eCQM QICore Content Implementation Guide
2023.0.0 - CI Build

eCQM QICore Content Implementation Guide, published by cqframework. This guide is not an authorized publication; it is the continuous build for version 2023.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/cqframework/ecqm-content-qicore-2023/ and changes regularly. See the Directory of published versions

## Measure: Dementia: Cognitive AssessmentFHIR

Official URL: http://ecqi.healthit.gov/ecqms/Measure/DementiaCognitiveAssessmentFHIR | Version: 0.0.004
Draft as of 2023-10-27 | ​ Responsible: American Academy of Neurology | Computable Name: DementiaCognitiveAssessmentFHIR
Other Identifiers: Short Name (use: usual, ), UUID:5dd075c9-2ce3-49be-a219-055e2444cfea (use: official, ), UUID:0207eaf9-c365-4740-b5db-fc41f8aa9906 (use: official, ), Endorser (use: official, ), Publisher (use: official, )
Usage:Program: EP/EC
Copyright/Legal: Attribution: The American Psychiatric Association’s (APA), PCPI’s, and American Medical Association’s (AMA) significant past efforts and contributions to the development and updating of the Measure are acknowledged. Copyright: (C)2023 American Academy of Neurology Institute (AANI). All rights reserved.

Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of cognition is performed and the results reviewed at least once within a 12-month period

