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: Adult Major Depressive Disorder (MDD): Suicide Risk AssessmentFHIR

Official URL: http://ecqi.healthit.gov/ecqms/Measure/AdultMajorDepressiveDisorderMDDSuicideRiskAssessmentFHIR | Version: 0.0.004
Draft as of 2023-10-27 | Responsible: Mathematica | Computable Name: AdultMajorDepressiveDisorderMDDSuicideRiskAssessmentFHIR
Other Identifiers: Short Name (use: usual, ), UUID:9e056df9-6c0c-4847-a88e-bc9932dd69bd (use: official, ), UUID:2c928085806c39a20180859994bf050e (use: official, ), Endorser (use: official, ), Publisher (use: official, )
Usage:Program: EP/EC
Copyright/Legal: Copyright 2023 Mathematica Inc. All Rights Reserved. The PCPI and American Medical Association’s (AMA) significant past efforts and contributions to the development and updating of the Measure is acknowledged.

Percentage of all patient visits for those patients that are 17 years of age or older at the start of the measurement period in which a new or recurrent diagnosis of major depressive disorder (MDD) was identified and a suicide risk assessment was completed during the visit

UNKNOWN

Title: | Adult Major Depressive Disorder (MDD): Suicide Risk AssessmentFHIR
Id: | AdultMajorDepressiveDisorderMDDSuicideRiskAssessmentFHIR
Download cql: | AdultMajorDepressiveDisorderMDDSuicideRiskAssessmentFHIR.cql
Version: | 0.0.004
Url: | Adult Major Depressive Disorder (MDD): Suicide Risk AssessmentFHIR
short-name identifier: | CMS161FHIR
version-independent identifier: | urn:uuid:9e056df9-6c0c-4847-a88e-bc9932dd69bd
version-specific identifier: | urn:uuid:2c928085806c39a20180859994bf050e
endorser (NQF) identifier: | 0104e
publisher (CMS) identifier: | 161FHIR
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: | AdultMajorDepressiveDisorderMDDSuicideRiskAssessmentFHIR
Publisher: | Mathematica
Author: | Mathematica: https://www.mathematica.org/, American Medical Association (AMA): https://www.ama-assn.org/
Description: | Percentage of all patient visits for those patients that are 17 years of age or older at the start of the measurement period in which a new or recurrent diagnosis of major depressive disorder (MDD) was identified and a suicide risk assessment was completed during the visit
Use Context: |
code | value
--- | ---
program |
Purpose: | UNKNOWN
Copyright: | Copyright 2023 Mathematica Inc. All Rights Reserved. The PCPI and American Medical Association's (AMA) significant past efforts and contributions to the development and updating of the Measure is acknowledged.
Disclaimer: | The Measure is not a clinical guideline, does not establish a standard of medical care, and has not been tested for all potential applications. The Measure, while copyrighted, can be reproduced and distributed, without modification, for noncommercial purposes, e.g., use by health care providers in connection with their practices. Commercial use is defined as the sale, license, or distribution of the Measure for commercial gain, or incorporation of the Measure into a product or service that is sold, licensed or distributed for commercial gain. Commercial uses of the Measure require a license agreement between the user and Mathematica. Neither Mathematica, the PCPI, nor the American Medical Association (AMA), nor the former AMA-convened Physician Consortium for Performance Improvement(R) (AMA-PCPI), nor their members shall be responsible for any use of the Measure. Mathematica encourages use of the Measure by other health care professionals, where appropriate. THE MEASURE AND SPECIFICATIONS ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND. 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 a third party is strictly prohibited. Mathematica, the AMA, and former members of the PCPI disclaim all liability for use or accuracy of any CPT(R) 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. Due to technical limitations, registered trademarks are indicated by (R) or [R].
