eCQM QICore Content Implementation Guide
2023.0.0 - CI Build

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

## Measure: Primary Open-Angle Glaucoma (POAG): Optic Nerve EvaluationFHIR

Official URL: http://ecqi.healthit.gov/ecqms/Measure/POAGOpticNerveEvaluationFHIR | Version: 0.0.004
Draft as of 2023-10-27 | ​ Responsible: American Academy of Ophthalmology | Computable Name: POAGOpticNerveEvaluationFHIR
Other Identifiers: Short Name (use: usual, ), UUID:7b41a49e-61af-4a73-8dfd-a6a76e8e7c49 (use: official, ), UUID:dad4363e-52b2-4add-9740-fb79aaf65e74 (use: official, ), Endorser (use: official, ), Publisher (use: official, )
Copyright/Legal: Copyright 2023 American Academy of Ophthalmology. All Rights Reserved.

Percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma (POAG) who have an optic nerve head evaluation during one or more visits within 12 months

UNKNOWN

Title: | Primary Open-Angle Glaucoma (POAG): Optic Nerve EvaluationFHIR
Id: | POAGOpticNerveEvaluationFHIR
Download cql: | POAGOpticNerveEvaluationFHIR.cql
Version: | 0.0.004
Url: | Primary Open-Angle Glaucoma (POAG): Optic Nerve EvaluationFHIR
short-name identifier: | CMS143FHIR
version-independent identifier: | urn:uuid:7b41a49e-61af-4a73-8dfd-a6a76e8e7c49
version-specific identifier: | urn:uuid:dad4363e-52b2-4add-9740-fb79aaf65e74
endorser (NQF) identifier: | 0086e
publisher (CMS) identifier: | 143FHIR
Effective Period: | 2024-01-01 ..2024-12-31
Status: | draft
Date: | 2023-10-27 08:12:32+0000
Approval Date: | 2023-08-14
Last Review Date: | 2023-08-14
Name: | POAGOpticNerveEvaluationFHIR
Publisher: | American Academy of Ophthalmology
Author: | ​American Academy of Ophthalmology: www.aao.org, American Medical Association (AMA): https://www.ama-assn.org/
Description: | Percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma (POAG) who have an optic nerve head evaluation during one or more visits within 12 months
Purpose: | UNKNOWN
Copyright: | Copyright 2023 American Academy of Ophthalmology. All Rights Reserved.
Disclaimer: | The Measure is not a clinical guideline, does not establish a standard of medical care, and has not been tested for all potential applications. The Measure, while copyrighted, can be reproduced and distributed, without modification, for noncommercial purposes, e.g., use by health care providers in connection with their practices. Commercial use is defined as the sale, license, or distribution of the Measure for commercial gain, or incorporation of the Measure into a product or service that is sold, licensed or distributed for commercial gain. Commercial uses of the Measure require a license agreement between the user and the American Academy of Ophthalmology (Academy). Neither the Academy, its members, the American Medical Association (AMA), nor the former AMA-convened Physician Consortium for Performance Improvement(R) (AMA-PCPI), nor PCPI, nor their members shall be responsible for any use of the Measure. The PCPI’s and AMA’s significant past efforts and contributions to the development and updating of the Measures are acknowledged. The National Committee for Quality Assurance's significant past efforts and contributions to the development and updating of the Measure is acknowledged. THE MEASURE AND SPECIFICATIONS ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND. Limited proprietary coding is contained in the Measure specifications for convenience. A license agreement must be entered prior to a third party’s use of Current Procedural Terminology (CPT[R]) or other proprietary code set contained in the Measures. Any other use of CPT or other coding by the third party is strictly prohibited. The Academy, its members, the AMA, and former members of the PCPI disclaim all liability for use or accuracy of any CPT or other coding contained in the specifications. CPT(R) contained in the Measure specifications is copyright 2004-2022 American Medical Association. LOINC(R) is copyright 2004-2022 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2022 International Health Terminology Standards Development Organisation. ICD-10 is copyright 2022 World Health Organization. All Rights Reserved. Due to technical limitations, registered trademarks are indicated by (R) or [R].
