01-01 through 2018-12-31
Approval Date 2019-03-08
Last Review Date 2019-03-08
Experimental true
Use Context Clinical Venue = EH
Jurisdiction 001 from http://unstats.un.org/unsd/methods/m49/m49.htm
Topic Health Quality Measure Document
Steward (Publisher) HL7 International / Clinical Quality Information
Description

This measure assesses the number of patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given the day of or the day after hospital admission or surgery end date for surgeries that start the day of or the day after hospital admission
Copyright

Measure specifications are in the Public Domain.

LOINC(R) is a registered trademark of the Regenstrief Institute.

This material contains SNOMED Clinical Terms(R) (SNOMED CT(C)) copyright 2004-2017 International Health Terminology Standards Development Organization. All rights reserved.
Disclaimer

These performance measures are not clinical guidelines and do not establish a standard of medical care, and have not been tested for all potential applications. The measures and specifications are provided without warranty
Measure Basis Encounter
Measure Scoring Proportion
Improvement Notation Increased score indicates improvement
Measure Type process from http://terminology.hl7.org/CodeSystem/measure-type
Rationale

Hospitalized patients at high-risk for VTE may develop an asymptomatic deep vein thrombosis (DVT), and die from pulmonary embolism (PE) even before the diagnosis is suspected. The majority of fatal events occur as sudden or abrupt death, underscoring the importance of prevention as the most critical action step for reducing death from PE (Geerts, et al, 2008).

The estimated annual incidence of deep-vein thrombosis (DVT) and pulmonary embolism (PE), known collectively as venous thromboembolism (VTE), is approximately 900,000 (Geerts, et al, 2008). Approximately two-thirds of cases of DVT or PE are associated with recent hospitalization. This is consistent with the 2001 report by The Agency for Healthcare Research and Quality (AHRQ). AHRQ indicates that "the appropriate application of effective preventive measures in hospitals has major potential for improving patient safety by reducing the incidence of venous thromboembolism" (Shojania, 2001).

Despite its proven effectiveness, rates of appropriate thromboprophylaxis remain low in both medical and surgical patients. A recent analysis from the ENDORSE survey, which evaluated prophylaxis rates in 17,084 major surgery patients, found that more than one third of patients at risk for VTE (38%) did not receive prophylaxis and that rates varied by surgery type (Cohen, et al., 2008).

In a review of evidence-based patient safety practices, the Agency for Healthcare Research and Quality defined thromboprophylaxis against VTE as the "number one patient safety practice" for hospitalized patients (Shojania, 2001). Updated "safe practices" published by the National Quality Forum (NQF) recommend routine evaluation of hospitalized patients for risk of VTE and use of appropriate prophylaxis (National Quality Forum. National Voluntary Consensus Standards for Prevention and Care of Venous Thromboembolism, 2006).

As noted by the ACCP, a vast number of randomized clinical trials provide irrefutable evidence that thromboprophylaxis reduces VTE events, and there are studies that have also shown that fatal PE is prevented by thromboprophylaxis (Geerts, et al. 2008).

Some select surgeries have previously been monitored in the Surgical Care Improvement Project; since performance on these surgeries has achieved very high levels, they are not included in this measure.
Clinical Recommendation Statement

Failure to recognize and protect patients at risk for venous thromboembolism (VTE) increases the chances for acutely ill hospitalized patients at high risk for developing a deep vein thrombosis or dying from a pulmonary emboli. Screening all patients is the only evidence based practice in reducing incidence of disease. All hospitalized patients should be evaluated for primary VTE prophylaxis, and given appropriate prophylaxis when indicated.
Measure Group (Rate) (ID: primary)
Supplemental Data Elements
Supplemental Data Element Usage Code: Supplemental Data
Description: No description provided
Logic Definition: SDE Ethnicity
Supplemental Data Element Usage Code: Supplemental Data
Description: No description provided
Logic Definition: SDE Payer
Supplemental Data Element Usage Code: Supplemental Data
Description: No description provided
Logic Definition: SDE Race
Supplemental Data Element Usage Code: Supplemental Data
Description: No description provided
Logic Definition: SDE Sex
Measure Logic
Primary Library EXM108 - Venous Thromboembolism Prophylaxis Library
Contents Population Criteria
Logic Definitions
Terminology
Dependencies
Data Requirements
Parameters
Population Criteria
Measure Group (Rate) (ID: primary)
Logic Definitions
Logic Definition Library Name: SupplementalDataElements 
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
Logic Definition Library Name: SupplementalDataElements 
define "SDE Payer":
  [Coverage: type in "Payer"] Payer
        return {
          code: Payer.type,
          period: Payer.period
        }
Logic Definition Library Name: SupplementalDataElements 
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
Logic Definition Library Name: SupplementalDataElements 
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
Logic Definition Library Name: TJCOverall 
define function "CalendarDayOfOrDayAfter"(StartValue DateTime ):
	Interval(Global."ToDate"(StartValue), Global."ToDate"(StartValue + 2 days))
Logic Definition Library Name: VTEICU 
define function "FromDayOfStartOfHospitalizationToDayAfterAdmission"(Encounter FHIR.Encounter ):
	Interval[Global."ToDate"(start of Global."HospitalizationWithObservation"(Encounter)), Global."ToDate"(start of Encounter.period + 2 days))
Logic Definition Library Name: EXM108 
define "SDE Sex":
	SDE."SDE Sex"
Logic Definition Library Name: EXM108 
define "Admission Without VTE or Obstetrical Conditions":
  Global."Inpatient Encounter" InpatientEncounter
    where not exists (
      (Global.EncounterDiagnosis(InpatientEncounter)) EncounterDiagnosis
        where EncounterDiagnosis.code in "Obstetrics"
          or EncounterDiagnosis.code in "Venous Thromboembolism"
          or EncounterDiagnosis.code in "Obstetrics VTE"
    )
Logic Definition Library Name: EXM108 
// Note: added FHIRHelpers.ToDate() in R4
define "Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions":
  ( Global."Inpatient Encounter" InpatientEncounter
        where Global."CalendarAgeInYearsAt"(FHIRHelpers.ToDate(Patient.birthDate), start of InpatientEncounter.period) >= 18
  )
    intersect "Admission Without VTE or Obstetrical Conditions"
Logic Definition Library Name: EXM108 
// 10/29: Replaced DeviceUseStatement with Procedure with a new value set and procedure.usdCode for specifying devices
define "VTE Prophylaxis by Medication Administered or Device Applied":
  ( ["MedicationAdministration": medication in "Low Dose Unfractionated Heparin for VTE Prophylaxis"] VTEMedication
      where VTEMedication.status ='completed'
			     and VTEMedication.dosage.route in "Subcutaneous route"
  )
   union (["MedicationAdministration": medication in "Low Molecular Weight Heparin for VTE Prophylaxis"] LMWH where LMWH.status = 'completed')
    union (["MedicationAdministration": medication in "Injectable Factor Xa Inhibitor for VTE Prophylaxis"] FactorXa where FactorXa.status = 'completed')
     union (["MedicationAdministration": medication in "Warfarin"] Warfarin where Warfarin.status = 'completed')
      union (
          ["Procedure": "Device Application"] DeviceApplied
          where DeviceApplied.status = 'complete'
                and (DeviceApplied.usedCode in "Intermittent pneumatic compression devices (IPC)"
                    or DeviceApplied.usedCode in"Venous foot pumps (VFP)"
                    or DeviceApplied.usedCode in "Graduated compression stockings (GCS)"
                    )
          )