Rationale: | This measure aims to improve rates of clinician assessment of suicide risk during an encounter where a new or recurrent episode of major depressive disorder (MDD) is identified. In an epidemiologic study of mental illness in the United States with a large, representative sample, 69% of respondents with lifetime suicide attempts had also met diagnostic criteria for MDD. When considering other mood disorders related to depression, such as dysthymia and bipolar disorders, this rate increases to 74% (Bolton & Robinson, 2010). In a study of individuals who had died by suicide and were enrolled in one of eight major health systems in the United States, individuals with a depressive disorder diagnosis had 7.20 increased odds of dying by suicide within one year, after adjusting for age and sociodemographic factors (Yeh et al., 2019). A recent meta-analysis (Moitra et al., 2021) presented similar findings in which depressive disorder conferred a predictive relative risk for suicide of 7.64 after adjusting for relevant factors. Suicide is associated with increased use of healthcare services, which provides an opportunity for intervention through assessment and intervention. Individuals who die by suicide are more likely to have any healthcare utilization (Ahmedani et al., 2019) and a higher frequency of healthcare visits than the general population (Chock, Bommersbach, Geske, & Bostwick, 2015). A study of individuals who died by suicide and were enrolled within one of eight health systems in the Mental Health Research Network in the United States found that 50% of these individuals had been seen in a healthcare setting within four weeks prior to death (Ahmedani et al., 2014). Better assessment and identification of suicide risk in the healthcare setting should lead to improved connection to treatment and reduction in suicide attempts and deaths by suicide. A recent analysis of depression severity and suicidal ideation symptom trajectories (Witt et al., 2021) found that suicidal ideation among children and young adults (15-25 years) might not improve with depression symptom severity. This evidence suggests the potential utility of continued suicide risk screening after improvements in depression symptoms.
Clinical recommendation statement: | A careful and ongoing evaluation of suicide risk is necessary for all patients with major depressive disorder (American Psychiatric Association, 2010a). Such an assessment includes specific inquiry about suicidal thoughts, intent, plans, means, and behaviors; identification of specific psychiatric symptoms (e.g., psychosis, severe anxiety, substance use, hopelessness, insomnia, agitation) or general medical conditions that may increase the likelihood of acting on suicidal ideas; assessment of past and, particularly, recent suicidal behavior; delineation of current stressors and potential protective factors (e.g., positive reasons for living, strong social support); and identification of any family history of suicide or mental illness (American Psychiatric Association, 2010a; Department of Veterans Affairs and Department of Defense, 2019). As part of the assessment process, impulsivity and potential for risk to others should also be evaluated, including any history of violence or violent or homicidal ideas, plans, or intentions, or the availability of firearms (American Psychiatric Association, 2010a; Department of Veterans Affairs and Department of Defense, 2019). The patient's risk of harm to him- or herself and to others should also be monitored as treatment proceeds (American Psychiatric Association, 2010a). Guidelines for Selecting a Treatment Setting for Patients at Risk for Suicide or Suicidal Behaviors (from American Psychiatric Association’s Practice Guideline for Assessment and Treatment of Patients With Suicidal Behaviors, 2010b): ADMISSION GENERALLY INDICATED After a suicide attempt or aborted suicide attempt if: Patient is psychotic Attempt was violent, near-lethal, or premeditated Precautions were taken to avoid rescue or discovery Persistent plan and/or intent is present Distress is increased or patient regrets surviving Patient is male, older than age 45 years, especially with new onset of psychiatric illness or suicidal thinking Patient has limited family and/or social support, including lack of stable living situation Current impulsive behavior, severe agitation, poor judgment, or refusal of help is evident Patient has change in mental status with a metabolic, toxic, infectious, or other etiology requiring further workup in a structured setting In the