Rationale: | Glaucoma is a group of diseases that damage the eye’s optic nerve and can result in vision loss and blindness. In 2011, 2.71 million persons in the U.S. had primary open-angle glaucoma (POAG) and in 2050, an estimated 7.32 million persons will have POAG (Vajaranant, Wu, Torres, & Varma, 2012). Furthermore, a study by Rein, Zhang, & Wirth (2006) estimated that the total financial burden of major visual disorders among U.S. residents aged 40 years or older was $35.4 billion in 2004: $16.2 billion in direct medical costs, $11.1 billion in other direct costs, and $8 billion in productivity losses. Of the direct medical costs, approximately $2.9 billion was attributable to glaucoma (Rein, Zhang, & Wirth, 2006). It is imperative that evidence-based care be delivered to all glaucoma patients. According to recent guidelines, optic nerve changes are one of the characteristics which reflect progression of glaucoma (the other characteristic is visual field). Examination of the optic nerve head (ONH) and retinal nerve fiber layer (RNFL) provides valuable structural information about optic nerve damage from glaucoma. Visible structural alterations of the ONH or RNFL may precede the onset of visual field defects. Careful study of the optic disc neural rim for small hemorrhages is important because these hemorrhages sometimes signal focal disc damage and visual field loss, and they may signify ongoing optic nerve damage in patients with glaucoma (Gedde et al., 2021). Despite evidence emphasizing the value of an optic nerve evaluation, there is a gap in documentation patterns of the optic nerve for both initial and follow-up care. This measure is intended to promote examination and documentation of the structure and function of the optic nerve, and to monitor and detect disease progression among patients diagnosed with POAG.
Clinical recommendation statement: | Ophthalmic Evaluation The ophthalmic evaluation specifically focuses on the following elements in the comprehensive adult medical eye evaluation: Visual acuity measurement Pupil examination Anterior segment examination IOP measurement Gonioscopy Optic nerve head (ONH) and retinal nerve fiber layer (RNFL) examination Fundus examination (Gedde et al., 2021) The optic nerve should be carefully examined for the signs of glaucoma damage, and its appearance should be serially documented (I+, moderate quality, strong recommendation) (Gedde et al., 2021).
Guidance (Usage): | Optic nerve head evaluation includes examination of the cup to disc ratio and identification of optic disc or retinal nerve abnormalities. Both of these components of the optic nerve head evaluation are examined using ophthalmoscopy. The measure, as written, does not specifically require documentation of laterality. Coding limitations in particular clinical terminologies do not currently allow for that level of specificity (ICD-10-CM includes laterality, but SNOMED-CT does not uniformly include this distinction). Therefore, at this time, it is not a requirement of this measure to indicate laterality of the diagnoses, findings or procedures. Available coding to capture the data elements specified in this measure has been provided. It is assumed that the eligible professional or eligible clinician will record laterality in the patient medical record, as quality care and clinical documentation should include laterality. This eCQM is a patient-based measure. Telehealth encounters are not eligible for this measure because the measure requires a clinical action that cannot be conducted via telehealth. This FHIR-based measure has been derived from the QDM-based measure: CMS143v12. Please refer to the HL7 QI-Core Implementation Guide (http://hl7.org/fhir/us/qicore/index.html) for more information on QI-Core and mapping recommendations from QDM to QI-Core 4.1.1 (http://hl7.org/fhir/us/qicore/qdm-to-qicore.html).