Logic Definition Library Name: EXM108 
define "Encounter With VTE Prophylaxis Received on Day of or Day After Admission or Procedure":
 	( from
      "Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter,
      "VTE Prophylaxis by Medication Administered or Device Applied" VTEProphylaxis
    where Coalesce(Global."Normalize Interval"(VTEProphylaxis.effective), Global."Normalize Interval"(VTEProphylaxis.performed)) starts during TJC."CalendarDayOfOrDayAfter"(start of QualifyingEncounter.period)
    return QualifyingEncounter
 	)
 	union (
    from
      "Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter,
      ["Procedure": "General or Neuraxial Anesthesia"] AnesthesiaProcedure,
      "VTE Prophylaxis by Medication Administered or Device Applied" VTEProphylaxis
    where Global."Normalize Interval"(AnesthesiaProcedure.performed) ends 1 day after day of start of QualifyingEncounter.period
      and Coalesce(Global."Normalize Interval"(VTEProphylaxis.effective), Global."Normalize Interval"(VTEProphylaxis.performed)) starts during TJC."CalendarDayOfOrDayAfter"(end of Global."Normalize Interval"(AnesthesiaProcedure.performed))
    return QualifyingEncounter
	)
Logic Definition Library Name: EXM108 
define "Encounter With Medication Oral Factor Xa Inhibitor Administered on Day of or Day After Admission or Procedure":
	( from
    		"Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter,
  			["MedicationAdministration": medication in "Oral Factor Xa Inhibitor for VTE Prophylaxis or VTE Treatment"] FactorXaMedication
    where FactorXaMedication.status = 'completed'
      and Global."Normalize Interval"(FactorXaMedication.effective) starts during TJC."CalendarDayOfOrDayAfter"(start of QualifyingEncounter.period)
    return QualifyingEncounter
    )
    union ( from
    				  "Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter,
      				["Procedure": "General or Neuraxial Anesthesia"] AnesthesiaProcedure,
      				["MedicationAdministration": medication in "Oral Factor Xa Inhibitor for VTE Prophylaxis or VTE Treatment"] FactorXaMedication
      			where FactorXaMedication.status = 'completed'
                and AnesthesiaProcedure.status = 'completed'
      			    and Global."Normalize Interval"(AnesthesiaProcedure.performed) ends 1 day after day of start of QualifyingEncounter.period
      					and Global."Normalize Interval"(FactorXaMedication.effective) starts during TJC."CalendarDayOfOrDayAfter"(end of Global."Normalize Interval"(AnesthesiaProcedure.performed))
      			return QualifyingEncounter
      		)
Logic Definition Library Name: EXM108 
define "Encounter With Prior or Present Diagnosis of Atrial Fibrillation or VTE":
	( "Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter
		with ["Condition": code in "Atrial Fibrillation/Flutter"] AtrialFibrillation
		such that FHIRHelpers.ToConcept(AtrialFibrillation.clinicalStatus) in { Global."active", Global."recurrence", Global."relapse" }
			and Global."Normalize Interval"(AtrialFibrillation.onset) starts on or before end of QualifyingEncounter.period
    )
    union ( "Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter
    				where Global.EncounterDiagnosis(QualifyingEncounter).code in "Atrial Fibrillation/Flutter"
    			)
    union ( "Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter
    				with ["Condition": code in "Venous Thromboembolism"] VTEDiagnosis
    				such that  FHIRHelpers.ToConcept(VTEDiagnosis.clinicalStatus) in { Global."inactive", Global."remission", Global."resolved" }
      					//and VTEDiagnosis.verificationStatus = 'confirmed'
    				and Global."Normalize Interval"(VTEDiagnosis.onset) before start of QualifyingEncounter.period
      		)
Logic Definition Library Name: EXM108 
define "Encounter With Prior or Present Procedure of Hip or Knee Replacement Surgery":
	"Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter
	with ( ["Procedure": "Hip Replacement Surgery"]
    			union ["Procedure": "Knee Replacement Surgery"] ) HipKneeProcedure
	such that HipKneeProcedure.status = 'completed'
	     and Global."Normalize Interval"(HipKneeProcedure.performed) starts on or before end of QualifyingEncounter.period
Logic Definition Library Name: EXM108 
define "Is In Low Risk for VTE or On Anticoagulant":
	  ( ["Observation": "Risk for venous thromboembolism"] VTERiskAssessment
			  where VTERiskAssessment.value in "Low Risk"
        and VTERiskAssessment.status in {'final','amended', 'corrected'}
	  )
  union ( ["Observation": "INR"] INRLabTest
        where INRLabTest.value as Quantity > 3.0
            and INRLabTest.status in {'final','amended', 'corrected'}
        return "Observation" { id: INRLabTest.id, effective: INRLabTest.issued }
        )
  union ((( ["MedicationAdministration": "Unfractionated Heparin"] UnfractionatedHeparin
          where UnfractionatedHeparin.dosage.route in "Intravenous route"
         )
         union ["MedicationAdministration": "Direct Thrombin Inhibitor"]
         union ["MedicationAdministration": "Glycoprotein IIb/IIIa Inhibitors"] ) AnticoagulantMedication
         where AnticoagulantMedication.status = 'complete'
         return "Observation" { id: AnticoagulantMedication.id, effective: AnticoagulantMedication.effective }
      )
Logic Definition Library Name: EXM108 
define "Low Risk for VTE or Anticoagulant Administered From Day of Start of Hospitalization To Day After Admission":
 	"Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter
    with "Is In Low Risk for VTE or On Anticoagulant" VTERiskAssessment
    such that Global."Normalize Interval"(VTERiskAssessment.effective) starts during VTEICU."FromDayOfStartOfHospitalizationToDayAfterAdmission"(QualifyingEncounter)
Logic Definition Library Name: EXM108 
define "Low Risk for VTE or Anticoagulant Administered on Day of or Day After Procedure":
 	from
   		"Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter,
   		["Procedure": "General or Neuraxial Anesthesia"] AnesthesiaProcedure,
   		"Is In Low Risk for VTE or On Anticoagulant" VTERiskAssessment
	where Global."Normalize Interval"(AnesthesiaProcedure.performed) ends 1 day after day of start of QualifyingEncounter.period
 			and Global."Normalize Interval"(VTERiskAssessment.effective) starts during TJC."CalendarDayOfOrDayAfter"(end of Global."Normalize Interval"(AnesthesiaProcedure.performed))
	return QualifyingEncounter
Logic Definition Library Name: EXM108 
define "Encounter With Low Risk for VTE or Anticoagulant Administered":
   "Low Risk for VTE or Anticoagulant Administered From Day of Start of Hospitalization To Day After Admission"
   	 union "Low Risk for VTE or Anticoagulant Administered on Day of or Day After Procedure"
Logic Definition Library Name: EXM108 
define "No VTE Prophylaxis Medication Administered or Ordered":
   ((	["MedicationAdministration": medication in "Low Dose Unfractionated Heparin for VTE Prophylaxis"]
     union
	    ["MedicationAdministration": medication in "Low Molecular Weight Heparin for VTE Prophylaxis"]
     union
	    ["MedicationAdministration": medication in "Injectable Factor Xa Inhibitor for VTE Prophylaxis"]
     union
	    ["MedicationAdministration": medication in "Warfarin"]
       ) MedicationAdm
       where MedicationAdm.status = 'not-done'
        )
  union
	   ((	["MedicationRequest": medication in "Low Dose Unfractionated Heparin for VTE Prophylaxis"]
  	union
  	 ["MedicationRequest": medication in "Low Molecular Weight Heparin for VTE Prophylaxis"]
    union
    	["MedicationRequest": medication in "Injectable Factor Xa Inhibitor for VTE Prophylaxis"]
    union
    	["MedicationRequest": medication in "Warfarin"]
    ) MedicationOrder
    	where	MedicationOrder.doNotPerform is true
        and MedicationOrder.status in {'completed', 'cancelled'}
        //11/5 discussion: all expressions for QI-Core must include a status.
        //Therefore, we need ServiceRequest.status = completed; and MedicationRequest.status = cancelled (or completed, since cancelled indicates it was once ordered but intentionally never filled).