presence of suicidal ideation with: Specific plan with high lethality High suicidal intent ADMISSION MAY BE NECESSARY After a suicide attempt or aborted suicide attempt, except in circumstances for which admission is generally indicated In the presence of suicidal ideation with: Psychosis Major psychiatric disorder Past attempts, particularly if medically serious Possibly contributing medical condition (e.g., acute neurological disorder, cancer, infection) Lack of response to or inability to cooperate with partial hospital or outpatient treatment Need for supervised setting for medication trial or electroconvulsive therapy (ECT) Need for skilled observation, clinical tests, or diagnostic assessments that require a structured setting Limited family and/or social support, including lack of stable living situation Lack of an ongoing clinician-patient relationship or lack of access to timely outpatient follow-up Evidence of putting one's affairs in order (e.g., giving away possessions, writing a will) In the absence of suicide attempts or reported suicidal ideation/plan/intent but evidence from the psychiatric evaluation and/or history from others suggests a high level of suicide risk and a recent acute increase in risk RELEASE FROM EMERGENCY DEPARTMENT WITH FOLLOW-UP RECOMMENDATIONS MAY BE POSSIBLE After a suicide attempt or in the presence of suicidal ideation/plan when: Suicidality is a reaction to precipitating events (e.g., exam failure, relationship difficulties), particularly if the patient's view of situation has changed since coming to emergency department Plan/method and intent have low lethality Patient has stable and supportive living situation Patient is able to cooperate with recommendations for follow-up, with treater contacted, if possible, if patient is currently in treatment OUTPATIENT TREATMENT MAY BE MORE BENEFICIAL THAN HOSPITALIZATION Patient has chronic suicidal ideation and/or self-injury without prior medically serious attempts, if a safe and supportive living situation is available and outpatient psychiatric care is ongoing
Guidance (Usage): | This eCQM is an episode-based measure and should be reported for each instance of a new or recurrent episode of major depressive disorder (MDD) during the measurement period. This measure should be reported for each eligible encounter during which a new or recurrent episode of MDD is identified in adults that turn 18 or older during the measurement period. As the guidelines state, it is important to assess for additional factors which may increase or decrease suicide risk, such as presence of additional symptoms (e.g., psychosis, severe anxiety, hopelessness, severe chronic pain); presence of substance abuse; history and seriousness of previous attempts, particularly, recent suicidal behavior; current stressors and potential protective factors (e.g., positive reasons for living, strong social support); family history of suicide or mental illness or recent exposure to suicide; impulsivity and potential for risk to others, including history of violence or violent or homicidal ideas, plans, or intentions; and putting one's affairs in order (e.g., giving away possessions, writing a will). In addition, although the measure focuses on the initial visit, it is critical that suicide risk be monitored especially for the 90 days following the initial visit and throughout MDD treatment. It is expected that a suicide risk assessment will be completed at the visit during which a new diagnosis is made or at the visit during which a recurrent episode is first identified (i.e., at the initial evaluation). For the purposes of this measure, an episode of MDD would be considered to be recurrent if a patient has not had an MDD-related encounter in the past 105 days. If there is a gap of 105 or more days between visits for MDD, that would imply a recurrent episode. The 105-day look-back period is an operational provision and not a clinical recommendation, or definition of relapse, remission, or recurrence. In recognition of the growing use of integrated and team-based care, the diagnosis of depression and the assessment for suicide risk need not be performed by the same provider or clinician. Suicide risk assessments completed via telehealth services can also meet numerator performance. Use of a standardized tool(s) or instrument(s) to assess suicide risk will meet numerator performance. Standardized tools can be mapped to the concept "Intervention, Performed": "Suicide risk assessment (procedure)" included in the numerator logic below, as no individual suicide risk assessment tool or instrument would satisfy the requirements alone. To ensure all patients with MDD are assessed for suicide risk, there are two clinical quality measures addressing suicide risk assessment; CMS177-Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment covers children and adolescents aged 6 through 16 at the start of the measurement period, and CMS161 covers the adult population aged 17 years and older at the start of the measurement period. This FHIR-based measure has been derived from the QDM-based measure: CMS161v12. 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: |