UNKNOWN

Title: | Dementia: Cognitive AssessmentFHIR
Id: | DementiaCognitiveAssessmentFHIR
Download cql: | DementiaCognitiveAssessmentFHIR.cql
Version: | 0.0.004
Url: | Dementia: Cognitive AssessmentFHIR
short-name identifier: | CMS149FHIR
version-independent identifier: | urn:uuid:5dd075c9-2ce3-49be-a219-055e2444cfea
version-specific identifier: | urn:uuid:0207eaf9-c365-4740-b5db-fc41f8aa9906
endorser (NQF) identifier: | 2872e
publisher (CMS) identifier: | 149FHIR
Effective Period: | 2024-01-01 ..2024-12-31
Status: | draft
Date: | 2023-10-27 08:12:31+0000
Approval Date: | 2023-08-14
Last Review Date: | 2023-08-14
Name: | DementiaCognitiveAssessmentFHIR
Publisher: | American Academy of Neurology
Author: | ​American Academy of Neurology: www.aan.com, American Medical Association (AMA): https://www.ama-assn.org/
Description: | Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of cognition is performed and the results reviewed at least once within a 12-month period
Use Context: |
code | value
--- | ---
program |
Purpose: | UNKNOWN
Copyright: | Attribution: The American Psychiatric Association’s (APA), PCPI’s, and American Medical Association’s (AMA) significant past efforts and contributions to the development and updating of the Measure are acknowledged. Copyright: (C)2023 American Academy of Neurology Institute (AANI). All rights reserved.
Disclaimer: | Limited proprietary coding may be contained in the Measure specifications for convenience. A license agreement must be entered prior to a third party’s use of Current Procedural Terminology (CPT[R]) or other proprietary code set contained in the Measure. Any other use of CPT or other coding by the third party is strictly prohibited. AANI, APA, AMA, and the former members of the PCPI disclaim all liability for use or accuracy of any CPT or other coding contained in the specifications. CPT(R) contained in the Measure specifications is copyright 2004-2022 American Medical Association. LOINC(R) is copyright 2004-2022 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2022 International Health Terminology Standards Development Organisation. ICD-10 is copyright 2022 World Health Organization. All Rights Reserved.
Rationale: | An estimated 5.8 million of adults in the US were living with dementia in 2019. Dementia is often characterized by the gradual onset and continuing cognitive decline in one or more domains including memory, communication and language, ability to focus or pay attention, reasoning and judgment and visual perception (Alzheimer’s Association, 2019). Cognitive deterioration represents a major source of morbidity and mortality and poses a significant burden on affected individuals and their caregivers (Daviglus et al., 2010). Although cognitive deterioration follows a different course depending on the type of dementia, significant rates of decline have been reported. For example, one study found that the annual rate of decline for Alzheimer's disease patients was more than four times that of older adults with no cognitive impairment (Wilson et al., 2010). Nevertheless, measurable cognitive abilities remain throughout the course of dementia (American Psychiatric Association, 2007). Initial and ongoing assessments of cognition are fundamental to the proper management of patients with dementia. These assessments serve as the basis for identifying treatment goals, developing a treatment plan, monitoring the effects of treatment, and modifying treatment as appropriate.
Clinical recommendation statement: | Ongoing assessment includes periodic monitoring of the development and evolution of cognitive and noncognitive psychiatric symptoms and their response to intervention (Category I). Both cognitive and noncognitive neuropsychiatric and behavioral symptoms of dementia tend to evolve over time, so regular monitoring allows detection of new symptoms and adaptation of treatment strategies to current needs... Cognitive symptoms that almost always require assessment include impairments in memory, executive function, language, judgment, and spatial abilities. It is often helpful to track cognitive status with a structured simple examination (American Psychiatric Association, 2007). The American Psychiatric Association recommends that patients with dementia be assessed for the type, frequency, severity, pattern, and timing of symptoms (Category 1C). Quantitative measures provide a structured replicable way to document the patient's baseline symptoms and determine which symptoms (if any) should be the target of intervention based on factors such as frequency of occurrence, magnitude, potential for associated harm to the patient or others, and associated distress to the patient. The exact frequency at which measures are warranted will depend on clinical circumstances. However, use of quantitative measures as treatment proceeds allows more precise tracking of whether nonpharmacological and pharmacological treatments are having their intended effect or whether a shift in the treatment plan is needed (American Psychiatric Association, 2016). Conduct and document an assessment and monitor changes in cognitive status using a reliable and valid instrument, e.g., Montreal Cognitive Assessment (MoCA), Ascertain Dementia 8 (AD8) or other tool. Cognitive status should be reassessed periodically to identify sudden changes, as well as to monitor the potential beneficial or harmful effects of environmental changes (including safety, care needs, and abuse and/or neglect), specific medications (both prescription and non-prescription, for appropriate use and contraindications), or other interventions. Proper assessment requires the use of a standardized, objective instrument that is relatively easy to use, reliable (with less variability between different assessors), and valid (results that would be similar to gold-standard evaluations) (California Department of Public Health, 2017). Recommendation: Perform regular, comprehensive person-centered assessments and timely interim assessments. Assessments, conducted at least every 6 months, should prioritize issues that help the person with dementia to live fully. These include assessments of the individual and care partner’s relationships and subjective experience and assessment of cognition, behavior, and function, using reliable and valid tools. Assessment is ongoing and dynamic, combining nomothetic (norm based) and idiographic (individualized) approaches (Fazio, Pace, Maslow, Zimmerman, & Kallmyer, 2018). Recommendation: Assess cognitive status, functional abilities, behavioral and psychological symptoms of dementia, medical status, living environment, and safety. Reassess regularly and when there is a significant change in condition (U.S. Department of Health and Human Services, 2016).