        //So the not done issue is handled by ServiceRequest.doNotPerform = True  Or MedicationRequest.doNotPerform = True
    )
Logic Definition Library Name: EXM108 
define "No VTE Prophylaxis Medication Due to Medical Reason From Day of Start of Hospitalization To Day After Admission":
   	"Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter
       with	"No VTE Prophylaxis Medication Administered or Ordered" NoVTEMedication
     	such that Coalesce(NoVTEMedication.statusReason,NoVTEMedication.reasonCode) in "Medical Reason"
      			and Coalesce(NoVTEMedication.authoredOn, start of Global."Normalize Interval"(NoVTEMedication.effective)) during VTEICU."FromDayOfStartOfHospitalizationToDayAfterAdmission"(QualifyingEncounter)
Logic Definition Library Name: EXM108 
define "No VTE Prophylaxis Device Applied or Ordered":
  ((
    ["ServiceRequest": "Venous foot pumps (VFP)"]
    union ["ServiceRequest": "Intermittent pneumatic compression devices (IPC)"]
    union ["ServiceRequest": "Graduated compression stockings (GCS)"]
    ) DeviceOrder
    where DeviceOrder.status = 'completed'
        and DeviceOrder.doNotPerform is true
    return {id: DeviceOrder.id, requestStatusReason: GetStatusReason(DeviceOrder), authoredOn: DeviceOrder.authoredOn}
    )
  union
    (
      ["Procedure": "Device Application"] DeviceApplied
      let DeviceNotDoneTiming: Global.GetExtension(DeviceApplied, 'qicore-recorded').value
      where (DeviceApplied.usedCode in "Intermittent pneumatic compression devices (IPC)"
            or DeviceApplied.usedCode in "Venous foot pumps (VFP)"
            or DeviceApplied.usedCode in "Graduated compression stockings (GCS)"
            )
         and  DeviceApplied.status = 'not-done'
         return {id: DeviceApplied.id, requestStatusReason: DeviceApplied.statusReason, authoredOn: DeviceNotDoneTiming}

    )
Logic Definition Library Name: EXM108 
define "No VTE Prophylaxis Device Due to Medical Reason From Day of Start of Hospitalization To Day After Admission":
  "Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter
  	with "No VTE Prophylaxis Device Applied or Ordered" NoVTEDevice
      such that NoVTEDevice.requestStatusReason in "Medical Reason"
        and  NoVTEDevice.authoredOn during VTEICU."FromDayOfStartOfHospitalizationToDayAfterAdmission"(QualifyingEncounter)
Logic Definition Library Name: EXM108 
define "No VTE Prophylaxis Medication Due to Medical Reason on Day of or Day After Procedure":
	from
  		"Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter,
  		["Procedure": "General or Neuraxial Anesthesia"] AnesthesiaProcedure,
  		"No VTE Prophylaxis Medication Administered or Ordered" NoVTEMedication
	where Coalesce(NoVTEMedication.statusReason,NoVTEMedication.reasonCode) in "Medical Reason"
			and AnesthesiaProcedure.status = 'completed'
			and Global."Normalize Interval"(AnesthesiaProcedure.performed) ends 1 day after day of start of QualifyingEncounter.period
			and Coalesce(NoVTEMedication.authoredOn, start of Global."Normalize Interval"(NoVTEMedication.effective)) during TJC."CalendarDayOfOrDayAfter"(end of Global."Normalize Interval"(AnesthesiaProcedure.performed))
  return QualifyingEncounter
Logic Definition Library Name: EXM108 
define "No VTE Prophylaxis Device Due to Medical Reason on Day of or Day After Procedure":
  from
  		"Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter,
  		["Procedure": "General or Neuraxial Anesthesia"] AnesthesiaProcedure,
  		"No VTE Prophylaxis Device Applied or Ordered" NoVTEDevice
  where  NoVTEDevice.requestStatusReason in "Medical Reason"
      and AnesthesiaProcedure.status = 'completed'
  		and Global."Normalize Interval"(AnesthesiaProcedure.performed) ends 1 day after day of start of QualifyingEncounter.period
      and NoVTEDevice.authoredOn during TJC."CalendarDayOfOrDayAfter"(end of Global."Normalize Interval"(AnesthesiaProcedure.performed))
  return QualifyingEncounter
Logic Definition Library Name: EXM108 
define "Encounter With No VTE Prophylaxis Due to Medical Reason":
   ( "No VTE Prophylaxis Medication Due to Medical Reason From Day of Start of Hospitalization To Day After Admission"
     intersect "No VTE Prophylaxis Device Due to Medical Reason From Day of Start of Hospitalization To Day After Admission"
   )
   union ( "No VTE Prophylaxis Medication Due to Medical Reason on Day of or Day After Procedure"
       intersect "No VTE Prophylaxis Device Due to Medical Reason on Day of or Day After Procedure"
       )
Logic Definition Library Name: EXM108 
define "No VTE Prophylaxis Medication or Device Due to Patient Refusal":
    ( "No VTE Prophylaxis Medication Administered or Ordered" NoVTEMedication
        where Coalesce(NoVTEMedication.statusReason,NoVTEMedication.reasonCode) in "Patient Refusal"
    )
  union ("No VTE Prophylaxis Device Applied or Ordered" NoVTEDevice
           where NoVTEDevice.requestStatusReason in "Patient Refusal"
        )
Logic Definition Library Name: EXM108 
define "No VTE Prophylaxis Due to Patient Refusal From Day of Start of Hospitalization To Day After Admission":
 	"Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter
	 with "No VTE Prophylaxis Medication or Device Due to Patient Refusal" PatientRefusal
   such that Coalesce(start of Global."Normalize Interval"(PatientRefusal.effective), PatientRefusal.authoredOn)
         during VTEICU."FromDayOfStartOfHospitalizationToDayAfterAdmission"(QualifyingEncounter)
Logic Definition Library Name: EXM108 
define "No VTE Prophylaxis Due to Patient Refusal on Day of or Day After Procedure":
 	from
   		"Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter,
   		["Procedure": "General or Neuraxial Anesthesia"] AnesthesiaProcedure,
   		"No VTE Prophylaxis Medication or Device Due to Patient Refusal" PatientRefusal
	where Global."Normalize Interval"(AnesthesiaProcedure.performed) ends 1 day after day of start of QualifyingEncounter.period
 			and Coalesce(start of Global."Normalize Interval"(PatientRefusal.effective), PatientRefusal.authoredOn)
             during TJC."CalendarDayOfOrDayAfter"(end of Global."Normalize Interval"(AnesthesiaProcedure.performed))
	return QualifyingEncounter
Logic Definition Library Name: EXM108 
define "Encounter With No VTE Prophylaxis Due to Patient Refusal":
 "No VTE Prophylaxis Due to Patient Refusal From Day of Start of Hospitalization To Day After Admission"
 	union "No VTE Prophylaxis Due to Patient Refusal on Day of or Day After Procedure"
Logic Definition Library Name: EXM108 
define "Numerator":
  "Encounter With VTE Prophylaxis Received on Day of or Day After Admission or Procedure"
    union ( "Encounter With Medication Oral Factor Xa Inhibitor Administered on Day of or Day After Admission or Procedure"
    			  intersect ( "Encounter With Prior or Present Diagnosis of Atrial Fibrillation or VTE"
    						    union "Encounter With Prior or Present Procedure of Hip or Knee Replacement Surgery"
    			            )
          )
    union "Encounter With Low Risk for VTE or Anticoagulant Administered"
    union "Encounter With No VTE Prophylaxis Due to Medical Reason"
    union "Encounter With No VTE Prophylaxis Due to Patient Refusal"
Logic Definition Library Name: EXM108 
define "Initial Population":
  "Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions"
Logic Definition Library Name: EXM108 
define "Denominator":
      "Initial Population"
Logic Definition Library Name: EXM108 
define "SDE Payer":
	SDE."SDE Payer"
Logic Definition Library Name: EXM108 
define "SDE Ethnicity":
  SDE."SDE Ethnicity"
Logic Definition Library Name: EXM108 
define "Encounter Less Than 2 Days":
  "Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter
  	where Global."LengthInDays"(QualifyingEncounter.period)< 2
Logic Definition Library Name: EXM108 
define "Encounter With ICU Location Stay 1 Day or More":
  "Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter
    where exists ( QualifyingEncounter.location Location