6419eb169ef3a941fbe47b3b
Initial Population: | Patient visits for patients that are 17 years of age or older at the start of the measurement period during which a new diagnosis of MDD, single or recurrent episode, was identified
Denominator: | Equals Initial Population
Denominator Exclusion: | None
Numerator: | Patient visits during which a new diagnosis of MDD, single or recurrent episode, was identified and a suicide risk assessment was completed during the visit
Numerator Exclusion: | Not Applicable
Denominator Exception: | None
Supplemental Data Guidance : | test1 test 2 test 3 test4
Supplemental Data Elements: | SDE Ethnicity SDE Payer SDE Race SDE Sex
Libraries: |
AdultMajorDepressiveDisorderMDDSuicideRiskAssessmentFHIR
Related Artifact Dependencies: | SupplementalDataElements version: 3.4.000 FHIRHelpers version: 4.3.000 CQMCommon version: 1.4.000 QICoreCommon version: 1.5.000 `http://hl7.org/fhir/v3/AdministrativeGender` ActCode SNOMED CT (all versions) Psych Visit - Diagnostic Evaluation Emergency Department Visit Office Visit Outpatient Consultation Psych Visit - Psychotherapy Psychoanalysis Telehealth Services Major Depressive Disorder-Active Payer
Parameters: |
name | use | min | max | type
--- | --- | --- | --- | ---
Measurement Period | In | 0 | 1 | Period
SDE Sex | Out | 0 | 1 | Coding
Numerator | Out | 0 | * | Resource
Denominator | Out | 0 | * | Resource
SDE Payer | Out | 0 | * | Resource
Initial Population | Out | 0 | * | Resource
SDE Ethnicity | Out | 0 | 1 | Resource
SDE Race | Out | 0 | 1 | Resource
DataRequirements: |
Type | Elements | Valueset Name | Valueset
--- | --- | --- | ---
Patient(QICorePatient) | ethnicity race |  |
Condition(QICoreCondition) | id id.value code |  |
Encounter(QICoreEncounter) | type condition condition.reference condition.reference.value status status.value class reasonCode period | Psych Visit Diagnostic Evaluation | Psych Visit - Diagnostic Evaluation
Encounter(QICoreEncounter) | type condition condition.reference condition.reference.value status status.value class reasonCode period | Emergency Department Visit | Emergency Department Visit
Encounter(QICoreEncounter) | type condition condition.reference condition.reference.value status status.value class reasonCode period | Office Visit | Office Visit
Encounter(QICoreEncounter) | type condition condition.reference condition.reference.value status status.value class reasonCode period | Outpatient Consultation | Outpatient Consultation
Encounter(QICoreEncounter) | type condition condition.reference condition.reference.value status status.value class reasonCode period | Psych Visit Psychotherapy | Psych Visit - Psychotherapy
Encounter(QICoreEncounter) | type condition condition.reference condition.reference.value status status.value class reasonCode period | Psychoanalysis | Psychoanalysis
Encounter(QICoreEncounter) | type condition condition.reference condition.reference.value status status.value class reasonCode period | Telehealth Services | Telehealth Services
Procedure(QICoreProcedure) | code status status.value performed |  |
Coverage(QICoreCoverage) | type period | Payer Type | Payer
Direct Reference Codes: |
display | code | system
--- | --- | ---
Male | M | http://hl7.org/fhir/v3/AdministrativeGender
Female | F | http://hl7.org/fhir/v3/AdministrativeGender
Ambulatory | AMB | http://terminology.hl7.org/CodeSystem/v3-ActCode
Suicide risk assessment (procedure) | 225337009 | http://snomed.info/sct
Logic Definitions: |
Group | Scoring | Population Criteria | Expression
--- | --- | --- | ---
6419eb169ef3a941fbe47b3b | Group scoring: proportion
|  | Initial Population |
    define "Initial Population":
      "New or Recurrent Major Depressive Disorder Encounter" NewOrRecurrentMDDEncounter
        where "AgeInYearsAt"(date from start of "Measurement Period") >= 17
|  | Denominator |
    define "Denominator":
      "Initial Population"
|  | Denominator Exclusion | None
|  | Numerator |
    define "Numerator":