Guidance (Usage): | Use of a standardized tool or instrument to assess cognition other than those listed will meet numerator performance if mapped to the concept "Intervention, Performed": "Cognitive Assessment" included in the numerator logic below. The requirement of two or more visits is to establish that the eligible professional or eligible clinician has an existing relationship with the patient. In recognition of the growing use of integrated and team-based care, the diagnosis of dementia and the assessment of cognitive function need not be performed by the same provider or clinician. The DSM-5 has replaced the term dementia with major neurocognitive disorder and mild neurocognitive disorder. For the purposes of this measure, the terms are equivalent. This eCQM is a patient-based measure. This FHIR-based measure has been derived from the QDM-based measure: CMS149v12. Please refer to the HL7 QI-Core Implementation Guide (http://hl7.org/fhir/us/qicore/index.html) for more information on QI-Core and mapping recommendations from QDM to QI-Core 4.1.1 (http://hl7.org/fhir/us/qicore/qdm-to-qicore.html).
Population Criteria: |
64758fe7be9def4e0b01b184
Initial Population: | All patients, regardless of age, with a diagnosis of dementia who have two or more visits during the measurement period
Denominator: | Equals Initial Population
Denominator Exclusion: | None
Numerator: | Patients for whom an assessment of cognition is performed and the results reviewed at least once within a 12-month period
Numerator Exclusion: | None
Denominator Exception: | Documentation of patient reason(s) for not assessing cognition
Supplemental Data Guidance : |
Supplemental Data Elements: | SDE Ethnicity SDE Payer SDE Race SDE Sex
Libraries: |
DementiaCognitiveAssessmentFHIR
Related Artifact Dependencies: | SupplementalDataElements version: 3.4.000 QICoreCommon version: 1.5.000 FHIRHelpers version: 4.3.000 `http://hl7.org/fhir/v3/AdministrativeGender` Condition Clinical Status Codes ConditionVerificationStatus Standardized Tools for Assessment of Cognition Cognitive Assessment Psych Visit - Diagnostic Evaluation Nursing Facility Visit Care Services in Long-Term Residential Facility Home Healthcare Services Psych Visit - Psychotherapy Behavioral/Neuropsych Assessment Occupational Therapy Evaluation Office Visit Outpatient Consultation Dementia & Mental Degenerations Patient Provider Interaction Payer Patient Reason
Parameters: |
name | use | min | max | type
--- | --- | --- | --- | ---
Measurement Period | In | 0 | 1 | Period
SDE Sex | Out | 0 | 1 | Coding
Numerator | Out | 0 | 1 | boolean
Denominator | Out | 0 | 1 | boolean
SDE Payer | Out | 0 | * | Resource
Initial Population | Out | 0 | 1 | boolean
SDE Ethnicity | Out | 0 | 1 | Resource
SDE Race | Out | 0 | 1 | Resource
Denominator Exceptions | Out | 0 | 1 | boolean
DataRequirements: |
Type | Elements | Valueset Name | Valueset
--- | --- | --- | ---
Patient(QICorePatient) | ethnicity race |  |
Encounter(QICoreEncounter) | type period status status.value | Psych Visit Diagnostic Evaluation | Psych Visit - Diagnostic Evaluation
Encounter(QICoreEncounter) | type period status status.value | Nursing Facility Visit | Nursing Facility Visit
Encounter(QICoreEncounter) | type period status status.value | Care Services in Long Term Residential Facility | Care Services in Long-Term Residential Facility
Encounter(QICoreEncounter) | type period status status.value | Home Healthcare Services | Home Healthcare Services
Encounter(QICoreEncounter) | type period status status.value | Psych Visit Psychotherapy | Psych Visit - Psychotherapy
Encounter(QICoreEncounter) | type period status status.value | Behavioral/Neuropsych Assessment | Behavioral/Neuropsych Assessment
Encounter(QICoreEncounter) | type period status status.value | Occupational Therapy Evaluation | Occupational Therapy Evaluation
Encounter(QICoreEncounter) | type period status status.value | Office Visit | Office Visit
Encounter(QICoreEncounter) | type period status status.value | Outpatient Consultation | Outpatient Consultation
Encounter(QICoreEncounter) | type period status status.value | Patient Provider Interaction | Patient Provider Interaction
Condition(QICoreCondition) | code verificationStatus | Dementia, Mental Degenerations | Dementia & Mental Degenerations
Observation(QICoreObservation) | code issued issued.value value status status.value | Standardized Tools for Assessment of Cognition | Standardized Tools for Assessment of Cognition
Observation(QICoreObservation) | code issued issued.value value status status.value | Cognitive Assessment | Cognitive Assessment
Coverage(QICoreCoverage) | type period | Payer Type | Payer
Observation(QICoreObservationNotDone) | code issued issued.value status status.value extension | Standardized Tools for Assessment of Cognition | Standardized Tools for Assessment of Cognition
Observation(QICoreObservationNotDone) | code issued issued.value status status.value extension | Cognitive Assessment | Cognitive Assessment
Direct Reference Codes: |
display | code | system
--- | --- | ---
Male | M | http://hl7.org/fhir/v3/AdministrativeGender
Female | F | http://hl7.org/fhir/v3/AdministrativeGender
| active | http://terminology.hl7.org/CodeSystem/condition-clinical
| recurrence | http://terminology.hl7.org/CodeSystem/condition-clinical
| relapse | http://terminology.hl7.org/CodeSystem/condition-clinical
| unconfirmed | http://terminology.hl7.org/CodeSystem/condition-ver-status
| refuted | http://terminology.hl7.org/CodeSystem/condition-ver-status
| entered-in-error | http://terminology.hl7.org/CodeSystem/condition-ver-status
Logic Definitions: |
Group | Scoring | Population Criteria | Expression
--- | --- | --- | ---
64758fe7be9def4e0b01b184 | Group scoring: proportion
|  | Initial Population |
    /***Population Criteria***/

