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

## : Safe Use of Opioids - Concurrent PrescribingFHIR - JSON Representation

Draft as of 2023-08-17

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    {
      "resourceType" : "Measure",
      "id" : "SafeUseofOpioidsConcurrentPrescribingFHIR",
      "meta" : {
        "profile" : [
          🔗 "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/computable-measure-cqfm"🔗 ,
          "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/publishable-measure-cqfm"🔗 ,
          "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/executable-measure-cqfm"
        ]
      },
      "text" : {
        "status" : "extensions",
        "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n    <table class=\"grid dict\">\n        \n            <tr>\n                <th scope=\"row\"><b>Title: </b></th>\n                <td style=\"padding-left: 4px;\">Safe Use of Opioids - Concurrent PrescribingFHIR</td>\n            </tr>\n        \n\n        \n\n        \n            <tr>\n                <th scope=\"row\"><b>Id: </b></th>\n                <td style=\"padding-left: 4px;\">SafeUseofOpioidsConcurrentPrescribingFHIR</td>\n            </tr>\n            \n                <tr>\n                    <th scope=\"row\"><b>Download cql: </b></th>\n                    <td style=\"padding-left: 4px;\"><a href=\"Library-SafeUseofOpioidsConcurrentPrescribingFHIR.cql\">SafeUseofOpioidsConcurrentPrescribingFHIR.cql</a></td>\n                </tr>\n            \n        \n\n        \n            <tr>\n                <th scope=\"row\"><b>Version: </b></th>\n                <td style=\"padding-left: 4px;\">0.1.000</td>\n            </tr>\n        \n\n        \n            <tr>\n                <th scope=\"row\"><b>Url: </b></th>\n                <td style=\"padding-left: 4px;\"><a href=\"Measure-SafeUseofOpioidsConcurrentPrescribingFHIR.html\">Safe Use of Opioids - Concurrent PrescribingFHIR</a></td>\n            </tr>\n        \n\n        \n            <tr>\n                <th scope=\"row\">\n                    <b>\n                        \n                            \n                                short-name identifier:\n                            \n                        \n                    </b>\n                </th>\n\n                <td style=\"padding-left: 4px;\">\n                    \n                        <p style=\"margin-bottom: 5px;\">\n                            <span>CMS506FHIR</span>\n                        </p>\n                    \n                </td>\n            </tr>\n        \n            <tr>\n                <th scope=\"row\">\n                    <b>\n                        \n                            \n                                version-independent identifier:\n                            \n                        \n                    </b>\n                </th>\n\n                <td style=\"padding-left: 4px;\">\n                    \n                        <p style=\"margin-bottom: 5px;\">\n                            <span>urn:uuid:95d529af-66b4-4cfd-bc1f-f43704dc47ad</span>\n                        </p>\n                    \n                </td>\n            </tr>\n        \n            <tr>\n                <th scope=\"row\">\n                    <b>\n                        \n                            \n                                version-specific identifier:\n                            \n                        \n                    </b>\n                </th>\n\n                <td style=\"padding-left: 4px;\">\n                    \n                        <p style=\"margin-bottom: 5px;\">\n                            <span>urn:uuid:4adc0abd-6de0-42e7-ab1a-37f53d3ddd1f</span>\n                        </p>\n                    \n                </td>\n            </tr>\n        \n            <tr>\n                <th scope=\"row\">\n                    <b>\n                        \n                            \n                                endorser (NQF) identifier:\n                            \n                        \n                    </b>\n                </th>\n\n                <td style=\"padding-left: 4px;\">\n                    \n                        <p style=\"margin-bottom: 5px;\">\n                            <span>3316e</span>\n                        </p>\n                    \n                </td>\n            </tr>\n        \n            <tr>\n                <th scope=\"row\">\n                    <b>\n                        \n                            \n                                publisher (CMS) identifier:\n                            \n                        \n                    </b>\n                </th>\n\n                <td style=\"padding-left: 4px;\">\n                    \n                        <p style=\"margin-bottom: 5px;\">\n                            <span>506FHIR</span>\n                        </p>\n                    \n                </td>\n            </tr>\n        \n\n        \n            <tr>\n                <th scope=\"row\"><b>Effective Period: </b></th>\n                <td style=\"padding-left: 4px;\">2024-01-01\n                    ..2024-12-31</td>\n            </tr>\n        \n\n        \n            <tr>\n                <th scope=\"row\"><b>Status: </b></th>\n                <td style=\"padding-left: 4px;\">draft</td>\n            </tr>\n        \n\n        \n\n        \n            <tr>\n                <th scope=\"row\"><b>Date: </b></th>\n                <td style=\"padding-left: 4px;\">2023-08-17 18:49:02+0000</td>\n            </tr>\n        \n\n        \n            <tr>\n                <th scope=\"row\"><b>Approval Date: </b></th>\n                <td style=\"padding-left: 4px;\">2023-08-18</td>\n            </tr>\n        \n\n        \n            <tr>\n                <th scope=\"row\"><b>Last Review Date: </b></th>\n                <td style=\"padding-left: 4px;\">2023-08-18</td>\n            </tr>\n        \n\n        \n            <tr>\n                <th scope=\"row\"><b>Name: </b></th>\n                <td style=\"padding-left: 4px;\">SafeUseofOpioidsConcurrentPrescribingFHIR</td>\n            </tr>\n        \n\n        \n            <tr>\n                <th scope=\"row\"><b>Publisher: </b></th>\n                <td style=\"padding-left: 4px;\">Centers for Medicare &amp; Medicaid Services (CMS)</td>\n            </tr>\n        \n\n        \n        <tr>\n            <th scope=\"row\"><b>Author: </b></th>\n            <td style=\"padding-left: 4px;\">Mathematica: <a href=\"https://www.mathematica.org/\">https://www.mathematica.org/</a></td>\n        </tr>\n        \n\n        \n\n        \n            <tr>\n                <th scope=\"row\"><b>Description: </b></th>\n                <td style=\"padding-left: 4px;\"><div><p>Proportion of inpatient hospitalizations for patients 18 years of age and older prescribed, or continued on, two or more opioids or an opioid and benzodiazepine concurrently at discharge</p>\n</div></td>\n            </tr>\n        \n\n        \n\n        \n\n        \n            <tr>\n                <th scope=\"row\"><b>Use Context: </b></th>\n                <td style=\"padding-left: 4px;\">\n                    <table class=\"grid-dict\">\n                        <tr>\n                            <th><b>code</b></th>\n                            <th><b>value</b></th>\n                        </tr>\n                        \n                            <tr>\n                                <td>program</td>\n                                <td/>\n                            </tr>\n                        \n                    </table>\n                </td>\n            </tr>\n        \n\n        \n\n        \n\n        \n            <tr>\n                <th scope=\"row\"><b>Purpose: </b></th>\n                <td style=\"padding-left: 4px;\"><div><p>UNKNOWN</p>\n</div></td>\n            </tr>\n        \n\n        \n            <tr>\n                <th scope=\"row\"><b>Copyright: </b></th>\n                <td style=\"padding-left: 4px;\"><div><p>Limited proprietary coding is contained in the Measure specifications for user convenience. Users of proprietary code sets should obtain all necessary licenses from the owners of the code sets. Mathematica disclaims all liability for use or accuracy of any third party codes contained in the specifications.</p>\n<p>CPT(R) contained in the measure specifications is copyright 2004-2022 American Medical Association. LOINC(R) 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 copyright 2022 World Health Organization. All Rights Reserved.</p>\n</div></td>\n            </tr>\n        \n\n        \n            <tr>\n                <th scope=\"row\"><b>Disclaimer: </b></th>\n                <td style=\"padding-left: 4px;\"><div><p>These performance measures are not clinical guidelines, do not establish a standard of medical care, and have not been tested for all potential applications.</p>\n<p>THE MEASURES AND SPECIFICATION ARE PROVIDED AS IS WITHOUT WARRANTY OF ANY KIND.</p>\n<p>Due to technical limitations, registered trademarks are indicated by (R) or [R] and unregistered trademarks are indicated by (TM) or [TM].</p>\n</div></td>\n            </tr>\n        \n\n        \n\n        \n\n        \n\n        \n\n        \n\n        \n\n        \n\n        \n\n        \n        <tr>\n            <th scope=\"row\"><b>Rationale: </b></th>\n            <td style=\"padding-left: 4px;\"><div><p>Unintentional opioid overdose fatalities have become a major public health concern in the United States (Rudd et al., 2016). Reducing the number of unintentional overdoses has become a priority for numerous federal organizations including, but not limited to, the Centers for Disease Control and Prevention (CDC), the Federal Interagency Workgroup for Opioid Adverse Drug Events, and the Substance Abuse and Mental Health Services Administration.</p>\n<p>Concurrent prescriptions of opioids or opioids and benzodiazepines places patients at a greater risk of unintentional overdose due to the increased risk of respiratory depression (Dowell, Haegerich, &amp; Chou, 2016 and Dowell, Ragan, Jones, Baldwin, &amp; Chou, 2022).  An analysis of national prescribing patterns shows that more than half of patients who received an opioid prescription in 2009 had filled another opioid prescription within the previous 30 days (National Institute on Drug Abuse, 2011). Studies of multiple claims and prescription databases have shown that between 5%-15% of patients receive concurrent opioid prescriptions and 5%-20% of patients receive concurrent opioid and benzodiazepine prescriptions across various settings (Liu et al., 2013; Mack et al., 2015, Park et al., 2015). Patients who have multiple opioid prescriptions have an increased risk for overdose (Jena et al., 2014). Rates of fatal overdose are ten times higher in patients who are co-dispensed opioid analgesics and benzodiazepines than opioids alone (Dasgupta et al., 2015). The number of opioid overdose deaths involving benzodiazepines increased 14% on average each year from 2006 to 2011, while the number of opioid analgesic overdose deaths not involving benzodiazepines did not change significantly (Jones &amp; McAninch, 2015). Furthermore, concurrent use of benzodiazepines with opioids was prevalent in 31%-51% of fatal overdoses (Dowell, Haegerich, &amp; Chou, 2016). One study found that eliminating concurrent use of opioids and benzodiazepines could reduce the risk of opioid overdose-related emergency department (ED) and inpatient visits by 15% and potentially could have prevented an estimated 2,630 deaths related to opioid painkiller overdoses in 2015 (Sun et al., 2017).</p>\n<p>A study on The Opioid Safety Initiative in the Veterans Health Administration (VHA), which includes an opioid and benzodiazepine concurrent prescribing measure that this measure is based on, was associated with a decrease of 20.67% overall and 0.86% patients per month (781 patients per month) receiving concurrent benzodiazepine with an opioid among all adult VHA patients who filled outpatient opioid prescriptions from October 2012 to September 2014 (Lin et al., 2017).</p>\n<p>Adopting a measure that calculates the proportion of patients with two or more opioids or opioids and benzodiazepines concurrently has the potential to reduce preventable mortality and reduce the costs associated with adverse events related to opioid use by (1) encouraging providers to identify patients with concurrent prescriptions of opioids or opioids and benzodiazepines and (2) discouraging providers from prescribing two or more opioids or opioids and benzodiazepines concurrently.</p>\n</div></td>\n        </tr>\n        \n\n        \n        <tr>\n            <th scope=\"row\"><b>Clinical recommendation statement: </b></th>\n            <td style=\"padding-left: 4px;\"><div><p>The CDC Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022 recommends that clinicians should:</p>\n<ul>\n<li>“[Use strategies minimizing] opioid use…for both opioid-naïve and opioid-tolerant patients with acute pain when possible. If patients receiving long-term opioid therapy require additional medication for acute pain, nonopioid medications should be used when possible.”</li>\n<li>”Use particular caution when prescribing opioid pain medication and benzodiazepines concurrently.&quot;</li>\n<li>“Review increased risks for respiratory depression when opioids are taken with benzodiazepines, other sedatives, alcohol, nonprescribed or illicit drugs (e.g., heroin), or other opioids (see Recommendations 8 and 11)”</li>\n<li>“Closely monitor patients who are unable to taper and who continue on high-dose or otherwise high-risk opioid regimens (e.g., opioids prescribed concurrently with benzodiazepines) and should work with patients to mitigate overdose risk (e.g., by providing overdose education and naloxone) (see Recommendation 8).”</li>\n<li>&quot;Discuss information from the PDMP with the patient and confirm that the patient is aware of any additional prescriptions.”</li>\n<li>“Discuss safety concerns, including increased risk for respiratory depression and overdose, with patients found to be receiving overlapping prescription opioids from multiple clinicians who are not coordinating the patient’s care or patients who are receiving medications that increase risk when combined with opioids (e.g., benzodiazepines) (see Recommendation 11), and offer naloxone (see Recommendation 8).</li>\n<li>&quot;Discuss safety concerns with other clinicians who are prescribing controlled substances for the patient. Ideally, clinicians should first discuss concerns with the patient and inform them that they plan to coordinate care with their other clinicians to improve the patient’s safety.”