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

## : Appropriate Treatment for ST-Segment Elevation Myocardial Infarction (STEMI) Patients in the Emergency Department (ED)FHIR - XML Representation

Draft as of 2023-10-27

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    <Measure xmlns="http://hl7.org/fhir">
      <id value="AppropriateTreatmentforSTEMIFHIR"/>
      <meta>
        <profile
                 value="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/computable-measure-cqfm"/>
        <profile
                 value="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/publishable-measure-cqfm"/>
        <profile
                 value="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/executable-measure-cqfm"/>
      </meta>
      <text>
        <status value="extensions"/>
        <div xmlns="http://www.w3.org/1999/xhtml">
        <table class="grid dict">

                <tr>
                    <th scope="row"><b>Title: </b></th>
                    <td style="padding-left: 4px;">Appropriate Treatment for ST-Segment Elevation Myocardial Infarction (STEMI) Patients in the Emergency Department (ED)FHIR</td>
                </tr>

                <tr>
                    <th scope="row"><b>Id: </b></th>
                    <td style="padding-left: 4px;">AppropriateTreatmentforSTEMIFHIR</td>
                </tr>

                    <tr>
                        <th scope="row"><b>Download cql: </b></th>
                        <td style="padding-left: 4px;"><a href="Library-AppropriateTreatmentforSTEMIFHIR.cql">AppropriateTreatmentforSTEMIFHIR.cql</a></td>
                    </tr>

                <tr>
                    <th scope="row"><b>Version: </b></th>
                    <td style="padding-left: 4px;">0.0.008</td>
                </tr>

                <tr>
                    <th scope="row"><b>Url: </b></th>
                    <td style="padding-left: 4px;"><a href="Measure-AppropriateTreatmentforSTEMIFHIR.html">Appropriate Treatment for ST-Segment Elevation Myocardial Infarction (STEMI) Patients in the Emergency Department (ED)FHIR</a></td>
                </tr>

                <tr>
                    <th scope="row">
                        <b>

                                    short-name identifier:

                        </b>
                    </th>

                    <td style="padding-left: 4px;">

                            <p style="margin-bottom: 5px;">
                                <span>CMS996FHIR</span>
                            </p>

                    </td>
                </tr>

                <tr>
                    <th scope="row">
                        <b>

                                    version-independent identifier:

                        </b>
                    </th>

                    <td style="padding-left: 4px;">

                            <p style="margin-bottom: 5px;">
                                <span>urn:uuid:a48685e0-4926-4ae8-9eb3-d8e8839b1704</span>
                            </p>

                    </td>
                </tr>

                <tr>
                    <th scope="row">
                        <b>

                                    version-specific identifier:

                        </b>
                    </th>

                    <td style="padding-left: 4px;">

                            <p style="margin-bottom: 5px;">
                                <span>urn:uuid:2c92808482113ece01821188a1500069</span>
                            </p>

                    </td>
                </tr>

                <tr>
                    <th scope="row">
                        <b>

                                    endorser (NQF) identifier:

                        </b>
                    </th>

                    <td style="padding-left: 4px;">

                            <p style="margin-bottom: 5px;">
                                <span>3613e</span>
                            </p>

                    </td>
                </tr>

                <tr>
                    <th scope="row">
                        <b>

                                    publisher (CMS) identifier:

                        </b>
                    </th>

                    <td style="padding-left: 4px;">

                            <p style="margin-bottom: 5px;">
                                <span>996FHIR</span>
                            </p>

                    </td>
                </tr>

                <tr>
                    <th scope="row"><b>Effective Period: </b></th>
                    <td style="padding-left: 4px;">2024-01-01
                        ..2024-12-31</td>
                </tr>

                <tr>
                    <th scope="row"><b>Status: </b></th>
                    <td style="padding-left: 4px;">draft</td>
                </tr>

                <tr>
                    <th scope="row"><b>Date: </b></th>
                    <td style="padding-left: 4px;">2023-10-27 08:12:31+0000</td>
                </tr>

                <tr>
                    <th scope="row"><b>Approval Date: </b></th>
                    <td style="padding-left: 4px;">2023-08-17</td>
                </tr>

                <tr>
                    <th scope="row"><b>Last Review Date: </b></th>
                    <td style="padding-left: 4px;">2023-08-17</td>
                </tr>