    define "Initial Population":
      exists "Dementia Encounter During Measurement Period"
        and ( Count("Qualifying Encounter During Measurement Period") >= 2 )
|  | Denominator |
    define "Denominator":
      "Initial Population"
|  | Denominator Exclusion | None
|  | Numerator |
    define "Numerator":
      exists "Assessment of Cognition Using Standardized Tools or Alternate Methods"
|  | Numerator Exclusion | None
|  | Denominator Exception |
    define "Denominator Exceptions":
      exists "Patient Reason for Not Performing Assessment of Cognition Using Standardized Tools or Alternate Methods"

Library Name | Name
--- | ---
SupplementalDataElements | SDE Sex
    define "SDE Sex":
      case
          when Patient.gender = 'male' then "M"
          when Patient.gender = 'female' then "F"
          else null
        end
Library Name | Name
DementiaCognitiveAssessmentFHIR | SDE Sex
    define "SDE Sex":
      SDE."SDE Sex"
Library Name | Name
DementiaCognitiveAssessmentFHIR | Encounter to Assess Cognition
    define "Encounter to Assess Cognition":
      ["Encounter": "Psych Visit Diagnostic Evaluation"]
        union ["Encounter": "Nursing Facility Visit"]
        union ["Encounter": "Care Services in Long Term Residential Facility"]
        union ["Encounter": "Home Healthcare Services"]
        union ["Encounter": "Psych Visit Psychotherapy"]
        union ["Encounter": "Behavioral/Neuropsych Assessment"]
        union ["Encounter": "Occupational Therapy Evaluation"]
        union ["Encounter": "Office Visit"]
        union ["Encounter": "Outpatient Consultation"]
Library Name | Name
DementiaCognitiveAssessmentFHIR | Dementia Encounter During Measurement Period
    define "Dementia Encounter During Measurement Period":
      "Encounter to Assess Cognition" EncounterAssessCognition
        with [Condition: "Dementia & Mental Degenerations"] Dementia
          such that EncounterAssessCognition.period.toInterval ( ) during "Measurement Period"
            and Dementia.prevalenceInterval ( ) overlaps EncounterAssessCognition.period
            and Dementia.isActive ( )
            and not ( Dementia.verificationStatus ~ QICoreCommon."unconfirmed"
                or Dementia.verificationStatus ~ QICoreCommon."refuted"
                or Dementia.verificationStatus ~ QICoreCommon."entered-in-error"
            )
Library Name | Name
DementiaCognitiveAssessmentFHIR | Assessment of Cognition Using Standardized Tools or Alternate Methods
    /***Definitions***/

    define "Assessment of Cognition Using Standardized Tools or Alternate Methods":
      ( ["Observation": "Standardized Tools for Assessment of Cognition"]
        union ["Observation": "Cognitive Assessment"] ) CognitiveAssessment
        with "Dementia Encounter During Measurement Period" EncounterDementia
          such that CognitiveAssessment.issued.toInterval ( ) starts 12 months or less on or before day of end of EncounterDementia.period
        where CognitiveAssessment.value is not null
          and CognitiveAssessment.status in { 'final', 'amended', 'corrected', 'preliminary' }
Library Name | Name
DementiaCognitiveAssessmentFHIR | Numerator
    define "Numerator":
      exists "Assessment of Cognition Using Standardized Tools or Alternate Methods"
Library Name | Name
DementiaCognitiveAssessmentFHIR | Qualifying Encounter During Measurement Period
    define "Qualifying Encounter During Measurement Period":
      ( "Encounter to Assess Cognition"
        union ["Encounter": "Patient Provider Interaction"] ) ValidEncounter
        where ValidEncounter.period during "Measurement Period"
          and ValidEncounter.status = 'finished'
Library Name | Name
DementiaCognitiveAssessmentFHIR | Initial Population
    /***Population Criteria***/