Population Criteria: |
6467cfd1be9def4e0b01b112
Initial Population: | All patients aged 18 years and older with a diagnosis of primary open-angle glaucoma
Denominator: | Equals Initial Population
Denominator Exclusion: | None
Numerator: | Patients who have an optic nerve head evaluation during one or more visits within 12 months
Numerator Exclusion: | None
Denominator Exception: | Documentation of medical reason(s) for not performing an optic nerve head evaluation
Supplemental Data Guidance : |
Supplemental Data Elements: | SDE Ethnicity SDE Payer SDE Race SDE Sex
Libraries: |
POAGOpticNerveEvaluationFHIR
Related Artifact Dependencies: | SupplementalDataElements version: 3.4.000 FHIRHelpers version: 4.3.000 QICoreCommon version: 1.5.000 `http://hl7.org/fhir/v3/AdministrativeGender` ActCode Condition Clinical Status Codes ConditionVerificationStatus Cup to Disc Ratio Office Visit Ophthalmological Services Outpatient Consultation Nursing Facility Visit Care Services in Long-Term Residential Facility Primary Open-Angle Glaucoma Optic Disc Exam for Structural Abnormalities Payer Medical Reason
Parameters: |
name | use | min | max | type
--- | --- | --- | --- | ---
Measurement Period | In | 0 | 1 | Period
SDE Sex | Out | 0 | 1 | Coding
Numerator | Out | 0 | 1 | boolean
Denominator | Out | 0 | 1 | boolean
SDE Payer | Out | 0 | * | Resource
Initial Population | Out | 0 | 1 | boolean
SDE Ethnicity | Out | 0 | 1 | Resource
SDE Race | Out | 0 | 1 | Resource
Denominator Exceptions | Out | 0 | 1 | boolean
DataRequirements: |
Type | Elements | Valueset Name | Valueset
--- | --- | --- | ---
Patient(QICorePatient) | ethnicity race |  |
Encounter(QICoreEncounter) | type period class status status.value | Office Visit | Office Visit
Encounter(QICoreEncounter) | type period class status status.value | Ophthalmological Services | Ophthalmological Services
Encounter(QICoreEncounter) | type period class status status.value | Outpatient Consultation | Outpatient Consultation
Encounter(QICoreEncounter) | type period class status status.value | Nursing Facility Visit | Nursing Facility Visit
Encounter(QICoreEncounter) | type period class status status.value | Care Services in Long-Term Residential Facility | Care Services in Long-Term Residential Facility
Condition(QICoreCondition) | code verificationStatus | Primary Open-Angle Glaucoma | Primary Open-Angle Glaucoma
Observation(QICoreObservation) | code effective value status status.value | Cup to Disc Ratio | Cup to Disc Ratio
Observation(QICoreObservation) | code effective value status status.value | Optic Disc Exam for Structural Abnormalities | Optic Disc Exam for Structural Abnormalities
Coverage(QICoreCoverage) | type period | Payer Type | Payer
Observation(QICoreObservationNotDone) | code issued issued.value status status.value extension | Cup to Disc Ratio | Cup to Disc Ratio
Observation(QICoreObservationNotDone) | code issued issued.value status status.value extension | Cup to Disc Ratio | Cup to Disc Ratio
Observation(QICoreObservationNotDone) | code issued issued.value status status.value extension | Optic Disc Exam for Structural Abnormalities | Optic Disc Exam for Structural Abnormalities
Observation(QICoreObservationNotDone) | code issued issued.value status status.value extension | Optic Disc Exam for Structural Abnormalities | Optic Disc Exam for Structural Abnormalities
Direct Reference Codes: |
display | code | system
--- | --- | ---
Male | M | http://hl7.org/fhir/v3/AdministrativeGender
Female | F | http://hl7.org/fhir/v3/AdministrativeGender
virtual | VR | http://terminology.hl7.org/CodeSystem/v3-ActCode