                <tr>
                    <th scope="row"><b>Name: </b></th>
                    <td style="padding-left: 4px;">AppropriateTreatmentforSTEMIFHIR</td>
                </tr>

                <tr>
                    <th scope="row"><b>Publisher: </b></th>
                    <td style="padding-left: 4px;">Centers for Medicare &amp; Medicaid Services (CMS)</td>
                </tr>

            <tr>
                <th scope="row"><b>Author: </b></th>
                <td style="padding-left: 4px;">Yale New Haven Health Service Corporation/ Center for Outcomes Research and Evaluation: <a href="https://medicine.yale.edu/core/">https://medicine.yale.edu/core/</a>, The Lewin Group: <a href="https://www.lewin.com/">https://www.lewin.com/</a></td>
            </tr>

                <tr>
                    <th scope="row"><b>Description: </b></th>
                    <td style="padding-left: 4px;"><div><p>Percentage of emergency department (ED) encounters for patients 18 years and older with a diagnosis of ST-segment elevation myocardial infarction (STEMI) that received appropriate treatment, defined as fibrinolytic therapy within 30 minutes of ED arrival, percutaneous coronary intervention (PCI) within 90 minutes of ED arrival, or transfer within 45 minutes of ED arrival</p>
    </div></td>
                </tr>

                <tr>
                    <th scope="row"><b>Purpose: </b></th>
                    <td style="padding-left: 4px;"><div><p>UNKNOWN</p>
    </div></td>
                </tr>

                <tr>
                    <th scope="row"><b>Copyright: </b></th>
                    <td style="padding-left: 4px;"><div><p>Limited proprietary coding is contained in these specifications for user convenience. Users of proprietary code sets should obtain all necessary licenses from the owners of the code sets.</p>
    <p>This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2022 International Health Terminology Standards Development Organisation. All rights reserved.</p>
    <p>LOINC(R) copyright 2004-2022 Regenstrief Institute, Inc.</p>
    <p>CPT(R) contained in the Measure specifications is copyright 2004-2022 American Medical Association.</p>
    <p>ICD-10 is copyright 2022 World Health Organization. All Rights Reserved.</p>
    </div></td>
                </tr>

                <tr>
                    <th scope="row"><b>Disclaimer: </b></th>
                    <td style="padding-left: 4px;"><div><p>These performance specifications are not clinical guidelines and do not establish a standard of medical care, and have not been tested for all potential applications.</p>
    <p>THE MEASURES AND SPECIFICATIONS ARE PROVIDED &quot;AS IS&quot; WITHOUT WARRANTY OF ANY KIND.</p>
    <p>Due to technical limitations, registered trademarks are indicated by (R) or [R] and unregistered trademarks are indicated by (TM) or [TM].</p>
    </div></td>
                </tr>

            <tr>
                <th scope="row"><b>Rationale: </b></th>
                <td style="padding-left: 4px;"><div><p>Studies have shown that delays in the treatment of acute myocardial infarction (AMI) leads to increased risk of in-hospital mortality and morbidity, with nearly two lives per 1,000 patients lost per hour of delay in treatment (Sohlpour &amp; Yusuf, 2014; Fibrinolytic Therapy Trialists’ Collaborative Group, 1994). For patients receiving fibrinolytic therapy, the American Heart Association (AHA) estimates that 65 lives will be saved per 1,000 patients if treatment is administered within the first hour of symptom onset, and 131 lives will be saved per 1,000 patients treated if fibrinolytic therapy is delivered within the first three hours (O’Connor et al., 2010).
    The total ischemic time—that is, the time from onset of STEMI symptoms to the initiation of some form of reperfusion therapy—is the principal determinant of health outcomes for patients with an AMI, so timely care is essential to minimize disease morbidity and mortality. Primary PCI is the preferred treatment approach, with guidelines recommending initiation of PCI within 120 minutes from first medical contact (O’Gara et al., 2013). In situations where it is unlikely or impossible for a patient to receive primary PCI within the 120-minute timeframe, fibrinolytic therapy may be used for reperfusion and should be rapidly administered to reduce mortality and minimize morbidity; guidelines recommend that fibrinolytic therapy administration occur within 30 minutes of hospital arrival; this may also require rapid transfer for PCI (O’Gara et al., 2013).
    Implementation of an eCQM addressing appropriateness and effectiveness of care for STEMI patients in the ED has the potential to improve the delivery of care furthering alignment with current clinical practice guidelines, while reducing adverse health outcomes such as mortality, bleeding events, and reinfarction. Use of the proposed eCQM could also reduce burden on facilities currently measured using the chart-abstracted Fibrinolytic Therapy Received within 30 Minutes of ED Arrival (OP-2) measure and broaden the population for which performance scores could be publicly reported.</p>
    </div></td>
            </tr>