</li>\n</ul>\n<p>In addition to the 2022 CDC Clinical Practice Guideline for Prescribing Opioids for Pain, opioid prescribing guidelines issued by various state agencies and professional societies for various settings agree with the recommendation to avoid concurrently prescribing opioids (American Academy of Emergency Medicine and Washington Agency Medical Directors’ Group (WAMDG)), and opioids and benzodiazepines (WAMDG, American Society of Interventional Pain Physicians, and New York City Department Of Health and Mental Hygiene) whenever possible as the combination of these medications may potentiate opioid-induced respiratory depression.</p>\n</div></td>\n        </tr>\n        \n\n        \n\n        \n            <tr>\n                <th scope=\"row\"><b>Guidance (Usage): </b></th>\n                <td style=\"padding-left: 4px;\">Clinician judgement, clinical appropriateness, or both may indicate concurrent prescribing of two unique opioids or an opioid and benzodiazepine is medically necessary, thus the measure is not expected to have a zero rate. \n\nInpatient hospitalizations with discharge medications of a new or continuing opioid or a new or continuing benzodiazepine prescription should be included in the initial population. \n\nInpatient hospitalizations with discharge medications of two or more new or continuing opioids or new or continuing opioid and benzodiazepine resulting in concurrent therapy at discharge should be included in the numerator. Each benzodiazepine and opioid included on the medication discharge list is considered a unique prescription.\n\nThe denominator population includes patients with inpatient hospitalizations and patients from Acute Hospital Care at Home programs, who are treated and billed as inpatients but receive care in their home.\n\nThis eCQM is an episode-based measure. An episode is defined as each inpatient hospitalization or encounter that ends during the measurement period.\n\nThis FHIR-based measure has been derived from the QDM-based measure: CMS506v6. \nPlease 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).</td>\n            </tr>\n        \n\n        \n            \n                <tr>\n                    <th scope=\"row\"><b>Population Criteria: </b></th>\n                    <td style=\"padding-left: 4px;\">\n                        \n                            <table class=\"grid-dict\">\n                                \n                                    <tr>\n                                        <th><b>64345d297c12bd4a0fdf28b2</b></th>\n                                    </tr>\n                                \n                                \n                                    <tr>\n                                        <td>Initial Population:</td>\n                                        \n                                            <td>Inpatient hospitalizations (inpatient stay less than or equal to 120 days) that end during the measurement period, where the patient is 18 years of age and older at the start of the encounter and prescribed one or more new or continuing opioid or benzodiazepine at discharge</td>\n                                        \n                                    </tr>\n                                \n                                    <tr>\n                                        <td>Denominator:</td>\n                                        \n                                            <td>Initial Population</td>\n                                        \n                                    </tr>\n                                \n                                    <tr>\n                                        <td>Denominator Exclusion:</td>\n                                        \n                                            <td>Inpatient hospitalizations where patients have cancer that begins prior to or during the encounter or are ordered or are receiving palliative or hospice care (including comfort measures, terminal care, and dying care) during the hospitalization or in an emergency department encounter or observation stay immediately prior to hospitalization, patients discharged to another inpatient care facility, and patients who expire during the inpatient stay.</td>\n                                        \n                                    </tr>\n                                \n                                    <tr>\n                                        <td>Numerator:</td>\n                                        \n                                            <td>Inpatient hospitalizations where the patient is prescribed or continuing to take two or more opioids or an opioid and benzodiazepine at discharge</td>\n                                        \n                                    </tr>\n                                \n                                    <tr>\n                                        <td>Numerator Exclusion:</td>\n                                        \n                                            <td>None</td>\n                                        \n                                    </tr>\n                                \n                                    <tr>\n                                        <td>Denominator Exception:</td>\n                                        \n                                            <td>None</td>\n                                        \n                                    </tr>\n                                \n                                \n                            </table>\n                        \n                    </td>\n                </tr>\n            \n        \n\n        \n            <tr>\n                <th scope=\"row\">\n                    <b> Supplemental Data Guidance\n                        : </b></th>\n                <td style=\"padding-left: 4px;\">  </td>\n            </tr>\n        \n\n        \n            <tr>\n                <th scope=\"row\"><b> Supplemental Data Elements: </b></th>\n                <td style=\"padding-left: 4px;\">\n                    \n                        \n                            \n                                SDE Ethnicity\n                            \n                        \n                    \n                        \n                            \n                                SDE Payer\n                            \n                        \n                    \n                        \n                            \n                                SDE Race\n                            \n                        \n                    \n                        \n                            \n                                SDE Sex\n                            \n                        \n                    \n                </td>\n            </tr>\n        \n\n        \n            <tr>\n                <th scope=\"row\"><b>Libraries: </b></th>\n                <td style=\"padding-left: 4px;\">\n                    <table class=\"grid-dict\">\n                        \n                            <tr>\n                                <td><a href=\"Library-SafeUseofOpioidsConcurrentPrescribingFHIR.html\">SafeUseofOpioidsConcurrentPrescribingFHIR</a></td>\n                            </tr>\n                        \n                    </table>\n                </td>\n            </tr>\n        \n\n        \n\n        \n            \n                <tr>\n                    <th scope=\"row\"><b>Related Artifact Dependencies: </b></th>\n                    <td style=\"padding-left: 4px;\">\n                        \n                            <li><code>Library/SupplementalDataElements|3.4.000</code></li>\n                        \n                            <li><code>Library/CQMCommon|1.4.000</code></li>\n                        \n                            <li><code>Library/FHIRHelpers|4.3.000</code></li>\n                        \n                            <li><code>Library/FHIRHelpers|4.3.000</code></li>\n                        \n                            <li><code>Library/QICoreCommon|1.5.000</code></li>\n                        \n                            <li><code>Library/FHIRHelpers|4.3.000</code></li>\n                        \n                            <li><code>Library/FHIRHelpers|4.3.000</code></li>\n                        \n                            <li><code>Library/QICoreCommon|1.5.000</code></li>\n                        \n                            <li><a href=\"http://terminology.hl7.org/7.1.0/CodeSystem-medicationrequest-category.html\">MedicationRequest Category Codes</a></li>\n                        \n                            <li><a href=\"http://terminology.hl7.org/7.1.0/CodeSystem-condition-category.html\">Condition Category Codes</a></li>\n                        \n                            <li><a href=\"http://hl7.org/fhir/us/core/STU3.1.1/CodeSystem-condition-category.html\">US Core Condition Category Extension Codes</a></li>\n                        \n                            <li><a href=\"http://terminology.hl7.org/7.1.0/CodeSystem-condition-clinical.html\">Condition Clinical Status Codes</a></li>\n                        \n                            <li><a href=\"https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.666.5.307/expansion\">Encounter Inpatient</a></li>\n                        \n                            <li><a href=\"https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1111.165/expansion\">Schedule II and III Opioid Medications</a></li>\n                        \n                            <li><a href=\"https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1125.1/expansion\">Schedule IV Benzodiazepines</a></li>\n                        \n                            <li><a href=\"https://vsac.nlm.nih.gov/valueset/2.16.840.1.114222.4.11.3591/expansion\">Payer</a></li>\n                        \n                            <li><a href=\"https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1111.161/expansion\">All Primary and Secondary Cancer</a></li>\n                        \n                            <li><a href=\"https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.600.1.1579/expansion\">Palliative or Hospice Care</a></li>\n                        \n                            <li><a href=\"https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1111.143/expansion\">Observation Services</a></li>\n                        \n                            <li><a href=\"https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.117.1.7.1.292/expansion\">Emergency Department Visit</a></li>\n                        \n                            <li><a href=\"https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.117.1.7.1.87/expansion\">Discharge To Acute Care Facility</a></li>\n                        \n                            <li><a href=\"https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1116.365/expansion\">Hospice Care Referral or Admission</a></li>\n                        \n                            <li><a href=\"https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.117.1.7.1.309/expansion\">Patient Expired</a></li>\n                        \n                    </td>\n                </tr>\n                <tr>\n                    <th scope=\"row\"><b>Parameters:</b></th>\n                    <td style=\"padding-left: 4px;\">\n                        <table class=\"grid-dict\">\n                            <tr>\n                                <th><b>name</b></th>\n                                <th><b>use</b></th>\n                                <th><b>min</b></th>\n                                <th><b>max</b></th>\n                                <th><b>type</b></th>\n                            </tr>\n                            \n                                <tr>\n                                    <td>Measurement Period</td>\n                                    <td>In</td>\n                                    <td>0</td>\n                                    <td>1</td>\n                                    <td>Period</td>\n                                </tr>\n                            \n                                <tr>\n                                    <td>SDE Sex</td>\n                                    <td>Out</td>\n                                    <td>0</td>\n                                    <td>1</td>\n                                    <td>Coding</td>\n                                </tr>\n                            \n                                <tr>\n                                    <td>Numerator</td>\n                                    <td>Out</td>\n                                    <td>0</td>\n                                    <td>*</td>\n                                    <td>Resource</td>\n                                </tr>\n                            \n                                <tr>\n                                    <td>Denominator</td>\n                                    <td>Out</td>\n                                    <td>0</td>\n                                    <td>*</td>\n                                    <td>Resource</td>\n                                </tr>\n                            \n                                <tr>\n                                    <td>SDE Payer</td>\n                                    <td>Out</td>\n                                    <td>0</td>\n                                    <td>*</td>\n                                    <td>Resource</td>\n                                </tr>\n                            \n                                <tr>\n                                    <td>Initial Population</td>\n                                    <td>Out</td>\n                                    <td>0</td>\n                                    <td>*</td>\n                                    <td>Resource</td>\n                                </tr>\n                            \n                                <tr>\n                                    <td>SDE Ethnicity</td>\n                                    <td>Out</td>\n                                    <td>0</td>\n                                    <td>1</td>\n                                    <td>Resource</td>\n                                </tr>\n                            \n                                <tr>\n                                    <td>Denominator Exclusion</td>\n                                    <td>Out</td>\n                                    <td>0</td>\n                                    <td>*</td>\n                                    <td>Resource</td>\n                                </tr>\n                            \n                                <tr>\n                                    <td>SDE Race</td>\n                                    <td>Out</td>\n                                    <td>0</td>\n                                    <td>1</td>\n                                    <td>Resource</td>\n                                </tr>\n                            \n                        </table>\n                    </td>\n                </tr>\n\n                <tr>\n                    <th scope=\"row\"><b>DataRequirements:</b></th>\n                    <td style=\"padding-left: 4px;\">\n                        <table class=\"grid-dict\">\n                            <tr>\n                                <th><b>Type</b></th>\n                                <th><b>Elements</b></th>\n                                <th><b>Valueset Name</b></th>\n                                <th><b>Valueset</b></th>\n                            </tr>\n                            \n                                <tr>\n                                    <td>Patient(<a href=\"http://hl7.org/fhir/us/qicore/STU4.1.1/StructureDefinition-qicore-patient.html\">QICorePatient</a>)</td>\n                                    <td>\n                                        \n                                    </td>\n                                    <td>\n                                        \n                                    </td>\n                                    <td/>\n                                </tr>\n                            \n                                <tr>\n                                    <td>Patient(<code>http://hl7.org/fhir/Patient</code>)</td>\n                                    <td>\n                                        \n                                            gender\n                                        \n                                            gender.value\n                                        \n                                            birthDate\n                                        \n                                            birthDate.value\n                                        \n                                    </td>\n                                    <td>\n                                        \n                                    </td>\n                                    <td/>\n                                </tr>\n                            \n                                <tr>\n                                    <td>Encounter(<a href=\"http://hl7.org/fhir/us/qicore/STU4.1.1/StructureDefinition-qicore-encounter.html\">QICoreEncounter</a>)</td>\n                                    <td>\n                                        \n                                            type\n                                        \n                                            status\n                                        \n                                            status.value\n                                        \n                                            period\n                                        \n                                    </td>\n                                    <td>\n                                        \n                                            \n                                                 Encounter Inpatient\n                                            \n                                        \n                                    </td>\n                                    <td><a href=\"https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.666.5.307/expansion\">Encounter Inpatient</a></td>\n                                </tr>\n                            \n                                <tr>\n                                    <td>Patient(<a href=\"http://hl7.org/fhir/us/qicore/STU4.1.1/StructureDefinition-qicore-patient.html\">QICorePatient</a>)</td>\n                                    <td>\n                                        \n                                    </td>\n                                    <td>\n                                        \n                                    </td>\n                                    <td/>\n                                </tr>\n                            \n                                <tr>\n                                    <td>Encounter(<a href=\"http://hl7.org/fhir/us/qicore/STU4.1.1/StructureDefinition-qicore-encounter.html\">QICoreEncounter</a>)</td>\n                                    <td>\n                                        \n                                            type\n                                        \n                                            status\n                                        \n                                            status.value\n                                        \n                                            period\n                                        \n                                    </td>\n                                    <td>\n                                        \n                                            \n                                                 Encounter Inpatient\n                                            \n                                        \n                                    </td>\n                                    <td><a href=\"https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.666.5.307/expansion\">Encounter Inpatient</a></td>\n                                </tr>\n                            \n                                <tr>\n                                    <td>MedicationRequest(<a href=\"http://hl7.org/fhir/us/qicore/STU4.1.1/StructureDefinition-qicore-medicationrequest.html\">QICoreMedicationRequest</a>)</td>\n                                    <td>\n                                        \n                                            medication\n                                        \n                                    </td>\n                                    <td>\n                                        \n                                            \n                                                 Schedule II, III Opioid Medications\n                                            \n                                        \n                                    </td>\n                                    <td><a href=\"https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1111.165/expansion\">Schedule II and III Opioid Medications</a></td>\n                                </tr>\n                            \n                                <tr>\n                                    <td>MedicationRequest(<a href=\"http://hl7.org/fhir/us/qicore/STU4.1.1/StructureDefinition-qicore-medicationrequest.html\">QICoreMedicationRequest</a>)</td>\n                                    <td>\n                                        \n                                            medication\n                                        \n                                    </td>\n                                    <td>\n                                        \n                                            \n                                                 Schedule II, III Opioid Medications\n                                            \n                                        \n                                    </td>\n                                    <td><a href=\"https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1111.165/expansion\">Schedule II and III Opioid Medications</a></td>\n                                </tr>\n                            \n                                <tr>\n                                    <td>MedicationRequest(<a href=\"http://hl7.org/fhir/us/qicore/STU4.1.1/StructureDefinition-qicore-medicationrequest.html\">QICoreMedicationRequest</a>)</td>\n                                    <td>\n                                        \n                                            medication\n                                        \n                                    </td>\n                                    <td>\n                                        \n                                            \n                                                 Schedule IV Benzodiazepines\n                                            \n                                        \n                                    </td>\n                                    <td><a href=\"https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1125.1/expansion\">Schedule IV Benzodiazepines</a></td>\n                                </tr>\n                            \n                                <tr>\n                                    <td>MedicationRequest(<a href=\"http://hl7.org/fhir/us/qicore/STU4.1.1/StructureDefinition-qicore-medicationrequest.html\">QICoreMedicationRequest</a>)</td>\n                                    <td>\n                                        \n                                            medication\n                                        \n                                            status\n                                        \n                                            status.value\n                                        \n                                            intent\n                                        \n                                            intent.value\n                                        \n                                            authoredOn\n                                        \n                                            authoredOn.value\n                                        \n                                    </td>\n                                    <td>\n                                        \n                                            \n                                                 Schedule IV Benzodiazepines\n                                            \n                                        \n                                    </td>\n                                    <td><a href=\"https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1125.1/expansion\">Schedule IV Benzodiazepines</a></td>\n                                </tr>\n                            \n                                <tr>\n                                    <td>Encounter(<a href=\"http://hl7.org/fhir/us/qicore/STU4.1.1/StructureDefinition-qicore-encounter.html\">QICoreEncounter</a>)</td>\n                                    <td>\n                                        \n                                            type\n                                        \n                                            status\n                                        \n                                            status.value\n                                        \n                                            period\n                                        \n                                    </td>\n                                    <td>\n                                        \n                                            \n                                                 Encounter Inpatient\n                                            \n                                        \n                                    </td>\n                                    <td><a href=\"https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.666.5.307/expansion\">Encounter Inpatient</a></td>\n                                </tr>\n                            \n                                <tr>\n                                    <td>MedicationRequest(<a href=\"http://hl7.org/fhir/us/qicore/STU4.1.1/StructureDefinition-qicore-medicationrequest.html\">QICoreMedicationRequest</a>)</td>\n                                    <td>\n                                        \n                                            medication\n                                        \n                                            status\n                                        \n                                            status.value\n                                        \n                                            intent\n                                        \n                                            intent.value\n                                        \n                                            authoredOn\n                                        \n                                            authoredOn.value\n                                        \n                                    </td>\n                                    <td>\n                                        \n                                            \n                                                 Schedule IV Benzodiazepines\n                                            \n                                        \n                                    </td>\n                                    <td><a href=\"https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1125.1/expansion\">Schedule IV Benzodiazepines</a></td>\n                                </tr>\n                            \n                                <tr>\n                                    <td>Encounter(<a href=\"http://hl7.org/fhir/us/qicore/STU4.1.1/StructureDefinition-qicore-encounter.html\">QICoreEncounter</a>)</td>\n                                    <td>\n                                        \n                                            type\n                                        \n                                            status\n                                        \n                                            status.value\n                                        \n                                            period\n                                        \n                                    </td>\n                                    <td>\n                                        \n                                            \n                                                 Encounter Inpatient\n                                            \n                                        \n                                    </td>\n                                    <td><a href=\"https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.666.5.307/expansion\">Encounter Inpatient</a></td>\n                                </tr>\n                            \n                                <tr>\n                                    <td>Encounter(<a