    		where Global.GetLocation(Location.location).type in "Intensive Care Unit"
    			and Global."LengthInDays"(Location.period)>= 1
    			and Location.period starts during TJC."CalendarDayOfOrDayAfter"(start of QualifyingEncounter.period)
	    )
Logic Definition Library Name: EXM108 
define "Encounter With Principal Diagnosis of Mental Disorder or Stroke":
  "Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter
    where Global."PrincipalDiagnosis"(QualifyingEncounter).code in "Mental Health Diagnoses"
        or Global."PrincipalDiagnosis"(QualifyingEncounter).code in "Hemorrhagic Stroke"
        or Global."PrincipalDiagnosis"(QualifyingEncounter).code in "Ischemic Stroke"
Logic Definition Library Name: EXM108 
define "SCIP VTE Selected Surgery":
  (	["Procedure": "General Surgery"]
    union ["Procedure": "Gynecological Surgery"]
    union ["Procedure": "Hip Fracture Surgery"]
    union ["Procedure": "Hip Replacement Surgery"]
    union ["Procedure": "Intracranial Neurosurgery"]
    union ["Procedure": "Knee Replacement Surgery"]
    union ["Procedure": "Urological Surgery"] ) Procedure
  where Procedure.status = 'completed'
Logic Definition Library Name: EXM108 
define "Encounter With Principal Procedure of SCIP VTE Selected Surgery":
  from
    "Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter,
    "SCIP VTE Selected Surgery" SelectedProcedure
  let EncounterProcedure: Global.GetExtension(QualifyingEncounter, 'qicore-encounter-procedure')
  where FHIRHelpers.ToInteger(Global.GetExtension(EncounterProcedure, 'rank').value as FHIR.positiveInt) = 1
    and Global.GetId(FHIRHelpers.ToString((Global.GetExtension(EncounterProcedure, 'procedure').value as FHIR.Reference).reference)) = SelectedProcedure.id
    and Global."Normalize Interval"(SelectedProcedure.performed) during QualifyingEncounter.period
Logic Definition Library Name: EXM108 
define "Intervention Comfort Measures":
	(["ServiceRequest": "Comfort Measures"] P
    		where P.intent = 'order'
  )
  	union
    	(["Procedure": "Comfort Measures"] InterventionPerformed
      	where InterventionPerformed.status in {'completed', 'in-progress'})
Logic Definition Library Name: EXM108 
define "Encounter With Intervention Comfort Measures From Day of Start of Hospitalization To Day After Admission":
	"Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter
		with "Intervention Comfort Measures" ComfortMeasure
		such that Coalesce(start of Global."Normalize Interval"(ComfortMeasure.performed), ComfortMeasure.authoredOn) during VTEICU."FromDayOfStartOfHospitalizationToDayAfterAdmission"(QualifyingEncounter)
Logic Definition Library Name: EXM108 
define "Encounter With Intervention Comfort Measures on Day of or Day After Procedure":
  from
    "Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter,
    ["Procedure": "General or Neuraxial Anesthesia"] AnesthesiaProcedure,
    "Intervention Comfort Measures" ComfortMeasure
  where AnesthesiaProcedure.status = 'completed'
      and Global."Normalize Interval"(AnesthesiaProcedure.performed) ends 1 day after day of start of QualifyingEncounter.period
      and Coalesce(start of Global."Normalize Interval"(ComfortMeasure.performed), ComfortMeasure.authoredOn) during TJC."CalendarDayOfOrDayAfter"(end of Global."Normalize Interval"(AnesthesiaProcedure.performed))
  return QualifyingEncounter
Logic Definition Library Name: EXM108 
define "Denominator Exclusion":
  "Encounter Less Than 2 Days"
     union "Encounter With ICU Location Stay 1 Day or More"
     union "Encounter With Principal Diagnosis of Mental Disorder or Stroke"
     union "Encounter With Principal Procedure of SCIP VTE Selected Surgery"
     union "Encounter With Intervention Comfort Measures From Day of Start of Hospitalization To Day After Admission"
     union "Encounter With Intervention Comfort Measures on Day of or Day After Procedure"
Logic Definition Library Name: EXM108 
define "SDE Race":
  SDE."SDE Race"
Logic Definition Library Name: EXM108 
//11/5: ServiceRequest not done reason is an extension in QI-Core R4 as ServiceRequest.extension:statusReason
define function GetStatusReason(requestReason ServiceRequest):
      Global.GetBaseExtension(requestReason, 'request-statusReason')
Logic Definition Library Name: MATGlobalCommonFunctions 
define "Inpatient Encounter":
	[Encounter: "Encounter Inpatient"] EncounterInpatient
		where EncounterInpatient.status = 'finished'
		    and "LengthInDays"(EncounterInpatient.period) <= 120
			and EncounterInpatient.period ends during "Measurement Period"
Logic Definition Library Name: MATGlobalCommonFunctions 
define function "LengthInDays"(Value Interval<DateTime>):
	difference in days between start of Value and end of Value
Logic Definition Library Name: MATGlobalCommonFunctions 
define function "CalendarAgeInYearsAt"(BirthDateTime DateTime, AsOf DateTime):
	years between ToDate(BirthDateTime)and ToDate(AsOf)
Logic Definition Library Name: MATGlobalCommonFunctions 
define function "ToDate"(Value DateTime):
	DateTime(year from Value, month from Value, day from Value, 0, 0, 0, 0, timezoneoffset from Value)
Logic Definition Library Name: MATGlobalCommonFunctions 
define function "EncounterDiagnosis"(Encounter Encounter):
  Encounter.diagnosis D
    return singleton from ([Condition] C where C.id = "GetId"(D.condition.reference))
Logic Definition Library Name: MATGlobalCommonFunctions 
define function "GetId"(uri String):
	Last(Split(uri, '/'))
Logic Definition Library Name: MATGlobalCommonFunctions 
/*
*
*    CQFMeasures Common Logic
*
*/

define function "Normalize Interval"(choice Choice<FHIR.dateTime, FHIR.Period, FHIR.Timing, FHIR.instant, FHIR.string, FHIR.Age, FHIR.Range>):
  case
	  when choice is FHIR.dateTime then
    	Interval[FHIRHelpers.ToDateTime(choice as FHIR.dateTime), FHIRHelpers.ToDateTime(choice as FHIR.dateTime)]
		when choice is FHIR.Period then
  		FHIRHelpers.ToInterval(choice as FHIR.Period)
		when choice is FHIR.instant then
			Interval[FHIRHelpers.ToDateTime(choice as FHIR.instant), FHIRHelpers.ToDateTime(choice as FHIR.instant)]
		when choice is FHIR.Age then
		  Interval[FHIRHelpers.ToDate(Patient.birthDate) + FHIRHelpers.ToQuantity(choice as FHIR.Age),
			  FHIRHelpers.ToDate(Patient.birthDate) + FHIRHelpers.ToQuantity(choice as FHIR.Age) + 1 year)
		when choice is FHIR.Range then
		  Interval[FHIRHelpers.ToDate(Patient.birthDate) + FHIRHelpers.ToQuantity((choice as FHIR.Range).low),
			  FHIRHelpers.ToDate(Patient.birthDate) + FHIRHelpers.ToQuantity((choice as FHIR.Range).high) + 1 year)
		when choice is FHIR.Timing then
		  Message(null as Interval<DateTime>, true, '1', 'Error', 'Cannot compute a single interval from a Timing type')
    when choice is FHIR.string then
      Message(null as Interval<DateTime>, true, '1', 'Error', 'Cannot compute an interval from a String value')
		else
			null as Interval<DateTime>
	end
Logic Definition Library Name: MATGlobalCommonFunctions 
define function "HospitalizationWithObservation"(TheEncounter FHIR.Encounter):
	TheEncounter Visit
		let ObsVisit: Last([Encounter: "Observation Services"] LastObs
				where LastObs.period ends 1 hour or less on or before start of Visit.period
				sort by end of period
			),
			VisitStart: Coalesce(start of ObsVisit.period, start of Visit.period),
			EDVisit: Last([Encounter: "Emergency Department Visit"] LastED
				where LastED.period ends 1 hour or less on or before VisitStart
				sort by end of period
			)
		return Interval[Coalesce(start of EDVisit.period, VisitStart), end of Visit.period]
Logic Definition Library Name: MATGlobalCommonFunctions 
define function "GetBaseExtension"(domainResource DomainResource, url String):
  singleton from "GetBaseExtensions"(domainResource, url)
Logic Definition Library Name: MATGlobalCommonFunctions 
/*
NOTE: Extensions are not the preferred approach, but are used as a way to access
content that is defined by extensions but not yet surfaced in the
CQL model info.