            <tr>
                <th scope="row"><b>Clinical recommendation statement: </b></th>
                <td style="padding-left: 4px;"><div><p>Primary PCI in STEMI:
    The 2013 ACCF/AHA clinical practice guideline for the management of STEMI recommends that:</p>
    <ul>
    <li>&quot;Primary PCI should be performed in patients with STEMI and ischemic symptoms of less than 12 hours’ duration.&quot;</li>
    <li>&quot;Primary PCI should be performed in patients with STEMI and ischemic symptoms of less than 12 hours’ duration who have contraindications to fibrinolytic therapy, irrespective of the time delay from first medical contact.&quot;</li>
    </ul>
    <p>Fibrinolytic Therapy when there is an Anticipated Delay to Performing Primary PCI within 120 Minutes of First Medical Contact:
    The 2013 ACCF/AHA clinical practice guideline for the management of STEMI recommends that:</p>
    <ul>
    <li>&quot;In the absence of contraindications, fibrinolytic therapy should be given to patients with STEMI and onset of ischemic symptoms within the previous 12 hours when it is anticipated that primary PCI cannot be performed within 120 minutes of first medical contact.”</li>
    </ul>
    <p>Transfer to a PCI-Capable Hospital after Fibrinolytic Therapy:
    The 2013 ACCF/AHA clinical practice guideline for the management of STEMI recommends that:</p>
    <ul>
    <li>Immediate transfer to a PCI-capable hospital for coronary angiography is recommended for suitable patients with STEMI who develop cardiogenic shock or acute severe HF, irrespective of the time delay from MI onset.</li>
    <li>Urgent transfer to a PCI-capable hospital for coronary angiography is reasonable for patients with STEMI who demonstrate evidence of failed reperfusion or reocclusion after fibrinolytic therapy.</li>
    <li>Transfer to a PCI-capable hospital for coronary angiography is reasonable for patients with STEMI who have received fibrinolytic therapy even when hemodynamically stable and with clinical evidence of successful reperfusion. Angiography can be performed as soon as logistically feasible at the receiving hospital, and ideally within 24 hours, but should not be performed within the first 2 to 3 hours after administration of fibrinolytic therapy.</li>
    </ul>
    </div></td>
            </tr>

                <tr>
                    <th scope="row"><b>Guidance (Usage): </b></th>
                    <td style="padding-left: 4px;">This eCQM is an episode-based measure and should be reported for each instance of an ED encounter during the measurement period for patients with a STEMI.

    This FHIR-based measure has been derived from the QDM-based measure: CMS996v4.

    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).</td>
                </tr>

                    <tr>
                        <th scope="row"><b>Population Criteria: </b></th>
                        <td style="padding-left: 4px;">

                                <table class="grid-dict">

                                        <tr>
                                            <th><b>6384fdb64ba3d47c885c02a6</b></th>
                                        </tr>

                                        <tr>
                                            <td>Initial Population:</td>

                                                <td>All emergency department encounters for patients 18 years and older with a diagnosis of ST-segment elevation myocardial infarction (STEMI)</td>