href=\"http://hl7.org/fhir/us/qicore/STU4.1.1/StructureDefinition-qicore-encounter.html\">QICoreEncounter</a>)</td>\n                                    <td>\n                                        \n                                            type\n                                        \n                                            status\n                                        \n                                            status.value\n                                        \n                                            period\n                                        \n                                    </td>\n                                    <td>\n                                        \n                                            \n                                                 Encounter Inpatient\n                                            \n                                        \n                                    </td>\n                                    <td><a href=\"https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.666.5.307/expansion\">Encounter Inpatient</a></td>\n                                </tr>\n                            \n                                <tr>\n                                    <td>Coverage(<a href=\"http://hl7.org/fhir/us/qicore/STU4.1.1/StructureDefinition-qicore-coverage.html\">QICoreCoverage</a>)</td>\n                                    <td>\n                                        \n                                            type\n                                        \n                                            period\n                                        \n                                    </td>\n                                    <td>\n                                        \n                                            \n                                                 Payer Type\n                                            \n                                        \n                                    </td>\n                                    <td><a href=\"https://vsac.nlm.nih.gov/valueset/2.16.840.1.114222.4.11.3591/expansion\">Payer</a></td>\n                                </tr>\n                            \n                                <tr>\n                                    <td>uri(<code>http://hl7.org/fhir/uri</code>)</td>\n                                    <td>\n                                        \n                                            value\n                                        \n                                    </td>\n                                    <td>\n                                        \n                                    </td>\n                                    <td/>\n                                </tr>\n                            \n                                <tr>\n                                    <td>Patient(<a href=\"http://hl7.org/fhir/us/qicore/STU4.1.1/StructureDefinition-qicore-patient.html\">QICorePatient</a>)</td>\n                                    <td>\n                                        \n                                            url\n                                        \n                                            extension\n                                        \n                                    </td>\n                                    <td>\n                                        \n                                    </td>\n                                    <td/>\n                                </tr>\n                            \n                                <tr>\n                                    <td>Patient(<a href=\"http://hl7.org/fhir/us/qicore/STU4.1.1/StructureDefinition-qicore-patient.html\">QICorePatient</a>)</td>\n                                    <td>\n                                        \n                                            url\n                                        \n                                            extension\n                                        \n                                    </td>\n                                    <td>\n                                        \n                                    </td>\n                                    <td/>\n                                </tr>\n                            \n                                <tr>\n                                    <td>Condition(<code>http://hl7.org/fhir/Condition</code>)</td>\n                                    <td>\n                                        \n                                            clinicalStatus\n                                        \n                                    </td>\n                                    <td>\n                                        \n                                    </td>\n                                    <td/>\n                                </tr>\n                            \n                                <tr>\n                                    <td>Condition(<a href=\"http://hl7.org/fhir/us/qicore/STU4.1.1/StructureDefinition-qicore-condition.html\">QICoreCondition</a>)</td>\n                                    <td>\n                                        \n                                            id\n                                        \n                                            id.value\n                                        \n                                    </td>\n                                    <td>\n                                        \n                                    </td>\n                                    <td/>\n                                </tr>\n                            \n                                <tr>\n                                    <td>ServiceRequest(<a href=\"http://hl7.org/fhir/us/qicore/STU4.1.1/StructureDefinition-qicore-servicerequest.html\">QICoreServiceRequest</a>)</td>\n                                    <td>\n                                        \n                                            code\n                                        \n                                    </td>\n                                    <td>\n                                        \n                                            \n                                                 Palliative or Hospice Care\n                                            \n                                        \n                                    </td>\n                                    <td><a href=\"https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.600.1.1579/expansion\">Palliative or Hospice Care</a></td>\n                                </tr>\n                            \n                                <tr>\n                                    <td>Procedure(<a href=\"http://hl7.org/fhir/us/qicore/STU4.1.1/StructureDefinition-qicore-procedure.html\">QICoreProcedure</a>)</td>\n                                    <td>\n                                        \n                                            code\n                                        \n                                    </td>\n                                    <td>\n                                        \n                                            \n                                                 Palliative or Hospice Care\n                                            \n                                        \n                                    </td>\n                                    <td><a href=\"https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.600.1.1579/expansion\">Palliative or Hospice Care</a></td>\n                                </tr>\n                            \n                                <tr>\n                                    <td>Patient(<a href=\"http://hl7.org/fhir/us/qicore/STU4.1.1/StructureDefinition-qicore-patient.html\">QICorePatient</a>)</td>\n                                    <td>\n                                        \n                                    </td>\n                                    <td>\n                                        \n                                    </td>\n                                    <td/>\n                                </tr>\n                            \n                                <tr>\n                                    <td>Encounter(<a href=\"http://hl7.org/fhir/us/qicore/STU4.1.1/StructureDefinition-qicore-encounter.html\">QICoreEncounter</a>)</td>\n                                    <td>\n                                        \n                                            type\n                                        \n                                            status\n                                        \n                                            status.value\n                                        \n                                            period\n                                        \n                                    </td>\n                                    <td>\n                                        \n                                            \n                                                 Observation Services\n                                            \n                                        \n                                    </td>\n                                    <td><a href=\"https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1111.143/expansion\">Observation Services</a></td>\n                                </tr>\n                            \n                                <tr>\n                                    <td>Encounter(<a href=\"http://hl7.org/fhir/us/qicore/STU4.1.1/StructureDefinition-qicore-encounter.html\">QICoreEncounter</a>)</td>\n                                    <td>\n                                        \n                                            type\n                                        \n                                            status\n                                        \n                                            status.value\n                                        \n                                            period\n                                        \n                                    </td>\n                                    <td>\n                                        \n                                            \n                                                 Emergency Department Visit\n                                            \n                                        \n                                    </td>\n                                    <td><a href=\"https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.117.1.7.1.292/expansion\">Emergency Department Visit</a></td>\n                                </tr>\n                            \n                                <tr>\n                                    <td>Encounter(<a href=\"http://hl7.org/fhir/us/qicore/STU4.1.1/StructureDefinition-qicore-encounter.html\">QICoreEncounter</a>)</td>\n                                    <td>\n                                        \n                                            type\n                                        \n                                            status\n                                        \n                                            status.value\n                                        \n                                            period\n                                        \n                                    </td>\n                                    <td>\n                                        \n                                            \n                                                 Observation Services\n                                            \n                                        \n                                    </td>\n                                    <td><a href=\"https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1111.143/expansion\">Observation Services</a></td>\n                                </tr>\n                            \n                                <tr>\n                                    <td>Encounter(<a href=\"http://hl7.org/fhir/us/qicore/STU4.1.1/StructureDefinition-qicore-encounter.html\">QICoreEncounter</a>)</td>\n                                    <td>\n                                        \n                                            type\n                                        \n                                            status\n                                        \n                                            status.value\n                                        \n                                            period\n                                        \n                                    </td>\n                                    <td>\n                                        \n                                            \n                                                 Emergency Department Visit\n                                            \n                                        \n                                    </td>\n                                    <td><a href=\"https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.117.1.7.1.292/expansion\">Emergency Department Visit</a></td>\n                                </tr>\n                            \n                                <tr>\n                                    <td>Condition(<a href=\"http://hl7.org/fhir/us/qicore/STU4.1.1/StructureDefinition-qicore-condition.html\">QICoreCondition</a>)</td>\n                                    <td>\n                                        \n                                            code\n                                        \n                                    </td>\n                                    <td>\n                                        \n                                            \n                                                 All Primary and Secondary Cancer\n                                            \n                                        \n                                    </td>\n                                    <td><a href=\"https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1111.161/expansion\">All Primary and Secondary Cancer</a></td>\n                                </tr>\n                            \n                                <tr>\n                                    <td>Patient(<a href=\"http://hl7.org/fhir/us/qicore/STU4.1.1/StructureDefinition-qicore-patient.html\">QICorePatient</a>)</td>\n                                    <td>\n                                        \n                                            url\n                                        \n                                            extension\n                                        \n                                    </td>\n                                    <td>\n                                        \n                                    </td>\n                                    <td/>\n                                </tr>\n                            \n                                <tr>\n                                    <td>Patient(<a href=\"http://hl7.org/fhir/us/qicore/STU4.1.1/StructureDefinition-qicore-patient.html\">QICorePatient</a>)</td>\n                                    <td>\n                                        \n                                            url\n                                        \n                                            extension\n                                        \n                                    </td>\n                                    <td>\n                                        \n                                    </td>\n                                    <td/>\n                                </tr>\n                            \n                                <tr>\n                                    <td>Coverage(<a href=\"http://hl7.org/fhir/us/qicore/STU4.1.1/StructureDefinition-qicore-coverage.html\">QICoreCoverage</a>)</td>\n                                    <td>\n                                        \n                                            type\n                                        \n                                            period\n                                        \n                                    </td>\n                                    <td>\n                                        \n                                            \n                                                 Payer Type\n                                            \n                                        \n                                    </td>\n                                    <td><a href=\"https://vsac.nlm.nih.gov/valueset/2.16.840.1.114222.4.11.3591/expansion\">Payer</a></td>\n                                </tr>\n                            \n                                <tr>\n                                    <td>Patient(<a href=\"http://hl7.org/fhir/us/qicore/STU4.1.1/StructureDefinition-qicore-patient.html\">QICorePatient</a>)</td>\n                                    <td>\n                                        \n                                            url\n                                        \n                                            extension\n                                        \n                                    </td>\n                                    <td>\n                                        \n                                    </td>\n                                    <td/>\n                                </tr>\n                            \n                                <tr>\n                                    <td>Patient(<a href=\"http://hl7.org/fhir/us/qicore/STU4.1.1/StructureDefinition-qicore-patient.html\">QICorePatient</a>)</td>\n                                    <td>\n                                        \n                                            url\n                                        \n                                            extension\n                                        \n                                    </td>\n                                    <td>\n                                        \n                                    </td>\n                                    <td/>\n                                </tr>\n                            \n                        </table>\n                    </td>\n                </tr>\n\n                \n                    <tr>\n                        <th scope=\"row\"><b>Direct Reference Codes:</b></th>\n                        <td style=\"padding-left: 4px;\">\n                            <table class=\"grid-dict\">\n                                <tr>\n                                    <th><b>display</b></th>\n                                    <th><b>code</b></th>\n                                    <th><b>system</b></th>\n                                </tr>\n                                \n                                    <tr>\n                                        <td>Community</td>\n                                        <td>community</td>\n                                        <td><a href=\"http://terminology.hl7.org/7.1.0/CodeSystem-medicationrequest-category.html\">http://terminology.hl7.org/CodeSystem/medicationrequest-category</a></td>\n                                    </tr>\n                                \n                                    <tr>\n                                        <td>Discharge</td>\n                                        <td>discharge</td>\n                                        <td><a href=\"http://terminology.hl7.org/7.1.0/CodeSystem-medicationrequest-category.html\">http://terminology.hl7.org/CodeSystem/medicationrequest-category</a></td>\n                                    </tr>\n                                \n                                    <tr>\n                                        <td>Problem List Item</td>\n                                        <td>problem-list-item</td>\n                                        <td><a href=\"http://terminology.hl7.org/7.1.0/CodeSystem-condition-category.html\">http://terminology.hl7.org/CodeSystem/condition-category</a></td>\n                                    </tr>\n                                \n                                    <tr>\n                                        <td>Health Concern</td>\n                                        <td>health-concern</td>\n                                        <td><a href=\"http://hl7.org/fhir/us/core/STU3.1.1/CodeSystem-condition-category.html\">http://hl7.org/fhir/us/core/CodeSystem/condition-category</a></td>\n                                    </tr>\n                                \n                                    <tr>\n                                        <td/>\n                                        <td>active</td>\n                                        <td><a href=\"http://terminology.hl7.org/7.1.0/CodeSystem-condition-clinical.html\">http://terminology.hl7.org/CodeSystem/condition-clinical</a></td>\n                                    </tr>\n                                \n                                    <tr>\n                                        <td/>\n                                        <td>recurrence</td>\n                                        <td><a href=\"http://terminology.hl7.org/7.1.0/CodeSystem-condition-clinical.html\">http://terminology.hl7.org/CodeSystem/condition-clinical</a></td>\n                                    </tr>\n                                \n                                    <tr>\n                                        <td/>\n                                        <td>relapse</td>\n                                        <td><a href=\"http://terminology.hl7.org/7.1.0/CodeSystem-condition-clinical.html\">http://terminology.hl7.org/CodeSystem/condition-clinical</a></td>\n                                    </tr>\n                                \n                            </table>\n                        </td>\n                    </tr>\n                \n\n                \n                <tr>\n                    <th scope=\"row\"><b>Logic Definitions:</b></th>\n                    <td style=\"padding-left: 4px;\">\n                        \n                        <table class=\"grid-dict\">\n                            <tr>\n                                <th><b>Group</b></th>\n                                <th><b>Scoring</b></th>\n                                <th><b>Population Criteria</b></th>\n                                <th><b>Expression</b></th>\n                            </tr>\n                            <tr>\n                                \n                                <td> 64345d297c12bd4a0fdf28b2 </td>\n                                <td>\n                                    \n                                        <b>Group scoring:</b>\n                                        \n                                            <span>  proportion </span>\n                                        \n                                    \n\n                                    \n\n                                    \n\n                                    \n\n                                    \n\n                                    \n\n                                    \n\n                                    \n\n                                </td>\n                                \n                                <tr>\n                                    <td/>\n                                    <td/>\n                                    <td>Initial Population</td>\n                                    <td>\n                                        \n                                            <pre><code class=\"language-cql\">define &quot;Initial Population&quot;:\n  &quot;Inpatient Encounters with an Opioid or Benzodiazepine at Discharge&quot;</code></pre>\n                                        \n                                    </td>\n                                </tr>\n                                \n                                <tr>\n                                    <td/>\n                                    <td/>\n                                    <td>Denominator</td>\n                                    <td>\n                                        \n                                            <pre><code class=\"language-cql\">define &quot;Denominator&quot;:\n  &quot;Initial Population&quot;</code></pre>\n                                        \n                                    </td>\n                                </tr>\n                                \n                                <tr>\n                                    <td/>\n                                    <td/>\n                                    <td>Denominator Exclusion</td>\n                                    <td>\n                                        \n                                            <pre><code class=\"language-cql\">define &quot;Denominator Exclusion&quot;:\n  /*Excludes encounters of patients with cancer or who are receiving palliative or hospice care at the time of the encounter*/\n  \n  &quot;Inpatient Encounters with an Opioid or Benzodiazepine at Discharge&quot; InpatientEncounter\n    where exists ( [Condition: &quot;All Primary and Secondary Cancer&quot;] Cancer\n        where ( Cancer.isProblemListItem ( )\n            or Cancer.isHealthConcern ( )\n        )\n          and Cancer.isActive ( )\n          and Cancer.prevalenceInterval ( ) overlaps InpatientEncounter.period\n    )\n      or exists ( ( InpatientEncounter.encounterDiagnosis ( ) ) InpatientEncounterDiagnosis\n          where InpatientEncounterDiagnosis.code in &quot;All Primary and Secondary Cancer&quot;\n      )\n      or exists ( &quot;Intervention Palliative or Hospice Care&quot; PalliativeOrHospiceCare\n          where Coalesce(PalliativeOrHospiceCare.performed.toInterval(), PalliativeOrHospiceCare.authoredOn.toInterval()) during day of CQMCommon.&quot;HospitalizationWithObservation&quot; ( InpatientEncounter )\n      )\n      or ( InpatientEncounter.hospitalization.dischargeDisposition in &quot;Discharge To Acute Care Facility&quot;\n          or InpatientEncounter.hospitalization.dischargeDisposition in &quot;Hospice Care Referral or Admission&quot;\n          or InpatientEncounter.hospitalization.dischargeDisposition in &quot;Patient Expired&quot;\n      )</code></pre>\n                                        \n                                    </td>\n                                </tr>\n                                \n                                <tr>\n                                    <td/>\n                                    <td/>\n                                    <td>Numerator</td>\n                                    <td>\n                                        \n                                            <pre><code class=\"language-cql\">define &quot;Numerator&quot;:\n  /*Encounters of patients prescribed two or more opioids or an opioid and benzodiazepine at discharge.*/\n  \n  ( &quot;Inpatient Encounter with Age Greater than or Equal to 18&quot; InpatientEncounter\n      where ( Count(&quot;Opioid at Discharge&quot; Opioids\n            return distinct Opioids.medication\n        ) &gt;= 2\n      )\n  )\n    union ( &quot;Inpatient Encounter with Age Greater than or Equal to 18&quot; InpatientEncounter\n        with &quot;Opioid at Discharge&quot; OpioidsDischarge\n          such that OpioidsDischarge.authoredOn during InpatientEncounter.period\n        with &quot;Benzodiazepine at Discharge&quot; BenzodiazepinesDischarge\n          such that BenzodiazepinesDischarge.authoredOn during day of InpatientEncounter.period\n    )</code></pre>\n                                        \n                                    </td>\n                                </tr>\n                                \n                                <tr>\n                                    <td/>\n                                    <td/>\n                                    <td>Numerator Exclusion</td>\n                                    <td>\n                                        \n                                            None\n                                        \n                                    </td>\n                                </tr>\n                                \n                                <tr>\n                                    <td/>\n                                    <td/>\n                                    <td>Denominator Exception</td>\n                                    <td>\n                                        \n                                            None\n                                        \n                                    </td>\n                                </tr>\n                                \n                                \n                            \n                            </tr>\n                        </table>\n                \n\n                <table class=\"grid-dict\">\n                    \n                        <tr>\n                            <th><b>Library Name</b></th>\n                            <th><b>Name</b></th>\n                        </tr>\n                        <tr>\n                            \n                                <td>SupplementalDataElements</td>\n                            \n                            \n                                <td>SDE Sex</td>\n                            \n                        </tr>\n                        <tr>\n                            \n                                <td/>\n                                <td>\n                                    <pre class=\"highlight language-cql\"><code class=\"language-cql\">define &quot;SDE Sex&quot;:\n  case\n      when Patient.gender = 'male' then Code { code: 'M', system: 'http://hl7.org/fhir/v3/AdministrativeGender', display: 'Male' }\n      when Patient.gender = 'female' then Code { code: 'F', system: 'http://hl7.org/fhir/v3/AdministrativeGender', display: 'Female' }\n      else null\n    end</code></pre>\n                                </td>\n                            \n                        </tr>\n                    \n                        <tr>\n                            <th><b>Library Name</b></th>\n                            <th><b>Name</b></th>\n                        </tr>\n                        <tr>\n                            \n                                <td>SafeUseofOpioidsConcurrentPrescribingFHIR</td>\n                            \n                            \n                                <td>SDE Sex</td>\n                            \n                        </tr>\n                        <tr>\n                            \n                                <td/>\n                                <td>\n                                    <pre class=\"highlight language-cql\"><code class=\"language-cql\">define &quot;SDE Sex&quot;:\n  SDE.