    define "Initial Population":
      exists "Dementia Encounter During Measurement Period"
        and ( Count("Qualifying Encounter During Measurement Period") >= 2 )
Library Name | Name
DementiaCognitiveAssessmentFHIR | Denominator
    define "Denominator":
      "Initial Population"
Library Name | Name
SupplementalDataElements | SDE Payer
    define "SDE Payer":
      [Coverage: type in "Payer Type"] Payer
        return {
          code: Payer.type,
          period: Payer.period
        }
Library Name | Name
DementiaCognitiveAssessmentFHIR | SDE Payer
    define "SDE Payer":
      SDE."SDE Payer"
Library Name | Name
SupplementalDataElements | SDE Ethnicity
    define "SDE Ethnicity":
      Patient.ethnicity E
        return Tuple {
          codes: { E.ombCategory } union E.detailed,
          display: E.text
        }
Library Name | Name
DementiaCognitiveAssessmentFHIR | SDE Ethnicity
    define "SDE Ethnicity":
      SDE."SDE Ethnicity"
Library Name | Name
SupplementalDataElements | SDE Race
    define "SDE Race":
      Patient.race R
        return Tuple {
          codes: R.ombCategory union R.detailed,
          display: R.text
        }
Library Name | Name
DementiaCognitiveAssessmentFHIR | SDE Race
    define "SDE Race":
      SDE."SDE Race"
Library Name | Name
DementiaCognitiveAssessmentFHIR | Patient Reason for Not Performing Assessment of Cognition Using Standardized Tools or Alternate Methods
    define "Patient Reason for Not Performing Assessment of Cognition Using Standardized Tools or Alternate Methods":
      ( [ObservationNotDone: code in "Standardized Tools for Assessment of Cognition"]
        union [ObservationNotDone: code in "Cognitive Assessment"] ) NoCognitiveAssessment
        with "Dementia Encounter During Measurement Period" EncounterDementia
          such that NoCognitiveAssessment.issued.toInterval ( ) during EncounterDementia.period
        where NoCognitiveAssessment.status = 'cancelled'
          and NoCognitiveAssessment.notDoneReason in "Patient Reason"
Library Name | Name
DementiaCognitiveAssessmentFHIR | Denominator Exceptions
    define "Denominator Exceptions":
      exists "Patient Reason for Not Performing Assessment of Cognition Using Standardized Tools or Alternate Methods"
Library Name | Name
QICoreCommon | toInterval
    /*
    @description: Normalizes a value that is a choice of timing-valued types to an equivalent interval
    @comment: Normalizes a choice type of DateTime, Quanitty, Interval<DateTime>, or Interval<Quantity> types
    to an equivalent interval. This selection of choice types is a superset of the majority of choice types that are used as possible
    representations for timing-valued elements in QICore, allowing this function to be used across any resource.
    The input can be provided as a DateTime, Quantity, Interval<DateTime> or Interval<Quantity>.
    The intent of this function is to provide a clear and concise mechanism to treat single
    elements that have multiple possible representations as intervals so that logic doesn't have to account
    for the variability. More complex calculations (such as medication request period or dispense period
    calculation) need specific guidance and consideration. That guidance may make use of this function, but
    the focus of this function is on single element calculations where the semantics are unambiguous.
    If the input is a DateTime, the result a DateTime Interval beginning and ending on that DateTime.
    If the input is a Quantity, the quantity is expected to be a calendar-duration interpreted as an Age,
    and the result is a DateTime Interval beginning on the Date the patient turned that age and ending immediately before one year later.
    If the input is a DateTime Interval, the result is the input.
    If the input is a Quantity Interval, the quantities are expected to be calendar-durations interpreted as an Age, and the result
    is a DateTime Interval beginning on the date the patient turned the age given as the start of the quantity interval, and ending
    immediately before one year later than the date the patient turned the age given as the end of the quantity interval.
    Any other input will reslt in a null DateTime Interval
    */
    define fluent function toInterval(choice Choice<DateTime, Quantity, Interval<DateTime>, Interval<Quantity>>):
      case
    	  when choice is DateTime then
        	Interval[choice as DateTime, choice as DateTime]
    		when choice is Interval<DateTime> then
      		choice as Interval<DateTime>
    		when choice is Quantity then
    		  Interval[Patient.birthDate + (choice as Quantity),
    			  Patient.birthDate + (choice as Quantity) + 1 year)
    		when choice is Interval<Quantity> then
    		  Interval[Patient.birthDate + (choice.low as Quantity),
    			  Patient.birthDate + (choice.high as Quantity) + 1 year)
    		else
    			null as Interval<DateTime>
    	end
Library Name | Name
QICoreCommon | prevalenceInterval
    /*
    @description: Returns an interval representing the normalized prevalence period of a given Condition.
    @comment: Uses the ToInterval and ToAbatementInterval functions to determine the widest potential interval from
    onset to abatement as specified in the given Condition. If the condition is active, the resulting interval will have
    a closed ending boundary. If the condition is not active, the resulting interval will have an open ending boundary.
    */
    define fluent function prevalenceInterval(condition Condition):
    if condition.clinicalStatus ~ "active"
      or condition.clinicalStatus ~ "recurrence"
      or condition.clinicalStatus ~ "relapse" then
      Interval[start of condition.onset.toInterval(), end of condition.abatementInterval()]
    else
      Interval[start of condition.onset.toInterval(), end of condition.abatementInterval())
Library Name | Name
QICoreCommon | isActive
    /* Candidates for FHIRCommon */

    /*
    @description: Returns true if the given condition has a clinical status of active, recurrence, or relapse
    */
    define fluent function isActive(condition Condition):
      condition.clinicalStatus ~ "active"
        or condition.clinicalStatus ~ "recurrence"
        or condition.clinicalStatus ~ "relapse"
Library Name | Name
FHIRHelpers | ToString
    define function ToString(value uri): value.value
Library Name | Name
FHIRHelpers | ToCode
    /*
    @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
            }