                                        </tr>

                                        <tr>
                                            <td>Denominator:</td>

                                                <td>Equals Initial Population</td>

                                        </tr>

                                        <tr>
                                            <td>Denominator Exclusion:</td>

                                                <td>Patients with the following conditions are excluded from measure denominator:
     • Expired in the ED
     • Bleeding or bleeding diathesis (excluding menses)
     • Intracranial or intraspinal surgery
     • Ischemic stroke
     • Known malignant intracranial neoplasm (primary or metastatic)
     • Known structural cerebral vascular lesion (e.g., AVM)
     • Significant facial and/or closed head trauma
     • Suspected aortic dissection
     •  Peptic ulcer
     •  Cardiopulmonary arrest, including: cardiac arrest, CPR, defibrillation, respiratory arrest, or ventricular fibrillation (V-fib), ventricular tachycardia (VT), or pulseless electrical activity (PEA); or, traumatic or prolonged (&gt;10 minutes) CPR
     • Allergic reaction to alteplase, streptokinase, anistreplase, tenecteplase, or reteplase
     • Intubation, including endotracheal intubation, mechanical ventilation, nasotracheal intubation, or orotracheal intubation
     • Mechanical circulatory assist device placement, including: aortic balloon pump, biventricular assist device, intra-aortic balloon, intra-aortic balloon counterpulsation, intra-aortic counterpulsation balloon pump, left ventricular device, percutaneous ventricular assist device, or ventricular assist device
     • Oral anticoagulant therapy
     • Advanced dementia
     • Pregnancy
     • Internal bleeding
     • Major surgery
     • Severe neurologic impairment (e.g., based on Glasgow coma scale or as indicated by the patient receiving therapeutic hypothermia in the ED)</td>

                                        </tr>

                                        <tr>
                                            <td>Numerator:</td>

                                                <td>Emergency department encounters with a diagnosis of STEMI:
     - where time from ED arrival to fibrinolysis is 30 minutes or fewer;
    OR
    - where PCI is performed within 90 minutes of arrival for non-transfer patients;
    OR
    - where the patient is transferred within 45 minutes of ED arrival.</td>

                                        </tr>

                                        <tr>
                                            <td>Numerator Exclusion:</td>

                                                <td>None</td>

                                        </tr>

                                        <tr>
                                            <td>Denominator Exception:</td>

                                                <td>None</td>

                                        </tr>

                                </table>

                        </td>
                    </tr>

                <tr>
                    <th scope="row">
                        <b> Supplemental Data Guidance
                            : </b></th>
                    <td style="padding-left: 4px;">  </td>
                </tr>

                <tr>
                    <th scope="row"><b> Supplemental Data Elements: </b></th>
                    <td style="padding-left: 4px;">

                                    SDE Ethnicity

                                    SDE Payer

                                    SDE Race

                                    SDE Sex

                    </td>
                </tr>

                <tr>
                    <th scope="row"><b>Libraries: </b></th>
                    <td style="padding-left: 4px;">
                        <table class="grid-dict">

                                <tr>
                                    <td><a href="Library-AppropriateTreatmentforSTEMIFHIR.html">AppropriateTreatmentforSTEMIFHIR</a></td>
                                </tr>

                        </table>
                    </td>
                </tr>

                    <tr>
                        <th scope="row"><b>Related Artifact Dependencies: </b></th>
                        <td style="padding-left: 4px;">

                                <li><a href="Library-SupplementalDataElements.html">SupplementalDataElements</a> version: 3.4.000</li>

                                <li><a href="Library-FHIRHelpers.html">FHIRHelpers</a> version: 4.3.000</li>

                                <li><a href="Library-CQMCommon.html">CQMCommon</a> version: 1.4.000</li>

                                <li><a href="Library-QICoreCommon.html">QICoreCommon</a> version: 1.5.000</li>

                                <li><code>http://hl7.org/fhir/v3/AdministrativeGender</code></li>

                                <li><a href="http://terminology.hl7.org/7.1.0/CodeSystem-v3-ActCode.html">ActCode</a></li>

                                <li><a href="http://terminology.hl7.org/7.1.0/CodeSystem-condition-clinical.html">Condition Clinical Status Codes</a></li>

                                <li><a href="http://terminology.hl7.org/7.1.0/CodeSystem-allergyintolerance-clinical.html">AllergyIntolerance Clinical Status Codes</a></li>

                                <li><a href="https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.464.1003.101.12.1085/expansion">ED</a></li>

                                <li><a href="https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.3157.4017/expansion">STEMI</a></li>

                                <li><a href="https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.3157.4020/expansion">Fibrinolytic Therapy</a></li>

                                <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>

                                <li><a href="https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.3157.2000.5/expansion">Percutaneous Coronary Intervention</a></li>