&quot;SDE Sex&quot;</code></pre>\n                                </td>\n                            \n                        </tr>\n                    \n                        <tr>\n                            <th><b>Library Name</b></th>\n                            <th><b>Name</b></th>\n                        </tr>\n                        <tr>\n                            \n                                <td>CQMCommon</td>\n                            \n                            \n                                <td>Inpatient Encounter</td>\n                            \n                        </tr>\n                        <tr>\n                            \n                                <td/>\n                                <td>\n                                    <pre class=\"highlight language-cql\"><code class=\"language-cql\">define &quot;Inpatient Encounter&quot;:\n  [Encounter: &quot;Encounter Inpatient&quot;] EncounterInpatient\n\t\twhere EncounterInpatient.status = 'finished'\n\t\tand EncounterInpatient.period ends during day of &quot;Measurement Period&quot;</code></pre>\n                                </td>\n                            \n                        </tr>\n                    \n                        <tr>\n                            <th><b>Library Name</b></th>\n                            <th><b>Name</b></th>\n                        </tr>\n                        <tr>\n                            \n                                <td>SafeUseofOpioidsConcurrentPrescribingFHIR</td>\n                            \n                            \n                                <td>Inpatient Encounter with Age Greater than or Equal to 18</td>\n                            \n                        </tr>\n                        <tr>\n                            \n                                <td/>\n                                <td>\n                                    <pre class=\"highlight language-cql\"><code class=\"language-cql\">define &quot;Inpatient Encounter with Age Greater than or Equal to 18&quot;:\n  CQMCommon.&quot;Inpatient Encounter&quot; InpatientHospitalEncounter\n    where AgeInYearsAt(date from start of InpatientHospitalEncounter.period) &gt;= 18</code></pre>\n                                </td>\n                            \n                        </tr>\n                    \n                        <tr>\n                            <th><b>Library Name</b></th>\n                            <th><b>Name</b></th>\n                        </tr>\n                        <tr>\n                            \n                                <td>SafeUseofOpioidsConcurrentPrescribingFHIR</td>\n                            \n                            \n                                <td>Opioid at Discharge</td>\n                            \n                        </tr>\n                        <tr>\n                            \n                                <td/>\n                                <td>\n                                    <pre class=\"highlight language-cql\"><code class=\"language-cql\">define &quot;Opioid at Discharge&quot;:\n  ( [MedicationRequest: &quot;Schedule II &amp; III Opioid Medications&quot;] OpioidMedications\n    where ( OpioidMedications.isCommunity ( )\n        or OpioidMedications.isDischarge ( )\n    ) ) OpioidDischargeMedication\n    where OpioidDischargeMedication.status in { 'active', 'completed' }\n      and OpioidDischargeMedication.intent = 'order'</code></pre>\n                                </td>\n                            \n                        </tr>\n                    \n                        <tr>\n                            <th><b>Library Name</b></th>\n                            <th><b>Name</b></th>\n                        </tr>\n                        <tr>\n                            \n                                <td>SafeUseofOpioidsConcurrentPrescribingFHIR</td>\n                            \n                            \n                                <td>Benzodiazepine at Discharge</td>\n                            \n                        </tr>\n                        <tr>\n                            \n                                <td/>\n                                <td>\n                                    <pre class=\"highlight language-cql\"><code class=\"language-cql\">define &quot;Benzodiazepine at Discharge&quot;:\n  ( [MedicationRequest: medication in &quot;Schedule IV Benzodiazepines&quot;] BenzoMedications\n    where ( BenzoMedications.isCommunity ( )\n        or BenzoMedications.isDischarge ( )\n    ) ) BenzodiazepineDischargeMedication\n    where BenzodiazepineDischargeMedication.status in { 'active', 'completed' }\n      and BenzodiazepineDischargeMedication.intent = 'order'</code></pre>\n                                </td>\n                            \n                        </tr>\n                    \n                        <tr>\n                            <th><b>Library Name</b></th>\n                            <th><b>Name</b></th>\n                        </tr>\n                        <tr>\n                            \n                                <td>SafeUseofOpioidsConcurrentPrescribingFHIR</td>\n                            \n                            \n                                <td>Numerator</td>\n                            \n                        </tr>\n                        <tr>\n                            \n                                <td/>\n                                <td>\n                                    <pre class=\"highlight language-cql\"><code class=\"language-cql\">define &quot;Numerator&quot;:\n  /*Encounters of patients prescribed two or more opioids or an opioid and benzodiazepine at discharge.*/\n  \n  ( &quot;Inpatient Encounter with Age Greater than or Equal to 18&quot; InpatientEncounter\n      where ( Count(&quot;Opioid at Discharge&quot; Opioids\n            return distinct Opioids.medication\n        ) &gt;= 2\n      )\n  )\n    union ( &quot;Inpatient Encounter with Age Greater than or Equal to 18&quot; InpatientEncounter\n        with &quot;Opioid at Discharge&quot; OpioidsDischarge\n          such that OpioidsDischarge.authoredOn during InpatientEncounter.period\n        with &quot;Benzodiazepine at Discharge&quot; BenzodiazepinesDischarge\n          such that BenzodiazepinesDischarge.authoredOn during day of InpatientEncounter.period\n    )</code></pre>\n                                </td>\n                            \n                        </tr>\n                    \n                        <tr>\n                            <th><b>Library Name</b></th>\n                            <th><b>Name</b></th>\n                        </tr>\n                        <tr>\n                            \n                                <td>SafeUseofOpioidsConcurrentPrescribingFHIR</td>\n                            \n                            \n                                <td>Inpatient Encounters with an Opioid or Benzodiazepine at Discharge</td>\n                            \n                        </tr>\n                        <tr>\n                            \n                                <td/>\n                                <td>\n                                    <pre class=\"highlight language-cql\"><code class=\"language-cql\">define &quot;Inpatient Encounters with an Opioid or Benzodiazepine at Discharge&quot;:\n  &quot;Inpatient Encounter with Age Greater than or Equal to 18&quot; InpatientEncounter\n    with ( &quot;Opioid at Discharge&quot;\n      union &quot;Benzodiazepine at Discharge&quot; ) OpioidOrBenzodiazepineAtDischarge\n      such that OpioidOrBenzodiazepineAtDischarge.authoredOn during day of InpatientEncounter.period</code></pre>\n                                </td>\n                            \n                        </tr>\n                    \n                        <tr>\n                            <th><b>Library Name</b></th>\n                            <th><b>Name</b></th>\n                        </tr>\n                        <tr>\n                            \n                                <td>SafeUseofOpioidsConcurrentPrescribingFHIR</td>\n                            \n                            \n                                <td>Initial Population</td>\n                            \n                        </tr>\n                        <tr>\n                            \n                                <td/>\n                                <td>\n                                    <pre class=\"highlight language-cql\"><code class=\"language-cql\">define &quot;Initial Population&quot;:\n  &quot;Inpatient Encounters with an Opioid or Benzodiazepine at Discharge&quot;</code></pre>\n                                </td>\n                            \n                        </tr>\n                    \n                        <tr>\n                            <th><b>Library Name</b></th>\n                            <th><b>Name</b></th>\n                        </tr>\n                        <tr>\n                            \n                                <td>SafeUseofOpioidsConcurrentPrescribingFHIR</td>\n                            \n                            \n                                <td>Denominator</td>\n                            \n                        </tr>\n                        <tr>\n                            \n                                <td/>\n                                <td>\n                                    <pre class=\"highlight language-cql\"><code class=\"language-cql\">define &quot;Denominator&quot;:\n  &quot;Initial Population&quot;</code></pre>\n                                </td>\n                            \n                        </tr>\n                    \n                        <tr>\n                            <th><b>Library Name</b></th>\n                            <th><b>Name</b></th>\n                        </tr>\n                        <tr>\n                            \n                                <td>SupplementalDataElements</td>\n                            \n                            \n                                <td>SDE Payer</td>\n                            \n                        </tr>\n                        <tr>\n                            \n                                <td/>\n                                <td>\n                                    <pre class=\"highlight language-cql\"><code class=\"language-cql\">define &quot;SDE Payer&quot;:\n  [Coverage: type in &quot;Payer Type&quot;] Payer\n    return {\n      code: Payer.type,\n      period: Payer.period\n    }</code></pre>\n                                </td>\n                            \n                        </tr>\n                    \n                        <tr>\n                            <th><b>Library Name</b></th>\n                            <th><b>Name</b></th>\n                        </tr>\n                        <tr>\n                            \n                                <td>SafeUseofOpioidsConcurrentPrescribingFHIR</td>\n                            \n                            \n                                <td>SDE Payer</td>\n                            \n                        </tr>\n                        <tr>\n                            \n                                <td/>\n                                <td>\n                                    <pre class=\"highlight language-cql\"><code class=\"language-cql\">define &quot;SDE Payer&quot;:\n  SDE.&quot;SDE Payer&quot;</code></pre>\n                                </td>\n                            \n                        </tr>\n                    \n                        <tr>\n                            <th><b>Library Name</b></th>\n                            <th><b>Name</b></th>\n                        </tr>\n                        <tr>\n                            \n                                <td>SupplementalDataElements</td>\n                            \n                            \n                                <td>SDE Ethnicity</td>\n                            \n                        </tr>\n                        <tr>\n                            \n                                <td/>\n                                <td>\n                                    <pre class=\"highlight language-cql\"><code class=\"language-cql\">define &quot;SDE Ethnicity&quot;:\n  Patient.ethnicity E\n    return Tuple {\n      codes: { E.ombCategory } union E.detailed,\n      display: E.text\n    }</code></pre>\n                                </td>\n                            \n                        </tr>\n                    \n                        <tr>\n                            <th><b>Library Name</b></th>\n                            <th><b>Name</b></th>\n                        </tr>\n                        <tr>\n                            \n                                <td>SafeUseofOpioidsConcurrentPrescribingFHIR</td>\n                            \n                            \n                                <td>SDE Ethnicity</td>\n                            \n                        </tr>\n                        <tr>\n                            \n                                <td/>\n                                <td>\n                                    <pre class=\"highlight language-cql\"><code class=\"language-cql\">define &quot;SDE Ethnicity&quot;:\n  SDE.