Ambulatory | AMB | http://terminology.hl7.org/CodeSystem/v3-ActCode
| active | http://terminology.hl7.org/CodeSystem/condition-clinical
| recurrence | http://terminology.hl7.org/CodeSystem/condition-clinical
| relapse | http://terminology.hl7.org/CodeSystem/condition-clinical
| unconfirmed | http://terminology.hl7.org/CodeSystem/condition-ver-status
| refuted | http://terminology.hl7.org/CodeSystem/condition-ver-status
| entered-in-error | http://terminology.hl7.org/CodeSystem/condition-ver-status
Logic Definitions: |
Group | Scoring | Population Criteria | Expression
--- | --- | --- | ---
6467cfd1be9def4e0b01b112 | Group scoring: proportion
|  | Initial Population |
    define "Initial Population":
      AgeInYearsAt(date from start of "Measurement Period") >= 18
        and exists "Primary Open Angle Glaucoma Encounter"
|  | Denominator |
    define "Denominator":
      "Initial Population"
|  | Denominator Exclusion | None
|  | Numerator |
    define "Numerator":
      exists "Cup to Disc Ratio Performed with Result"
        and exists "Optic Disc Exam Performed with Result"
|  | Numerator Exclusion | None
|  | Denominator Exception |
    define "Denominator Exceptions":
      exists "Medical Reason for Not Performing Cup to Disc Ratio"
        or exists "Medical Reason for Not Performing Optic Disc Exam"

Library Name | Name
--- | ---
SupplementalDataElements | SDE Sex
    define "SDE Sex":
      case
          when Patient.gender = 'male' then "M"
          when Patient.gender = 'female' then "F"
          else null
        end
Library Name | Name
POAGOpticNerveEvaluationFHIR | SDE Sex
    define "SDE Sex":
      SDE."SDE Sex"
Library Name | Name
POAGOpticNerveEvaluationFHIR | Qualifying Encounter During Measurement Period
    define "Qualifying Encounter During Measurement Period":
      ( ["Encounter": "Office Visit"]
        union ["Encounter": "Ophthalmological Services"]
        union ["Encounter": "Outpatient Consultation"]
        union ["Encounter": "Nursing Facility Visit"]
        union ["Encounter": "Care Services in Long-Term Residential Facility"] ) QualifyingEncounter
        where QualifyingEncounter.period during "Measurement Period"
          and QualifyingEncounter.class !~ "virtual"
          and QualifyingEncounter.class ~ "AMB"
          and QualifyingEncounter.status = 'finished'
Library Name | Name
POAGOpticNerveEvaluationFHIR | Primary Open Angle Glaucoma Encounter
    define "Primary Open Angle Glaucoma Encounter":
      "Qualifying Encounter During Measurement Period" ValidQualifyingEncounter
        with ["Condition": "Primary Open-Angle Glaucoma"] PrimaryOpenAngleGlaucoma
          such that PrimaryOpenAngleGlaucoma.prevalenceInterval ( ) overlaps ValidQualifyingEncounter.period
            and PrimaryOpenAngleGlaucoma.isActive ( )
            and not ( PrimaryOpenAngleGlaucoma.verificationStatus ~ QICoreCommon."unconfirmed"
                or PrimaryOpenAngleGlaucoma.verificationStatus ~ QICoreCommon."refuted"
                or PrimaryOpenAngleGlaucoma.verificationStatus ~ QICoreCommon."entered-in-error"
            )
Library Name | Name
POAGOpticNerveEvaluationFHIR | Cup to Disc Ratio Performed with Result
    define "Cup to Disc Ratio Performed with Result":
      ["Observation": "Cup to Disc Ratio"] CupToDiscExamPerformed
        with "Primary Open Angle Glaucoma Encounter" EncounterWithPOAG
          such that CupToDiscExamPerformed.effective.toInterval ( ) during EncounterWithPOAG.period
        where CupToDiscExamPerformed.value is not null
          and CupToDiscExamPerformed.status in { 'final', 'amended', 'corrected' }