*/
define function "GetBaseExtensions"(domainResource DomainResource, url String):
  domainResource.extension E
	  where E.url = ('http://hl7.org/fhir/StructureDefinition/' + url)
		return E
Logic Definition Library Name: MATGlobalCommonFunctions 
define function "GetExtension"(domainResource DomainResource, url String):
  singleton from "GetExtensions"(domainResource, url)
Logic Definition Library Name: MATGlobalCommonFunctions 
/*
NOTE: Extensions are not the preferred approach, but are used as a way to access
content that is defined by extensions but not yet surfaced in the
CQL model info.
*/
define function "GetExtensions"(domainResource DomainResource, url String):
  domainResource.extension E
	  where E.url = ('http://hl7.org/fhir/us/qicore/StructureDefinition/' + url)
		return E
Logic Definition Library Name: MATGlobalCommonFunctions 
// Returns the location for the given location reference
define function GetLocation(reference Reference):
  singleton from (
    [Location] L where L.id = GetId(reference.reference)
  )
Logic Definition Library Name: MATGlobalCommonFunctions 
// Returns the condition that is specified as the principal diagnosis for the encounter
// TODO: BTR 2019-07-30: Shouldn't need the FHIRHelpers reference here, investigate
define function "PrincipalDiagnosis"(Encounter Encounter):
	(singleton from (Encounter.diagnosis D where FHIRHelpers.ToInteger(D.rank) = 1)) PD
		return singleton from ([Condition] C where C.id = "GetId"(PD.condition.reference))
Logic Definition Library Name: MATGlobalCommonFunctions 
define function "GetExtension"(element Element, url String):
  singleton from "GetExtensions"(element, url)
Logic Definition Library Name: MATGlobalCommonFunctions 
/*
NOTE: Extensions are not the preferred approach, but are used as a way to access
content that is defined by extensions but not yet surfaced in the
CQL model info.
*/
define function "GetExtensions"(element Element, url String):
  element.extension E
	  where E.url = (url)
		return E
Logic Definition Library Name: FHIRHelpers 
define function ToString(value AdministrativeGender): value.value
Logic Definition Library Name: FHIRHelpers 
define function ToString(value EncounterStatus): value.value
Logic Definition Library Name: FHIRHelpers 
/*
@description: Converts the given [Period](https://hl7.org/fhir/datatypes.html#Period)
value to a CQL DateTime Interval
@comment: If the start value of the given period is unspecified, the starting
boundary of the resulting interval will be open (meaning the start of the interval
is unknown, as opposed to interpreted as the beginning of time).
*/
define function ToInterval(period FHIR.Period):
    if period is null then
        null
    else
        if period."start" is null then
            Interval(period."start".value, period."end".value]
        else
            Interval[period."start".value, period."end".value]
Logic Definition Library Name: FHIRHelpers 
define function ToDate(value date): value.value
Logic Definition Library Name: FHIRHelpers 
define function ToString(value string): value.value
Logic Definition Library Name: FHIRHelpers 
/*
@description: Converts the given FHIR [CodeableConcept](https://hl7.org/fhir/datatypes.html#CodeableConcept) value to a CQL Concept.
*/
define function ToConcept(concept FHIR.CodeableConcept):
    if concept is null then
        null
    else
        System.Concept {
            codes: concept.coding C return ToCode(C),
            display: concept.text.value
        }
Logic Definition Library Name: FHIRHelpers 
/*
@description: Converts the given FHIR [Coding](https://hl7.org/fhir/datatypes.html#Coding) value to a CQL Code.
*/
define function ToCode(coding FHIR.Coding):
    if coding is null then
        null
    else
        System.Code {
          code: coding.code.value,
          system: coding.system.value,
          version: coding.version.value,
          display: coding.display.value
        }
Logic Definition Library Name: FHIRHelpers 
define function ToString(value MedicationAdministrationStatus): value.value
Logic Definition Library Name: FHIRHelpers 
define function ToString(value ProcedureStatus): value.value
Logic Definition Library Name: FHIRHelpers 
define function ToDateTime(value dateTime): value.value
Logic Definition Library Name: FHIRHelpers 
define function ToDateTime(value instant): value.value
Logic Definition Library Name: FHIRHelpers 
/*
@description: Converts the given FHIR [Quantity](https://hl7.org/fhir/datatypes.html#Quantity) 
value to a CQL Quantity
@comment: If the given quantity has a comparator specified, a runtime error is raised. If the given quantity
has a system other than UCUM (i.e. `http://unitsofmeasure.org`) or CQL calendar units (i.e. `http://hl7.org/fhirpath/CodeSystem/calendar-units`)
an error is raised. For UCUM to calendar units, the `ToCalendarUnit` function is used.
@seealso: ToCalendarUnit
*/
define function ToQuantity(quantity FHIR.Quantity):
    case
        when quantity is null then null
        when quantity.value is null then null
        when quantity.comparator is not null then
            Message(null, true, 'FHIRHelpers.ToQuantity.ComparatorQuantityNotSupported', 'Error', 'FHIR Quantity value has a comparator and cannot be converted to a System.Quantity value.')
        when quantity.system is null or quantity.system.value = 'http://unitsofmeasure.org'
              or quantity.system.value = 'http://hl7.org/fhirpath/CodeSystem/calendar-units' then
            System.Quantity { value: quantity.value.value, unit: ToCalendarUnit(Coalesce(quantity.code.value, quantity.unit.value, '1')) }
        else
            Message(null, true, 'FHIRHelpers.ToQuantity.InvalidFHIRQuantity', 'Error', 'Invalid FHIR Quantity code: ' & quantity.unit.value & ' (' & quantity.system.value & '|' & quantity.code.value & ')')
    end
Logic Definition Library Name: FHIRHelpers 
/*
@description: Converts a UCUM definite duration unit to a CQL calendar duration
unit using conversions specified in the [quantities](https://cql.hl7.org/02-authorsguide.html#quantities) 
topic of the CQL specification.