&quot;SDE Ethnicity&quot;</code></pre>\n                                </td>\n                            \n                        </tr>\n                    \n                        <tr>\n                            <th><b>Library Name</b></th>\n                            <th><b>Name</b></th>\n                        </tr>\n                        <tr>\n                            \n                                <td>SafeUseofOpioidsConcurrentPrescribingFHIR</td>\n                            \n                            \n                                <td>Intervention Palliative or Hospice Care</td>\n                            \n                        </tr>\n                        <tr>\n                            \n                                <td/>\n                                <td>\n                                    <pre class=\"highlight language-cql\"><code class=\"language-cql\">define &quot;Intervention Palliative or Hospice Care&quot;:\n  [ServiceRequest: &quot;Palliative or Hospice Care&quot;]\n    union [Procedure: &quot;Palliative or Hospice Care&quot;]</code></pre>\n                                </td>\n                            \n                        </tr>\n                    \n                        <tr>\n                            <th><b>Library Name</b></th>\n                            <th><b>Name</b></th>\n                        </tr>\n                        <tr>\n                            \n                                <td>SafeUseofOpioidsConcurrentPrescribingFHIR</td>\n                            \n                            \n                                <td>Denominator Exclusion</td>\n                            \n                        </tr>\n                        <tr>\n                            \n                                <td/>\n                                <td>\n                                    <pre class=\"highlight language-cql\"><code class=\"language-cql\">define &quot;Denominator Exclusion&quot;:\n  /*Excludes encounters of patients with cancer or who are receiving palliative or hospice care at the time of the encounter*/\n  \n  &quot;Inpatient Encounters with an Opioid or Benzodiazepine at Discharge&quot; InpatientEncounter\n    where exists ( [Condition: &quot;All Primary and Secondary Cancer&quot;] Cancer\n        where ( Cancer.isProblemListItem ( )\n            or Cancer.isHealthConcern ( )\n        )\n          and Cancer.isActive ( )\n          and Cancer.prevalenceInterval ( ) overlaps InpatientEncounter.period\n    )\n      or exists ( ( InpatientEncounter.encounterDiagnosis ( ) ) InpatientEncounterDiagnosis\n          where InpatientEncounterDiagnosis.code in &quot;All Primary and Secondary Cancer&quot;\n      )\n      or exists ( &quot;Intervention Palliative or Hospice Care&quot; PalliativeOrHospiceCare\n          where Coalesce(PalliativeOrHospiceCare.performed.toInterval(), PalliativeOrHospiceCare.authoredOn.toInterval()) during day of CQMCommon.&quot;HospitalizationWithObservation&quot; ( InpatientEncounter )\n      )\n      or ( InpatientEncounter.hospitalization.dischargeDisposition in &quot;Discharge To Acute Care Facility&quot;\n          or InpatientEncounter.hospitalization.dischargeDisposition in &quot;Hospice Care Referral or Admission&quot;\n          or InpatientEncounter.hospitalization.dischargeDisposition in &quot;Patient Expired&quot;\n      )</code></pre>\n                                </td>\n                            \n                        </tr>\n                    \n                        <tr>\n                            <th><b>Library Name</b></th>\n                            <th><b>Name</b></th>\n                        </tr>\n                        <tr>\n                            \n                                <td>SupplementalDataElements</td>\n                            \n                            \n                                <td>SDE Race</td>\n                            \n                        </tr>\n                        <tr>\n                            \n                                <td/>\n                                <td>\n                                    <pre class=\"highlight language-cql\"><code class=\"language-cql\">define &quot;SDE Race&quot;:\n  Patient.race R\n    return Tuple {\n      codes: R.ombCategory union R.detailed,\n      display: R.text\n    }</code></pre>\n                                </td>\n                            \n                        </tr>\n                    \n                        <tr>\n                            <th><b>Library Name</b></th>\n                            <th><b>Name</b></th>\n                        </tr>\n                        <tr>\n                            \n                                <td>SafeUseofOpioidsConcurrentPrescribingFHIR</td>\n                            \n                            \n                                <td>SDE Race</td>\n                            \n                        </tr>\n                        <tr>\n                            \n                                <td/>\n                                <td>\n                                    <pre class=\"highlight language-cql\"><code class=\"language-cql\">define &quot;SDE Race&quot;:\n  SDE.&quot;SDE Race&quot;</code></pre>\n                                </td>\n                            \n                        </tr>\n                    \n                    </table>\n                </td>\n            </tr>\n            \n        \n    \n\n    </table>\n</div>"
      },
      "contained" : [
        {
          "resourceType" : "Library",
          "id" : "effective-data-requirements",
          "extension" : [
            {
              "url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-directReferenceCode",
              "valueCoding" : {
                "system" : "http://terminology.hl7.org/CodeSystem/medicationrequest-category",
                "code" : "community",
                "display" : "Community"
              }
            },
            {
              "url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-directReferenceCode",
              "valueCoding" : {
                "system" : "http://terminology.hl7.org/CodeSystem/medicationrequest-category",
                "code" : "discharge",
                "display" : "Discharge"
              }
            },
            {
              "url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-directReferenceCode",
              "valueCoding" : {
                "system" : "http://terminology.hl7.org/CodeSystem/condition-category",
                "code" : "problem-list-item",
                "display" : "Problem List Item"
              }
            },
            {
              "url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-directReferenceCode",
              "valueCoding" : {
                "system" : "http://hl7.org/fhir/us/core/CodeSystem/condition-category",
                "code" : "health-concern",
                "display" : "Health Concern"
              }
            },
            {
              "url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-directReferenceCode",
              "valueCoding" : {
                "system" : "http://terminology.hl7.org/CodeSystem/condition-clinical",
                "code" : "active"
              }
            },
            {
              "url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-directReferenceCode",
              "valueCoding" : {
                "system" : "http://terminology.hl7.org/CodeSystem/condition-clinical",
                "code" : "recurrence"
              }
            },
            {
              "url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-directReferenceCode",
              "valueCoding" : {
                "system" : "http://terminology.hl7.org/CodeSystem/condition-clinical",
                "code" : "relapse"
              }
            },
            {
              "extension" : [
                {
                  "url" : "libraryName",
                  "valueString" : "SupplementalDataElements"
                },
                {
                  "url" : "name",
                  "valueString" : "SDE Sex"
                },
                {
                  "url" : "statement",
                  "valueString" : "define \"SDE Sex\":\n  case\n      when Patient.gender = 'male' then Code { code: 'M', system: 'http://hl7.org/fhir/v3/AdministrativeGender', display: 'Male' }\n      when Patient.gender = 'female' then Code { code: 'F', system: 'http://hl7.org/fhir/v3/AdministrativeGender', display: 'Female' }\n      else null\n    end"
                },
                {
                  "url" : "displaySequence",
                  "valueInteger" : 0
                }
              ],
              "url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
            },
            {
              "extension" : [
                {
                  "url" : "libraryName",
                  "valueString" : "SafeUseofOpioidsConcurrentPrescribingFHIR"
                },
                {
                  "url" : "name",
                  "valueString" : "SDE Sex"
                },
                {
                  "url" : "statement",
                  "valueString" : "define \"SDE Sex\":\n  SDE.\"SDE Sex\""
                },
                {
                  "url" : "displaySequence",
                  "valueInteger" : 1
                }
              ],
              "url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
            },
            {
              "extension" : [
                {
                  "url" : "libraryName",
                  "valueString" : "CQMCommon"
                },
                {
                  "url" : "name",
                  "valueString" : "Inpatient Encounter"
                },
                {
                  "url" : "statement",
                  "valueString" : "define \"Inpatient Encounter\":\n  [Encounter: \"Encounter Inpatient\"] EncounterInpatient\n\t\twhere EncounterInpatient.status = 'finished'\n\t\tand EncounterInpatient.period ends during day of \"Measurement Period\""
                },
                {
                  "url" : "displaySequence",
                  "valueInteger" : 2
                }
              ],
              "url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
            },
            {
              "extension" : [
                {
                  "url" : "libraryName",
                  "valueString" : "SafeUseofOpioidsConcurrentPrescribingFHIR"
                },
                {
                  "url" : "name",
                  "valueString" : "Inpatient Encounter with Age Greater than or Equal to 18"
                },
                {
                  "url" : "statement",
                  "valueString" : "define \"Inpatient Encounter with Age Greater than or Equal to 18\":\n  CQMCommon.\"Inpatient Encounter\" InpatientHospitalEncounter\n    where AgeInYearsAt(date from start of InpatientHospitalEncounter.period) >= 18"
                },
                {
                  "url" : "displaySequence",
                  "valueInteger" : 3
                }
              ],
              "url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
            },
            {
              "extension" : [
                {
                  "url" : "libraryName",
                  "valueString" : "SafeUseofOpioidsConcurrentPrescribingFHIR"
                },
                {
                  "url" : "name",
                  "valueString" : "Opioid at Discharge"
                },
                {
                  "url" : "statement",
                  "valueString" : "define \"Opioid at Discharge\":\n  ( [MedicationRequest: \"Schedule II & III Opioid Medications\"] OpioidMedications\n    where ( OpioidMedications.isCommunity ( )\n        or OpioidMedications.isDischarge ( )\n    ) ) OpioidDischargeMedication\n    where OpioidDischargeMedication.status in { 'active', 'completed' }\n      and OpioidDischargeMedication.intent = 'order'"
                },
                {
                  "url" : "displaySequence",
                  "valueInteger" : 4
                }
              ],
              "url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
            },
            {
              "extension" : [
                {
                  "url" : "libraryName",
                  "valueString" : "SafeUseofOpioidsConcurrentPrescribingFHIR"
                },
                {
                  "url" : "name",
                  "valueString" : "Benzodiazepine at Discharge"
                },
                {
                  "url" : "statement",
                  "valueString" : "define \"Benzodiazepine at Discharge\":\n  ( [MedicationRequest: medication in \"Schedule IV Benzodiazepines\"] BenzoMedications\n    where ( BenzoMedications.isCommunity ( )\n        or BenzoMedications.isDischarge ( )\n    ) ) BenzodiazepineDischargeMedication\n    where BenzodiazepineDischargeMedication.status in { 'active', 'completed' }\n      and BenzodiazepineDischargeMedication.intent = 'order'"
                },
                {
                  "url" : "displaySequence",
                  "valueInteger" : 5
                }
              ],
              "url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
            },
            {
              "extension" : [
                {
                  "url" : "libraryName",
                  "valueString" : "SafeUseofOpioidsConcurrentPrescribingFHIR"
                },
                {
                  "url" : "name",
                  "valueString" : "Numerator"
                },
                {
                  "url" : "statement",