                                <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>

                                <li><a href="https://vsac.nlm.nih.gov/valueset/2.16.840.1.114222.4.11.3591/expansion">Payer</a></li>

                                <li><a href="https://tx.fhir.org/r4/ValueSet/2.16.840.1.113762.1.4.1170.4-20211007">Thrombolytic Therapy Allergen</a></li>

                                <li><a href="https://tx.fhir.org/r4/ValueSet/2.16.840.1.113762.1.4.1170.6-20250211">Thrombolytics Adverse Event</a></li>

                                <li><a href="https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.3157.4036/expansion">Active Bleeding or Bleeding Diathesis (Excluding Menses)</a></li>

                                <li><a href="https://tx.fhir.org/r4/ValueSet/2.16.840.1.113762.1.4.1170.3-20211005">Malignant Intracranial Neoplasm Group</a></li>

                                <li><a href="https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.3157.4025/expansion">Cerebral Vascular Lesion</a></li>

                                <li><a href="https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.3157.4043/expansion">Dementia</a></li>

                                <li><a href="https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.3157.4055/expansion">Pregnancy</a></li>

                                <li><a href="https://tx.fhir.org/r4/ValueSet/2.16.840.1.113762.1.4.1170.5-20250211">Allergy to Thrombolytics</a></li>

                                <li><a href="https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.3157.4045/expansion">Anticoagulant Medications, Oral</a></li>

                                <li><a href="https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.3157.4028/expansion">Aortic Dissection</a></li>

                                <li><a href="https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.464.1003.114.12.1012/expansion">Neurologic impairment</a></li>

                                <li><a href="https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.3157.4048/expansion">Cardiopulmonary Arrest</a></li>

                                <li><a href="https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.3157.4056/expansion">Major Surgical Procedure</a></li>

                                <li><a href="https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1045.69/expansion">Endotracheal Intubation</a></li>

                                <li><a href="https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.3157.4052/expansion">Mechanical Circulatory Assist Device</a></li>

                                <li><a href="https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.464.1003.104.12.1024/expansion">Ischemic Stroke</a></li>

                                <li><a href="https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.3157.4026/expansion">Closed Head Trauma</a></li>

                                <li><a href="https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.3157.4031/expansion">Active Peptic Ulcer</a></li>

                                <li><a href="https://tx.fhir.org/r4/ValueSet/2.16.840.1.113762.1.4.1170.2-20220218">Intracranial or Intraspinal Surgery</a></li>

                                <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>

                        </td>
                    </tr>
                    <tr>
                        <th scope="row"><b>Parameters:</b></th>
                        <td style="padding-left: 4px;">
                            <table class="grid-dict">
                                <tr>
                                    <th><b>name</b></th>
                                    <th><b>use</b></th>
                                    <th><b>min</b></th>
                                    <th><b>max</b></th>
                                    <th><b>type</b></th>
                                </tr>

                                    <tr>
                                        <td>Measurement Period</td>
                                        <td>In</td>
                                        <td>0</td>
                                        <td>1</td>
                                        <td>Period</td>
                                    </tr>

                                    <tr>
                                        <td>SDE Sex</td>
                                        <td>Out</td>
                                        <td>0</td>
                                        <td>1</td>
                                        <td>Coding</td>
                                    </tr>

                                    <tr>
                                        <td>Numerator</td>
                                        <td>Out</td>
                                        <td>0</td>
                                        <td>*</td>
                                        <td>Resource</td>
                                    </tr>

                                    <tr>
                                        <td>Denominator</td>
                                        <td>Out</td>
                                        <td>0</td>
                                        <td>*</td>
                                        <td>Resource</td>
                                    </tr>

                                    <tr>
                                        <td>SDE Payer</td>
                                        <td>Out</td>
                                        <td>0</td>
                                        <td>*</td>
                                        <td>Resource</td>
                                    </tr>

                                    <tr>
                                        <td>Initial Population</td>
                                        <td>Out</td>
                                        <td>0</td>
                                        <td>*</td>
                                        <td>Resource</td>
                                    </tr>

                                    <tr>
                                        <td>SDE Ethnicity</td>
                                        <td>Out</td>
                                        <td>0</td>
                                        <td>1</td>
                                        <td>Resource</td>
                                    </tr>