@comment: Note that for durations above days (or weeks), the conversion is understood to be approximate
*/
define function ToCalendarUnit(unit System.String):
    case unit
        when 'ms' then 'millisecond'
        when 's' then 'second'
        when 'min' then 'minute'
        when 'h' then 'hour'
        when 'd' then 'day'
        when 'wk' then 'week'
        when 'mo' then 'month'
        when 'a' then 'year'
        else unit
    end
Logic Definition Library Name: FHIRHelpers 
define function ToString(value ObservationStatus): value.value
Logic Definition Library Name: FHIRHelpers 
define function ToBoolean(value boolean): value.value
Logic Definition Library Name: FHIRHelpers 
define function ToString(value MedicationRequestStatus): value.value
Logic Definition Library Name: FHIRHelpers 
define function ToString(value ServiceRequestStatus): value.value
Logic Definition Library Name: FHIRHelpers 
define function ToString(value uri): value.value
Logic Definition Library Name: FHIRHelpers 
define function ToInteger(value integer): value.value
Logic Definition Library Name: FHIRHelpers 
define function ToString(value ServiceRequestIntent): value.value
Terminology
Code System Description: Code system ConditionClinicalStatusCodes
Resource: Condition Clinical Status Codes
Canonical URL: http://terminology.hl7.org/CodeSystem/condition-clinical
Code System Description: Code system LOINC
Resource: Logical Observation Identifiers, Names and Codes (LOINC)
Canonical URL: http://loinc.org
Value Set Description: Value set Encounter Inpatient
Resource: Encounter Inpatient
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.666.5.307
Value Set Description: Value set Obstetrics
Resource: Obstetrical or Pregnancy Related Conditions
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.263
Value Set Description: Value set Venous Thromboembolism
Resource: Venous Thromboembolism
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.279
Value Set Description: Value set Obstetrics VTE
Resource: Obstetrics VTE
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.264
Value Set Description: Value set Low Dose Unfractionated Heparin for VTE Prophylaxis
Resource: Low Dose Unfractionated Heparin for VTE Prophylaxis
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1045.39
Value Set Description: Value set Subcutaneous route
Resource: Subcutaneous route
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.223
Value Set Description: Value set Low Molecular Weight Heparin for VTE Prophylaxis
Resource: Low Molecular Weight Heparin for VTE Prophylaxis
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.219
Value Set Description: Value set Injectable Factor Xa Inhibitor for VTE Prophylaxis
Resource: Injectable Factor Xa Inhibitor for VTE Prophylaxis
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.211
Value Set Description: Value set Warfarin
Resource: Warfarin
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.232
Value Set Description: Value set Device Application
Resource: Device Application
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1110.48
Value Set Description: Value set Intermittent pneumatic compression devices (IPC)
Resource: Intermittent pneumatic compression devices
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.214
Value Set Description: Value set Venous foot pumps (VFP)
Resource: Venous foot pumps
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.230
Value Set Description: Value set Graduated compression stockings (GCS)
Resource: Graduated compression stockings
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.256
Value Set Description: Value set General or Neuraxial Anesthesia
Resource: General or Neuraxial Anesthesia
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.666.5.1743
Value Set Description: Value set Oral Factor Xa Inhibitor for VTE Prophylaxis or VTE Treatment
Resource: Oral Factor Xa Inhibitor for VTE Prophylaxis or VTE Treatment
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.134
Value Set Description: Value set Atrial Fibrillation/Flutter
Resource: Atrial Fibrillation or Flutter
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.202
Value Set Description: Value set Hip Replacement Surgery
Resource: Hip Replacement Surgery
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.259
Value Set Description: Value set Knee Replacement Surgery
Resource: Knee Replacement Surgery
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.261
Value Set Description: Value set Low Risk
Resource: Low Risk
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.400
Value Set Description: Value set INR
Resource: INR
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.213
Value Set Description: Value set Unfractionated Heparin
Resource: Unfractionated Heparin
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.218
Value Set Description: Value set Intravenous route
Resource: Intravenous route
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.222
Value Set Description: Value set Direct Thrombin Inhibitor
Resource: Direct Thrombin Inhibitor
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.205
Value Set Description: Value set Glycoprotein IIb/IIIa Inhibitors
Resource: Glycoprotein IIb IIIa Inhibitors
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1045.41
Value Set Description: Value set Observation Services
Resource: Observation Services
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1111.143
Value Set Description: Value set Emergency Department Visit
Resource: Emergency Department Visit
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.292
Value Set Description: Value set Medical Reason
Resource: Medical Reason For Not Providing Treatment
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.473
Value Set Description: Value set Patient Refusal
Resource: Patient Refusal
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.93
Value Set Description: Value set Payer
Resource: Payer Type
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591
Value Set Description: Value set Intensive Care Unit
Resource: Intensive Care Unit
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1110.23
Value Set Description: Value set Mental Health Diagnoses
Resource: Mental Health Diagnoses
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.105.12.1004
Value Set Description: Value set Hemorrhagic Stroke
Resource: Hemorrhagic Stroke
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.212
Value Set Description: Value set Ischemic Stroke
Resource: Ischemic Stroke
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.247
Value Set Description: Value set General Surgery
Resource: General Surgery
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.255
Value Set Description: Value set Gynecological Surgery
Resource: Gynecological Surgery
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.257
Value Set Description: Value set Hip Fracture Surgery
Resource: Hip Fracture Surgery
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.258
Value Set Description: Value set Intracranial Neurosurgery
Resource: Intracranial Neurosurgery
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.260
Value Set Description: Value set Urological Surgery
Resource: Urological Surgery
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.272
Value Set Description: Value set Comfort Measures
Resource: Comfort Measures
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/1.3.6.1.4.1.33895.1.3.0.45
Direct Reference Code Code: active
System: http://terminology.hl7.org/CodeSystem/condition-clinical
Direct Reference Code Code: recurrence
System: http://terminology.hl7.org/CodeSystem/condition-clinical
Direct Reference Code Code: relapse
System: http://terminology.hl7.org/CodeSystem/condition-clinical
Direct Reference Code Code: inactive
System: http://terminology.hl7.org/CodeSystem/condition-clinical
Direct Reference Code Code: remission
System: http://terminology.hl7.org/CodeSystem/condition-clinical
Direct Reference Code Code: resolved
System: http://terminology.hl7.org/CodeSystem/condition-clinical
Direct Reference Code Display: Risk for venous thromboembolism
Code: 72136-5
System: http://loinc.org
Dependencies
Dependency Description: FHIR model information
Resource: http://hl7.org/fhir/uv/cql/Library/FHIR-ModelInfo|4.0.1
Canonical URL: http://hl7.org/fhir/uv/cql/Library/FHIR-ModelInfo|4.0.1
Dependency Description: Library SDE
Resource: Supplemental Data Elements version: 2.0.000
Canonical URL: http://hl7.org/fhir/uv/cqm/Library/SupplementalDataElements|2.0.000
Dependency Description: Library FHIRHelpers
Resource: http://hl7.org/fhir/uv/cql/Library/FHIRHelpers|4.0.1
Canonical URL: http://hl7.org/fhir/uv/cql/Library/FHIRHelpers|4.0.1
Dependency Description: Library Global
Resource: MAT Global Common Functions FHIR Library version: 5.0.000
Canonical URL: http://hl7.org/fhir/uv/cqm/Library/MATGlobalCommonFunctions|5.0.000
Dependency Description: Library TJC
Resource: TJC Overall Library version: 4.0.000
Canonical URL: http://hl7.org/fhir/uv/cqm/Library/TJCOverall|4.0.000
Dependency Description: Library VTEICU
Resource: VTE ICU Library version: 5.0.000
Canonical URL: http://hl7.org/fhir/uv/cqm/Library/VTEICU|5.0.000
Data Requirements
Data Requirement Type: Patient
Profile(s): Patient
Must Support Elements: url, extension, value
Data Requirement Type: Encounter