      "New or Recurrent Major Depressive Disorder Encounter" NewOrRecurrentMDDEncounter
        with ["Procedure": "Suicide risk assessment (procedure)"] SuicideRiskAssessment
          such that SuicideRiskAssessment.status = 'completed'
            and QICoreCommon."ToInterval" ( SuicideRiskAssessment.performed ) during NewOrRecurrentMDDEncounter.period
|  | Numerator Exclusion | None
|  | Denominator Exception | None

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
AdultMajorDepressiveDisorderMDDSuicideRiskAssessmentFHIR | SDE Sex
    define "SDE Sex":
      SDE."SDE Sex"
Library Name | Name
AdultMajorDepressiveDisorderMDDSuicideRiskAssessmentFHIR | Major Depressive Disorder Encounter
    define "Major Depressive Disorder Encounter":
      ( ["Encounter": "Psych Visit Diagnostic Evaluation"]
        union ["Encounter": "Emergency Department Visit"]
        union ["Encounter": "Office Visit"]
        union ["Encounter": "Outpatient Consultation"]
        union ["Encounter": "Psych Visit Psychotherapy"]
        union ["Encounter": "Psychoanalysis"]
        union ["Encounter": "Telehealth Services"] ) ValidEncounter
        where ValidEncounter.status = 'finished'
          and ValidEncounter.class ~ "AMB"
          and ( ValidEncounter.reasonCode in "Major Depressive Disorder Active"
              or exists ( ( CQMCommon."EncounterDiagnosis" ( ValidEncounter ) ) EncounterDiagnosis
                  where EncounterDiagnosis.code in "Major Depressive Disorder Active"
              )
          )
Library Name | Name
AdultMajorDepressiveDisorderMDDSuicideRiskAssessmentFHIR | New or Recurrent Major Depressive Disorder Encounter
    define "New or Recurrent Major Depressive Disorder Encounter":
      "Major Depressive Disorder Encounter" NewOrRecurrentMDDEncounter
        without "Major Depressive Disorder Encounter" PriorMDDEpisodeEncounter
          such that ( PriorMDDEpisodeEncounter !~ NewOrRecurrentMDDEncounter
              and PriorMDDEpisodeEncounter.period ends 104 days or less before day of start of NewOrRecurrentMDDEncounter.period
          )
        where NewOrRecurrentMDDEncounter.period during "Measurement Period"
Library Name | Name
AdultMajorDepressiveDisorderMDDSuicideRiskAssessmentFHIR | Numerator
    define "Numerator":
      "New or Recurrent Major Depressive Disorder Encounter" NewOrRecurrentMDDEncounter
        with ["Procedure": "Suicide risk assessment (procedure)"] SuicideRiskAssessment
          such that SuicideRiskAssessment.status = 'completed'
            and QICoreCommon."ToInterval" ( SuicideRiskAssessment.performed ) during NewOrRecurrentMDDEncounter.period
Library Name | Name
AdultMajorDepressiveDisorderMDDSuicideRiskAssessmentFHIR | Initial Population
    define "Initial Population":
      "New or Recurrent Major Depressive Disorder Encounter" NewOrRecurrentMDDEncounter
        where "AgeInYearsAt"(date from start of "Measurement Period") >= 17
Library Name | Name
AdultMajorDepressiveDisorderMDDSuicideRiskAssessmentFHIR | 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
AdultMajorDepressiveDisorderMDDSuicideRiskAssessmentFHIR | 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
AdultMajorDepressiveDisorderMDDSuicideRiskAssessmentFHIR | 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
AdultMajorDepressiveDisorderMDDSuicideRiskAssessmentFHIR | SDE Race
    define "SDE Race":
      SDE."SDE Race"
Library Name | Name
FHIRHelpers | ToConcept
    /*
    @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
            }
Library Name | Name
CQMCommon | EncounterDiagnosis
    /*
    @description: Returns the Condition resource referenced by the `diagnosis.condition` element of the Encounter
    @deprecated: This function is deprecated. Use the fluent function `encounterDiagnosis()` instead.
    */
    define function "EncounterDiagnosis"(Encounter Encounter ):
      Encounter.diagnosis D
    	return singleton from ([Condition] C where C.id = D.condition.reference.getId())
Library Name | Name
QICoreCommon | getId
    /*
    @description: Returns the tail of the given uri (i.e. everything after the last slash in the URI).
    @comment: This function can be used to determine the logical id of a given resource. It can be used in
    a single-server environment to trace references. However, this function does not attempt to resolve
    or distinguish the base of the given url, and so cannot be used safely in multi-server environments.
    */
    define fluent function getId(uri String):
      Last(Split(uri, '/'))
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
            }