                  "valueString" : "define \"Numerator\":\n  /*Encounters of patients prescribed two or more opioids or an opioid and benzodiazepine at discharge.*/\n  \n  ( \"Inpatient Encounter with Age Greater than or Equal to 18\" InpatientEncounter\n      where ( Count(\"Opioid at Discharge\" Opioids\n            return distinct Opioids.medication\n        ) >= 2\n      )\n  )\n    union ( \"Inpatient Encounter with Age Greater than or Equal to 18\" InpatientEncounter\n        with \"Opioid at Discharge\" OpioidsDischarge\n          such that OpioidsDischarge.authoredOn during InpatientEncounter.period\n        with \"Benzodiazepine at Discharge\" BenzodiazepinesDischarge\n          such that BenzodiazepinesDischarge.authoredOn during day of InpatientEncounter.period\n    )"
                },
                {
                  "url" : "displaySequence",
                  "valueInteger" : 6
                }
              ],
              "url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
            },
            {
              "extension" : [
                {
                  "url" : "libraryName",
                  "valueString" : "SafeUseofOpioidsConcurrentPrescribingFHIR"
                },
                {
                  "url" : "name",
                  "valueString" : "Inpatient Encounters with an Opioid or Benzodiazepine at Discharge"
                },
                {
                  "url" : "statement",
                  "valueString" : "define \"Inpatient Encounters with an Opioid or Benzodiazepine at Discharge\":\n  \"Inpatient Encounter with Age Greater than or Equal to 18\" InpatientEncounter\n    with ( \"Opioid at Discharge\"\n      union \"Benzodiazepine at Discharge\" ) OpioidOrBenzodiazepineAtDischarge\n      such that OpioidOrBenzodiazepineAtDischarge.authoredOn during day of InpatientEncounter.period"
                },
                {
                  "url" : "displaySequence",
                  "valueInteger" : 7
                }
              ],
              "url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
            },
            {
              "extension" : [
                {
                  "url" : "libraryName",
                  "valueString" : "SafeUseofOpioidsConcurrentPrescribingFHIR"
                },
                {
                  "url" : "name",
                  "valueString" : "Initial Population"
                },
                {
                  "url" : "statement",
                  "valueString" : "define \"Initial Population\":\n  \"Inpatient Encounters with an Opioid or Benzodiazepine at Discharge\""
                },
                {
                  "url" : "displaySequence",
                  "valueInteger" : 8
                }
              ],
              "url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
            },
            {
              "extension" : [
                {
                  "url" : "libraryName",
                  "valueString" : "SafeUseofOpioidsConcurrentPrescribingFHIR"
                },
                {
                  "url" : "name",
                  "valueString" : "Denominator"
                },
                {
                  "url" : "statement",
                  "valueString" : "define \"Denominator\":\n  \"Initial Population\""
                },
                {
                  "url" : "displaySequence",
                  "valueInteger" : 9
                }
              ],
              "url" : "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
            },
            {
              "extension" : [
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                  "valueString" : "SupplementalDataElements"
                },
                {
                  "url" : "name",
                  "valueString" : "SDE Payer"
                },
                {
                  "url" : "statement",
                  "valueString" : "define \"SDE Payer\":\n  [Coverage: type in \"Payer Type\"] Payer\n    return {\n      code: Payer.type,\n      period: Payer.period\n    }"
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                {
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              ],
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                  "url" : "statement",
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                  "url" : "statement",
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                  "url" : "statement",
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          "parameter" : [
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                "code" : "endorser"
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            ]
          },
          "system" : "https://madie.cms.gov/measure/nqfId",
          "value" : "3316e",
          "assigner" : {
            "display" : "NQF"
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        },
        {
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          "type" : {
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                "code" : "publisher"
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          },
          "system" : "https://madie.cms.gov/measure/cmsId",
          "value" : "506FHIR",
          "assigner" : {
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      "version" : "0.1.000",
      "name" : "SafeUseofOpioidsConcurrentPrescribingFHIR",
      "title" : "Safe Use of Opioids - Concurrent PrescribingFHIR",
      "status" : "draft",
      "experimental" : false,
      "date" : "2023-08-17T18:49:02+00:00",
      "publisher" : "Centers for Medicare & Medicaid Services (CMS)",
      "contact" : [
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              "value" : "https://www.cms.gov/"
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      ],
      "description" : "Proportion of inpatient hospitalizations for patients 18 years of age and older prescribed, or continued on, two or more opioids or an opioid and benzodiazepine concurrently at discharge",
      "useContext" : [
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            "code" : "program"
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          "valueCodeableConcept" : {
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                "code" : "eh-cah",
                "display" : "EH/CAH"
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            ]
          }
        }
      ],
      "purpose" : "UNKNOWN",
      "usage" : "Clinician judgement, clinical appropriateness, or both may indicate concurrent prescribing of two unique opioids or an opioid and benzodiazepine is medically necessary, thus the measure is not expected to have a zero rate. \n\nInpatient hospitalizations with discharge medications of a new or continuing opioid or a new or continuing benzodiazepine prescription should be included in the initial population. \n\nInpatient hospitalizations with discharge medications of two or more new or continuing opioids or new or continuing opioid and benzodiazepine resulting in concurrent therapy at discharge should be included in the numerator. Each benzodiazepine and opioid included on the medication discharge list is considered a unique prescription.\n\nThe denominator population includes patients with inpatient hospitalizations and patients from Acute Hospital Care at Home programs, who are treated and billed as inpatients but receive care in their home.\n\nThis eCQM is an episode-based measure. An episode is defined as each inpatient hospitalization or encounter that ends during the measurement period.\n\nThis FHIR-based measure has been derived from the QDM-based measure: CMS506v6. \nPlease 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).",
      "copyright" : "Limited proprietary coding is contained in the Measure specifications for user convenience. Users of proprietary code sets should obtain all necessary licenses from the owners of the code sets. Mathematica disclaims all liability for use or accuracy of any third party codes contained in the specifications.\n\nCPT(R) contained in the measure specifications is copyright 2004-2022 American Medical Association. LOINC(R) 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 copyright 2022 World Health Organization. All Rights Reserved.",
      "approvalDate" : "2023-08-18",
      "lastReviewDate" : "2023-08-18",
      "effectivePeriod" : {
        "start" : "2024-01-01",
        "end" : "2024-12-31"
      },
      "author" : [
        {
          "name" : "Mathematica",
          "telecom" : [
            {
              "system" : "url",
              "value" : "https://www.mathematica.org/"
            }
          ]
        }
      ],
      "library" : [
        🔗 "http://ecqi.healthit.gov/ecqms/Library/SafeUseofOpioidsConcurrentPrescribingFHIR"
      ],
      "disclaimer" : "These performance measures are not clinical guidelines, do not establish a standard of medical care, and have not been tested for all potential applications.\n\nTHE MEASURES AND SPECIFICATION ARE PROVIDED AS IS WITHOUT WARRANTY OF ANY KIND.\n\nDue to technical limitations, registered trademarks are indicated by (R) or [R] and unregistered trademarks are indicated by (TM) or [TM].",
      "rationale" : "Unintentional opioid overdose fatalities have become a major public health concern in the United States (Rudd et al., 2016). Reducing the number of unintentional overdoses has become a priority for numerous federal organizations including, but not limited to, the Centers for Disease Control and Prevention (CDC), the Federal Interagency Workgroup for Opioid Adverse Drug Events, and the Substance Abuse and Mental Health Services Administration. \n\nConcurrent prescriptions of opioids or opioids and benzodiazepines places patients at a greater risk of unintentional overdose due to the increased risk of respiratory depression (Dowell, Haegerich, & Chou, 2016 and Dowell, Ragan, Jones, Baldwin, & Chou, 2022).  An analysis of national prescribing patterns shows that more than half of patients who received an opioid prescription in 2009 had filled another opioid prescription within the previous 30 days (National Institute on Drug Abuse, 2011). Studies of multiple claims and prescription databases have shown that between 5%-15% of patients receive concurrent opioid prescriptions and 5%-20% of patients receive concurrent opioid and benzodiazepine prescriptions across various settings (Liu et al., 2013; Mack et al., 2015, Park et al., 2015). Patients who have multiple opioid prescriptions have an increased risk for overdose (Jena et al., 2014). Rates of fatal overdose are ten times higher in patients who are co-dispensed opioid analgesics and benzodiazepines than opioids alone (Dasgupta et al., 2015). The number of opioid overdose deaths involving benzodiazepines increased 14% on average each year from 2006 to 2011, while the number of opioid analgesic overdose deaths not involving benzodiazepines did not change significantly (Jones & McAninch, 2015). Furthermore, concurrent use of benzodiazepines with opioids was prevalent in 31%-51% of fatal overdoses (Dowell, Haegerich, & Chou, 2016). One study found that eliminating concurrent use of opioids and benzodiazepines could reduce the risk of opioid overdose-related emergency department (ED) and inpatient visits by 15% and potentially could have prevented an estimated 2,630 deaths related to opioid painkiller overdoses in 2015 (Sun et al., 2017). \n\nA study on The Opioid Safety Initiative in the Veterans Health Administration (VHA), which includes an opioid and benzodiazepine concurrent prescribing measure that this measure is based on, was associated with a decrease of 20.67% overall and 0.86% patients per month (781 patients per month) receiving concurrent benzodiazepine with an opioid among all adult VHA patients who filled outpatient opioid prescriptions from October 2012 to September 2014 (Lin et al., 2017).\n\nAdopting a measure that calculates the proportion of patients with two or more opioids or opioids and benzodiazepines concurrently has the potential to reduce preventable mortality and reduce the costs associated with adverse events related to opioid use by (1) encouraging providers to identify patients with concurrent prescriptions of opioids or opioids and benzodiazepines and (2) discouraging providers from prescribing two or more opioids or opioids and benzodiazepines concurrently.",
      "clinicalRecommendationStatement" : "The CDC Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022 recommends that clinicians should:\n- “[Use strategies minimizing] opioid use…for both opioid-naïve and opioid-tolerant patients with acute pain when possible. If patients receiving long-term opioid therapy require additional medication for acute pain, nonopioid medications should be used when possible.”\n- ”Use particular caution when prescribing opioid pain medication and benzodiazepines concurrently.\"\n- “Review increased risks for respiratory depression when opioids are taken with benzodiazepines, other sedatives, alcohol, nonprescribed or illicit drugs (e.g., heroin), or other opioids (see Recommendations 8 and 11)”\n- “Closely monitor patients who are unable to taper and who continue on high-dose or otherwise high-risk opioid regimens (e.g., opioids prescribed concurrently with benzodiazepines) and should work with patients to mitigate overdose risk (e.g., by providing overdose education and naloxone) (see Recommendation 8).”\n- \"Discuss information from the PDMP with the patient and confirm that the patient is aware of any additional prescriptions.”\n- “Discuss safety concerns, including increased risk for respiratory depression and overdose, with patients found to be receiving overlapping prescription opioids from multiple clinicians who are not coordinating the patient’s care or patients who are receiving medications that increase risk when combined with opioids (e.g., benzodiazepines) (see Recommendation 11), and offer naloxone (see Recommendation 8).\n- \"Discuss safety concerns with other clinicians who are prescribing controlled substances for the patient. Ideally, clinicians should first discuss concerns with the patient and inform them that they plan to coordinate care with their other clinicians to improve the patient’s safety.” \n\nIn addition to the 2022 CDC Clinical Practice Guideline for Prescribing Opioids for Pain, opioid prescribing guidelines issued by various state agencies and professional societies for various settings agree with the recommendation to avoid concurrently prescribing opioids (American Academy of Emergency Medicine and Washington Agency Medical Directors’ Group (WAMDG)), and opioids and benzodiazepines (WAMDG, American Society of Interventional Pain Physicians, and New York City Department Of Health and Mental Hygiene) whenever possible as the combination of these medications may potentiate opioid-induced respiratory depression.",
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