Profile(s): Encounter
Must Support Elements: type, status, period, condition, condition.reference, location, rank
Code Filter(s):
Path: type
ValueSet: Encounter Inpatient
Data Requirement Type: Encounter
Profile(s): Encounter
Must Support Elements: type, period, condition, condition.reference, location, rank
Code Filter(s):
Path: type
ValueSet: Observation Services
Data Requirement Type: Encounter
Profile(s): Encounter
Must Support Elements: type, period, condition, condition.reference, location, rank
Code Filter(s):
Path: type
ValueSet: Emergency Department Visit
Data Requirement Type: Condition
Profile(s): Condition
Must Support Elements: code, clinicalStatus, onset
Code Filter(s):
Path: code
ValueSet: Atrial Fibrillation or Flutter
Data Requirement Type: Condition
Profile(s): Condition
Must Support Elements: code, clinicalStatus, onset
Code Filter(s):
Path: code
ValueSet: Venous Thromboembolism
Data Requirement Type: Condition
Profile(s): Condition
Must Support Elements: id, code
Data Requirement Type: MedicationAdministration
Profile(s): MedicationAdministration
Must Support Elements: medication, status, effective, dosage, dosage.route, id
Code Filter(s):
Path: medication
ValueSet: Oral Factor Xa Inhibitor for VTE Prophylaxis or VTE Treatment
Data Requirement Type: MedicationAdministration
Profile(s): MedicationAdministration
Must Support Elements: medication, dosage, dosage.route, status, id, effective
Code Filter(s):
Path: medication
ValueSet: Unfractionated Heparin
Data Requirement Type: MedicationAdministration
Profile(s): MedicationAdministration
Must Support Elements: medication, dosage, dosage.route, status, id, effective
Code Filter(s):
Path: medication
ValueSet: Direct Thrombin Inhibitor
Data Requirement Type: MedicationAdministration
Profile(s): MedicationAdministration
Must Support Elements: medication, dosage, dosage.route, status, id, effective
Code Filter(s):
Path: medication
ValueSet: Glycoprotein IIb IIIa Inhibitors
Data Requirement Type: MedicationAdministration
Profile(s): MedicationAdministration
Must Support Elements: medication.reference, dosage, dosage.route, status, id, effective
Data Requirement Type: MedicationAdministration
Profile(s): MedicationAdministration
Must Support Elements: medication, status, dosage, dosage.route, id, effective
Code Filter(s):
Path: medication
ValueSet: Low Dose Unfractionated Heparin for VTE Prophylaxis
Data Requirement Type: MedicationAdministration
Profile(s): MedicationAdministration
Must Support Elements: medication, status, dosage, dosage.route, id, effective
Code Filter(s):
Path: medication
ValueSet: Low Molecular Weight Heparin for VTE Prophylaxis
Data Requirement Type: MedicationAdministration
Profile(s): MedicationAdministration
Must Support Elements: medication, status, dosage, dosage.route, id, effective
Code Filter(s):
Path: medication
ValueSet: Injectable Factor Xa Inhibitor for VTE Prophylaxis
Data Requirement Type: MedicationAdministration
Profile(s): MedicationAdministration
Must Support Elements: medication, status, dosage, dosage.route, id, effective
Code Filter(s):
Path: medication
ValueSet: Warfarin
Data Requirement Type: Procedure
Profile(s): Procedure
Must Support Elements: code, status, usedCode, performed, id, statusReason
Code Filter(s):
Path: code
ValueSet: Device Application
Data Requirement Type: Procedure
Profile(s): Procedure
Must Support Elements: code, status, performed, id
Code Filter(s):
Path: code
ValueSet: General Surgery
Data Requirement Type: Procedure
Profile(s): Procedure
Must Support Elements: code, status, performed, id
Code Filter(s):
Path: code
ValueSet: Gynecological Surgery
Data Requirement Type: Procedure
Profile(s): Procedure
Must Support Elements: code, status, performed, id
Code Filter(s):
Path: code
ValueSet: Hip Fracture Surgery
Data Requirement Type: Procedure
Profile(s): Procedure
Must Support Elements: code, status, performed, id
Code Filter(s):
Path: code
ValueSet: Hip Replacement Surgery
Data Requirement Type: Procedure
Profile(s): Procedure
Must Support Elements: code, status, performed, id
Code Filter(s):
Path: code
ValueSet: Intracranial Neurosurgery
Data Requirement Type: Procedure
Profile(s): Procedure
Must Support Elements: code, status, performed, id
Code Filter(s):
Path: code
ValueSet: Knee Replacement Surgery
Data Requirement Type: Procedure
Profile(s): Procedure
Must Support Elements: code, status, performed, id
Code Filter(s):
Path: code
ValueSet: Urological Surgery
Data Requirement Type: Procedure
Profile(s): Procedure
Must Support Elements: code, status, performed, id
Code Filter(s):
Path: code
ValueSet: Comfort Measures
Data Requirement Type: Procedure
Profile(s): Procedure
Must Support Elements: code, performed, status, id
Code Filter(s):
Path: code
ValueSet: General or Neuraxial Anesthesia
Data Requirement Type: Observation
Profile(s): Observation
Must Support Elements: code, value, status, effective
Code Filter(s):
Path: code
Code(s): LOINC: 72136-5 (Risk for venous thromboembolism)
Data Requirement Type: Observation
Profile(s): Observation
Must Support Elements: code, value, status, id, issued, effective
Code Filter(s):
Path: code
ValueSet: INR
Data Requirement Type: Medication
Profile(s): Medication
Must Support Elements: id, code
Data Requirement Type: MedicationRequest
Profile(s): MedicationRequest
Must Support Elements: medication, doNotPerform, status
Code Filter(s):
Path: medication
ValueSet: Low Dose Unfractionated Heparin for VTE Prophylaxis
Data Requirement Type: MedicationRequest
Profile(s): MedicationRequest
Must Support Elements: medication, doNotPerform, status
Code Filter(s):
Path: medication
ValueSet: Low Molecular Weight Heparin for VTE Prophylaxis
Data Requirement Type: MedicationRequest
Profile(s): MedicationRequest
Must Support Elements: medication, doNotPerform, status
Code Filter(s):
Path: medication
ValueSet: Injectable Factor Xa Inhibitor for VTE Prophylaxis
Data Requirement Type: MedicationRequest
Profile(s): MedicationRequest
Must Support Elements: medication, doNotPerform, status
Code Filter(s):
Path: medication
ValueSet: Warfarin
Data Requirement Type: ServiceRequest
Profile(s): ServiceRequest
Must Support Elements: code, status, doNotPerform, id, authoredOn
Code Filter(s):
Path: code
ValueSet: Venous foot pumps
Data Requirement Type: ServiceRequest
Profile(s): ServiceRequest
Must Support Elements: code, status, doNotPerform, id, authoredOn
Code Filter(s):
Path: code
ValueSet: Intermittent pneumatic compression devices
Data Requirement Type: ServiceRequest
Profile(s): ServiceRequest
Must Support Elements: code, status, doNotPerform, id, authoredOn
Code Filter(s):
Path: code
ValueSet: Graduated compression stockings
Data Requirement Type: ServiceRequest
Profile(s): ServiceRequest
Must Support Elements: code, intent, status, doNotPerform, id, authoredOn
Code Filter(s):
Path: code
ValueSet: Comfort Measures
Data Requirement Type: Coverage
Profile(s): Coverage
Must Support Elements: type, period
Code Filter(s):
Path: type
ValueSet: Payer Type
Data Requirement Type: Location
Profile(s): Location
Must Support Elements: id
Parameters
Name Use Card. Type Documentation
Measurement Period In 0..1 Period
SDE Sex Out 0..1 Coding
Numerator Out 0..* Encounter
Denominator Out 0..* Encounter
SDE Payer Out 0..* Resource
Initial Population Out 0..* Encounter
SDE Ethnicity Out 0..* Coding
Denominator Exclusion Out 0..* Resource
SDE Race Out 0..* Coding
Generated using version 0.5.4 of the sample-content-ig Liquid templates
<status value="active"/> <experimental value="true"/> <date value="2025-08-13"/> <publisher value="HL7 International / Clinical Quality Information"/> <contact> <telecom> <system value="url"/> <value value="http://www.hl7.org/Special/committees/cqi"/> </telecom> </contact> <description value="This measure assesses the number of patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given the day of or the day after hospital admission or surgery end date for surgeries that start the day of or the day after hospital admission"/> <useContext> <code> <system value="http://terminology.hl7.org/CodeSystem/usage-context-type"/> <code value="venue"/> <display value="Clinical Venue"/> </code> <valueCodeableConcept> <coding> <system value="http://hl7.org/fhir/uv/cqm/CodeSystem/intended-venue-codes"/> <code value="eh"/> <display value="EH"/> </coding> </valueCodeableConcept> </useContext> <jurisdiction> <coding> <system value="http://unstats.un.org/unsd/methods/m49/m49.htm"/> <code value="001"/> </coding> </jurisdiction> <copyright value="Measure specifications are in the Public Domain. LOINC(R) is a registered trademark of the Regenstrief Institute. This material contains SNOMED Clinical Terms(R) (SNOMED CT(C)) copyright 2004-2017 International Health Terminology Standards Development Organization. All rights reserved."