Library Name | Name
POAGOpticNerveEvaluationFHIR | Optic Disc Exam Performed with Result
    define "Optic Disc Exam Performed with Result":
      ["Observation": "Optic Disc Exam for Structural Abnormalities"] OpticDiscExamPerformed
        with "Primary Open Angle Glaucoma Encounter" EncounterWithPOAG
          such that OpticDiscExamPerformed.effective.toInterval ( ) during EncounterWithPOAG.period
        where OpticDiscExamPerformed.value is not null
          and OpticDiscExamPerformed.status in { 'final', 'amended', 'corrected' }
Library Name | Name
POAGOpticNerveEvaluationFHIR | Numerator
    define "Numerator":
      exists "Cup to Disc Ratio Performed with Result"
        and exists "Optic Disc Exam Performed with Result"
Library Name | Name
POAGOpticNerveEvaluationFHIR | Initial Population
    define "Initial Population":
      AgeInYearsAt(date from start of "Measurement Period") >= 18
        and exists "Primary Open Angle Glaucoma Encounter"
Library Name | Name
POAGOpticNerveEvaluationFHIR | Denominator
    define "Denominator":
      "Initial Population"
Library Name | Name
SupplementalDataElements | SDE Payer
    define "SDE Payer":
      [Coverage: type in "Payer Type"] Payer
        return {
          code: Payer.type,
          period: Payer.period
        }
Library Name | Name
POAGOpticNerveEvaluationFHIR | SDE Payer
    define "SDE Payer":
      SDE."SDE Payer"
Library Name | Name
SupplementalDataElements | SDE Ethnicity
    define "SDE Ethnicity":
      Patient.ethnicity E
        return Tuple {
          codes: { E.ombCategory } union E.detailed,
          display: E.text
        }
Library Name | Name
POAGOpticNerveEvaluationFHIR | SDE Ethnicity
    define "SDE Ethnicity":
      SDE."SDE Ethnicity"
Library Name | Name
SupplementalDataElements | SDE Race
    define "SDE Race":
      Patient.race R
        return Tuple {
          codes: R.ombCategory union R.detailed,
          display: R.text
        }
Library Name | Name
POAGOpticNerveEvaluationFHIR | SDE Race
    define "SDE Race":
      SDE."SDE Race"
Library Name | Name
POAGOpticNerveEvaluationFHIR | Medical Reason for Not Performing Cup to Disc Ratio
    define "Medical Reason for Not Performing Cup to Disc Ratio":
      ["ObservationNotDone": "Cup to Disc Ratio"] CupToDiscExamNotPerformed
        with "Primary Open Angle Glaucoma Encounter" EncounterWithPOAG
          such that CupToDiscExamNotPerformed.issued.toInterval ( ) during EncounterWithPOAG.period
        where CupToDiscExamNotPerformed.status = 'cancelled'
          and CupToDiscExamNotPerformed.notDoneReason in "Medical Reason"
Library Name | Name
POAGOpticNerveEvaluationFHIR | Medical Reason for Not Performing Optic Disc Exam
    define "Medical Reason for Not Performing Optic Disc Exam":
      ["ObservationNotDone": "Optic Disc Exam for Structural Abnormalities"] OpticDiscExamNotPerformed
        with "Primary Open Angle Glaucoma Encounter" EncounterWithPOAG
          such that OpticDiscExamNotPerformed.issued.toInterval ( ) during EncounterWithPOAG.period
        where OpticDiscExamNotPerformed.status = 'cancelled'
          and OpticDiscExamNotPerformed.notDoneReason in "Medical Reason"
Library Name | Name
POAGOpticNerveEvaluationFHIR | Denominator Exceptions
    define "Denominator Exceptions":
      exists "Medical Reason for Not Performing Cup to Disc Ratio"
        or exists "Medical Reason for Not Performing Optic Disc Exam"
Library Name | Name
QICoreCommon | prevalenceInterval
    /*
    @description: Returns an interval representing the normalized prevalence period of a given Condition.