                                    <tr>
                                        <td>Denominator Exclusions</td>
                                        <td>Out</td>
                                        <td>0</td>
                                        <td>*</td>
                                        <td>Resource</td>
                                    </tr>

                                    <tr>
                                        <td>SDE Race</td>
                                        <td>Out</td>
                                        <td>0</td>
                                        <td>1</td>
                                        <td>Resource</td>
                                    </tr>

                            </table>
                        </td>
                    </tr>

                    <tr>
                        <th scope="row"><b>DataRequirements:</b></th>
                        <td style="padding-left: 4px;">
                            <table class="grid-dict">
                                <tr>
                                    <th><b>Type</b></th>
                                    <th><b>Elements</b></th>
                                    <th><b>Valueset Name</b></th>
                                    <th><b>Valueset</b></th>
                                </tr>

                                    <tr>
                                        <td>Patient(<a href="http://hl7.org/fhir/us/qicore/STU4.1.1/StructureDefinition-qicore-patient.html">QICorePatient</a>)</td>
                                        <td>

                                                ethnicity

                                                race

                                        </td>
                                        <td>

                                        </td>
                                        <td/>
                                    </tr>

                                    <tr>
                                        <td>Condition(<a href="http://hl7.org/fhir/us/qicore/STU4.1.1/StructureDefinition-qicore-condition.html">QICoreCondition</a>)</td>
                                        <td>

                                                id

                                                id.value

                                                code

                                        </td>
                                        <td>

                                        </td>
                                        <td/>
                                    </tr>

                                    <tr>
                                        <td>Condition(<a href="http://hl7.org/fhir/us/qicore/STU4.1.1/StructureDefinition-qicore-condition.html">QICoreCondition</a>)</td>
                                        <td>

                                                code

                                                clinicalStatus

                                        </td>
                                        <td>

                                                     STEMI

                                        </td>
                                        <td><a href="https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.3157.4017/expansion">STEMI</a></td>
                                    </tr>

                                    <tr>
                                        <td>Condition(<a href="http://hl7.org/fhir/us/qicore/STU4.1.1/StructureDefinition-qicore-condition.html">QICoreCondition</a>)</td>
                                        <td>

                                                code

                                        </td>
                                        <td>

                                                     Active Bleeding Excluding Menses or Bleeding Diathesis

                                        </td>
                                        <td><a href="https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.3157.4036/expansion">Active Bleeding or Bleeding Diathesis (Excluding Menses)</a></td>
                                    </tr>

                                    <tr>
                                        <td>Condition(<a href="http://hl7.org/fhir/us/qicore/STU4.1.1/StructureDefinition-qicore-condition.html">QICoreCondition</a>)</td>
                                        <td>

                                                code

                                        </td>
                                        <td>

                                                     Malignant Intracranial Neoplasm Group

                                        </td>
                                        <td><a href="https://tx.fhir.org/r4/ValueSet/2.16.840.1.113762.1.4.1170.3-20211005">Malignant Intracranial Neoplasm Group</a></td>
                                    </tr>

                                    <tr>
                                        <td>Condition(<a href="http://hl7.org/fhir/us/qicore/STU4.1.1/StructureDefinition-qicore-condition.html">QICoreCondition</a>)</td>
                                        <td>

                                                code

                                        </td>
                                        <td>

                                                     Cerebral Vascular Lesion

                                        </td>
                                        <td><a href="https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.3157.4025/expansion">Cerebral Vascular Lesion</a></td>
                                    </tr>

                                    <tr>
                                        <td>Condition(<a href="http://hl7.org/fhir/us/qicore/STU4.1.1/StructureDefinition-qicore-condition.html">QICoreCondition</a>)</td>
                                        <td>

                                                code

                                        </td>
                                        <td>

                                                     Dementia

                                        </td>
                                        <td><a href="https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.3157.4043/expansion">Dementia</a></td>
                                    </tr>

                                    <tr>
                                        <td>Condition(<a href="http://hl7.org/fhir/us/qicore/STU4.1.1/StructureDefinition-qicore-condition.html">QICoreCondition</a>)</td>
                                        <td>

                                                code

                                        </td>
                                        <td>

                                                     Pregnancy

                                        </td>
                                        <td><a href="https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.3157.4055/expansion">Pregnancy</a></td>
                                    </tr>