/> <approvalDate value="2019-03-08"/> <lastReviewDate value="2019-03-08"/> <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> <library value="http://hl7.org/fhir/uv/cqm/Library/EXM108"/> <disclaimer value="These performance measures are not clinical guidelines and do not establish a standard of medical care, and have not been tested for all potential applications. The measures and specifications are provided without warranty"/> <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="Hospitalized patients at high-risk for VTE may develop an asymptomatic deep vein thrombosis (DVT), and die from pulmonary embolism (PE) even before the diagnosis is suspected. The majority of fatal events occur as sudden or abrupt death, underscoring the importance of prevention as the most critical action step for reducing death from PE (Geerts, et al, 2008). The estimated annual incidence of deep-vein thrombosis (DVT) and pulmonary embolism (PE), known collectively as venous thromboembolism (VTE), is approximately 900,000 (Geerts, et al, 2008). Approximately two-thirds of cases of DVT or PE are associated with recent hospitalization. This is consistent with the 2001 report by The Agency for Healthcare Research and Quality (AHRQ). AHRQ indicates that "the appropriate application of effective preventive measures in hospitals has major potential for improving patient safety by reducing the incidence of venous thromboembolism" (Shojania, 2001). Despite its proven effectiveness, rates of appropriate thromboprophylaxis remain low in both medical and surgical patients. A recent analysis from the ENDORSE survey, which evaluated prophylaxis rates in 17,084 major surgery patients, found that more than one third of patients at risk for VTE (38%) did not receive prophylaxis and that rates varied by surgery type (Cohen, et al., 2008). In a review of evidence-based patient safety practices, the Agency for Healthcare Research and Quality defined thromboprophylaxis against VTE as the "number one patient safety practice" for hospitalized patients (Shojania, 2001). Updated "safe practices" published by the National Quality Forum (NQF) recommend routine evaluation of hospitalized patients for risk of VTE and use of appropriate prophylaxis (National Quality Forum. National Voluntary Consensus Standards for Prevention and Care of Venous Thromboembolism, 2006). As noted by the ACCP, a vast number of randomized clinical trials provide irrefutable evidence that thromboprophylaxis reduces VTE events, and there are studies that have also shown that fatal PE is prevented by thromboprophylaxis (Geerts, et al. 2008). Some select surgeries have previously been monitored in the Surgical Care Improvement Project; since performance on these surgeries has achieved very high levels, they are not included in this measure."/> <clinicalRecommendationStatement value="Failure to recognize and protect patients at risk for venous thromboembolism (VTE) increases the chances for acutely ill hospitalized patients at high risk for developing a deep vein thrombosis or dying from a pulmonary emboli. Screening all patients is the only evidence based practice in reducing incidence of disease. All hospitalized patients should be evaluated for primary VTE prophylaxis, and given appropriate prophylaxis when indicated."/> <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="When low dose unfractionated heparin is administered for VTE Prophylaxis, the intended administration route for low dose unfractionated heparin is subcutaneous. Reasons for no pharmacological and no mechanical VTE prophylaxis must be explicitly documented by the MD/APN/PA or pharmacist and linked with VTE prophylaxis. Ambulation alone is not a sufficient reason for not administering VTE prophylaxis. In order for ambulation/patient ambulating to be considered as an acceptable reason, there needs to be explicit documentation, e.g., "patient out of bed and ambulating in halls - no VTE prophylaxis needed.""/> <group id="group-1"> <extension url="http://hl7.org/fhir/5.0/StructureDefinition/extension-Measure.group.linkId"> <valueString value="primary"/> </extension> <population> <extension url="http://hl7.org/fhir/5.0/StructureDefinition/extension-Measure.group.population.linkId"> <valueString value="primary-exm108-initial-population"/> </extension> <code> <coding> <system value="http://terminology.hl7.org/CodeSystem/measure-population"/> <code value="initial-population"/> <display value="Initial Population"/> </coding> </code> <description value="Patients age 18 and older discharged from hospital inpatient acute care without a diagnosis of venous thromboembolism (VTE) or obstetrics with a length of stay less than or equal to 120 days that ends during the measurement period"/> <criteria> <language value="text/cql-identifier"/> <expression value="Initial Population"/> </criteria> </population> <population> <extension url="http://hl7.org/fhir/5.0/StructureDefinition/extension-Measure.group.population.linkId"> <valueString value="primary-exm108-numerator"/> </extension> <code> <coding> <system value="http://terminology.hl7.org/CodeSystem/measure-population"/> <code value="numerator"/> <display value="Numerator"/> </coding> </code> <description value="Patients who received VTE prophylaxis: - the day of or the day after hospital admission - the day of or the day after surgery end date for surgeries that end the day of or the day after hospital admission Patients who have documentation of a reason why no VTE prophylaxis was given: - between arrival and hospital admission - the day of or the day after hospital admission - the day of or the day after surgery end date (for surgeries that end the day of or the day after hospital admission)"/> <criteria> <language value="text/cql-identifier"/> <expression value="Numerator"/> </criteria> </population> <population> <extension url="http://hl7.org/fhir/5.0/StructureDefinition/extension-Measure.group.population.linkId"> <valueString value="primary-exm108-denominator"/> </extension> <code> <coding> <system value="http://terminology.hl7.org/CodeSystem/measure-population"/> <code value="denominator"/> <display value="Denominator"/> </coding> </code> <description value="All patients in the initial population"/> <criteria> <language value="text/cql-identifier"/> <expression value="Denominator"/> </criteria> </population> <population> <extension url="http://hl7.org/fhir/5.0/StructureDefinition/extension-Measure.group.population.linkId"> <valueString value="primary-exm108-denominator-exclusion"/> </extension> <code> <coding> <system value="http://terminology.hl7.org/CodeSystem/measure-population"/> <code value="denominator-exclusion"/> <display value="Denominator Exclusion"/> </coding> </code> <description value="* Patients who have a length of stay less than 2 days * Patients with comfort measures documented anytime between arrival and the day after hospital admission * Patients with comfort measures documented by the day after surgery end date for surgeries that start the day of or the day after hospital admission * Patients who are direct admits to intensive care unit (ICU), or transferred to ICU the day of or the day after hospital admission with ICU length of stay greater than or equal to one day * Patients with a principal diagnosis of mental disorders or stroke * Patients with a principal procedure of Surgical Care Improvement Project (SCIP) VTE selected surgeries"/> <criteria> <language value="text/cql-identifier"/> <expression value="Denominator Exclusion"/> </criteria> </population> </group> <supplementalData> <extension url="http://hl7.org/fhir/5.0/StructureDefinition/extension-Measure.supplementalData.linkId"> <valueString value="primary-sde-ethnicity"/> </extension> <extension url="http://hl7.org/fhir/uv/cqm/StructureDefinition/cqm-includeInReportType"> <valueCode value="summary"/> </extension> <usage> <coding> <system value="http://terminology.hl7.org/CodeSystem/measure-data-usage"/> <code value="supplemental-data"/> </coding> </usage> <criteria> <language value="text/cql-identifier"/> <expression value="SDE Ethnicity"/> </criteria> </supplementalData> <supplementalData> <extension url="http://hl7.org/fhir/5.0/StructureDefinition/extension-Measure.supplementalData.linkId"> <valueString value="primary-sde-payer"/> </extension> <extension url="http://hl7.org/fhir/uv/cqm/StructureDefinition/cqm-includeInReportType"> <valueCode value="summary"/> </extension> <usage> <coding> <system value="http://terminology.hl7.org/CodeSystem/measure-data-usage"/> <code value="supplemental-data"/> </coding> </usage> <criteria> <language value="text/cql-identifier"/> <expression value="SDE Payer"/> </criteria> </supplementalData> <supplementalData> <extension url="http://hl7.org/fhir/5.0/StructureDefinition/extension-Measure.supplementalData.linkId"> <valueString value="primary-sde-race"/> </extension> <extension url="http://hl7.org/fhir/uv/cqm/StructureDefinition/cqm-includeInReportType"> <valueCode value="summary"/> </extension> <usage> <coding> <system value="http://terminology.hl7.org/CodeSystem/measure-data-usage"/> <code value="supplemental-data"/> </coding> </usage> <criteria> <language value="text/cql-identifier"/> <expression value="SDE Race"/> </criteria> </supplementalData> <supplementalData> <extension url="http://hl7.org/fhir/5.0/StructureDefinition/extension-Measure.supplementalData.linkId"> <valueString value="primary-sde-sex"/> </extension> <extension url="http://hl7.org/fhir/uv/cqm/StructureDefinition/cqm-includeInReportType"> <valueCode value="summary"/> </extension> <usage> <coding> <system value="http://terminology.hl7.org/CodeSystem/measure-data-usage"/> <code value="supplemental-data"/> </coding> </usage> <criteria> <language value="text/cql-identifier"/> <expression value="SDE Sex"/> </criteria> </supplementalData> </Measure>