    @comment: Uses the ToInterval and ToAbatementInterval functions to determine the widest potential interval from
    onset to abatement as specified in the given Condition. If the condition is active, the resulting interval will have
    a closed ending boundary. If the condition is not active, the resulting interval will have an open ending boundary.
    */
    define fluent function prevalenceInterval(condition Condition):
    if condition.clinicalStatus ~ "active"
      or condition.clinicalStatus ~ "recurrence"
      or condition.clinicalStatus ~ "relapse" then
      Interval[start of condition.onset.toInterval(), end of condition.abatementInterval()]
    else
      Interval[start of condition.onset.toInterval(), end of condition.abatementInterval())
Library Name | Name
QICoreCommon | isActive
    /* Candidates for FHIRCommon */

    /*
    @description: Returns true if the given condition has a clinical status of active, recurrence, or relapse
    */
    define fluent function isActive(condition Condition):
      condition.clinicalStatus ~ "active"
        or condition.clinicalStatus ~ "recurrence"
        or condition.clinicalStatus ~ "relapse"
Library Name | Name
QICoreCommon | toInterval
    /*
    @description: Normalizes a value that is a choice of timing-valued types to an equivalent interval
    @comment: Normalizes a choice type of DateTime, Quanitty, Interval<DateTime>, or Interval<Quantity> types
    to an equivalent interval. This selection of choice types is a superset of the majority of choice types that are used as possible
    representations for timing-valued elements in QICore, allowing this function to be used across any resource.
    The input can be provided as a DateTime, Quantity, Interval<DateTime> or Interval<Quantity>.
    The intent of this function is to provide a clear and concise mechanism to treat single
    elements that have multiple possible representations as intervals so that logic doesn't have to account
    for the variability. More complex calculations (such as medication request period or dispense period
    calculation) need specific guidance and consideration. That guidance may make use of this function, but
    the focus of this function is on single element calculations where the semantics are unambiguous.
    If the input is a DateTime, the result a DateTime Interval beginning and ending on that DateTime.
    If the input is a Quantity, the quantity is expected to be a calendar-duration interpreted as an Age,
    and the result is a DateTime Interval beginning on the Date the patient turned that age and ending immediately before one year later.
    If the input is a DateTime Interval, the result is the input.
    If the input is a Quantity Interval, the quantities are expected to be calendar-durations interpreted as an Age, and the result
    is a DateTime Interval beginning on the date the patient turned the age given as the start of the quantity interval, and ending
    immediately before one year later than the date the patient turned the age given as the end of the quantity interval.
    Any other input will reslt in a null DateTime Interval
    */
    define fluent function toInterval(choice Choice<DateTime, Quantity, Interval<DateTime>, Interval<Quantity>>):
      case
    	  when choice is DateTime then
        	Interval[choice as DateTime, choice as DateTime]
    		when choice is Interval<DateTime> then
      		choice as Interval<DateTime>
    		when choice is Quantity then
    		  Interval[Patient.birthDate + (choice as Quantity),
    			  Patient.birthDate + (choice as Quantity) + 1 year)
    		when choice is Interval<Quantity> then
    		  Interval[Patient.birthDate + (choice.low as Quantity),
    			  Patient.birthDate + (choice.high as Quantity) + 1 year)
    		else
    			null as Interval<DateTime>
    	end
Library Name | Name
FHIRHelpers | ToString
    define function ToString(value uri): value.value
Library Name | Name
FHIRHelpers | ToCode
    /*
    @description: Converts the given FHIR [Coding](https://hl7.org/fhir/datatypes.html#Coding) value to a CQL Code.
    */
    define function ToCode(coding FHIR.Coding):
        if coding is null then
            null
        else
            System.Code {
              code: coding.code.value,
              system: coding.system.value,
              version: coding.version.value,
              display: coding.display.value
            }