                                    <tr>
                                        <td>Condition(<a href="http://hl7.org/fhir/us/qicore/STU4.1.1/StructureDefinition-qicore-condition.html">QICoreCondition</a>)</td>
                                        <td>

                                                code

                                        </td>
                                        <td>

                                                     Allergy to thrombolytics

                                        </td>
                                        <td><a href="https://tx.fhir.org/r4/ValueSet/2.16.840.1.113762.1.4.1170.5-20250211">Allergy to Thrombolytics</a></td>
                                    </tr>

                                    <tr>
                                        <td>Condition(<a href="http://hl7.org/fhir/us/qicore/STU4.1.1/StructureDefinition-qicore-condition.html">QICoreCondition</a>)</td>
                                        <td>

                                                code

                                        </td>
                                        <td>

                                                     Aortic Dissection and Rupture

                                        </td>
                                        <td><a href="https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.3157.4028/expansion">Aortic Dissection</a></td>
                                    </tr>

                                    <tr>
                                        <td>Condition(<a href="http://hl7.org/fhir/us/qicore/STU4.1.1/StructureDefinition-qicore-condition.html">QICoreCondition</a>)</td>
                                        <td>

                                                code

                                        </td>
                                        <td>

                                                     Neurologic impairment

                                        </td>
                                        <td><a href="https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.464.1003.114.12.1012/expansion">Neurologic impairment</a></td>
                                    </tr>

                                    <tr>
                                        <td>Condition(<a href="http://hl7.org/fhir/us/qicore/STU4.1.1/StructureDefinition-qicore-condition.html">QICoreCondition</a>)</td>
                                        <td>

                                                code

                                        </td>
                                        <td>

                                                     Ischemic Stroke

                                        </td>
                                        <td><a href="https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.464.1003.104.12.1024/expansion">Ischemic Stroke</a></td>
                                    </tr>

                                    <tr>
                                        <td>Condition(<a href="http://hl7.org/fhir/us/qicore/STU4.1.1/StructureDefinition-qicore-condition.html">QICoreCondition</a>)</td>
                                        <td>

                                                code

                                        </td>
                                        <td>

                                                     Closed Head and Facial Trauma

                                        </td>
                                        <td><a href="https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.3157.4026/expansion">Closed Head Trauma</a></td>
                                    </tr>

                                    <tr>
                                        <td>Condition(<a href="http://hl7.org/fhir/us/qicore/STU4.1.1/StructureDefinition-qicore-condition.html">QICoreCondition</a>)</td>
                                        <td>

                                                code

                                        </td>
                                        <td>

                                                     Active Peptic Ulcer

                                        </td>
                                        <td><a href="https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.3157.4031/expansion">Active Peptic Ulcer</a></td>
                                    </tr>

                                    <tr>
                                        <td>Condition(<a href="http://hl7.org/fhir/us/qicore/STU4.1.1/StructureDefinition-qicore-condition.html">QICoreCondition</a>)</td>
                                        <td>

                                                code

                                        </td>
                                        <td>

                                                     Cardiopulmonary Arrest

                                        </td>
                                        <td><a href="https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.3157.4048/expansion">Cardiopulmonary Arrest</a></td>
                                    </tr>

                                    <tr>
                                        <td>Encounter(<a href="http://hl7.org/fhir/us/qicore/STU4.1.1/StructureDefinition-qicore-encounter.html">QICoreEncounter</a>)</td>
                                        <td>

                                                type

                                                status

                                                status.value

                                                class

                                                period

                                                condition

                                                condition.reference

                                                condition.reference.value

                                                location

                                                location.type

                                                hospitalization

                                                hospitalization.dischargeDisposition

                                        </td>
                                        <td>

                                                     ED

                                        </td>
                                        <td><a href="https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.464.1003.101.12.1085/expansion">ED</a></td>
                                    </tr>

                                    <tr>
                                        <td>Encounter(<a href="http://hl7.org/fhir/us/qicore/STU4.1.1/StructureDefinition-qicore-encounter.html">QICoreEncounter</a>)</td>
                                        <td>

                                                type

                                                status

                                                status.value

                                                class

                                                reasonCode

                                                period

                                                condition

                                                condition.reference

                                                condition.reference.value

                                                location

                                                location.type

                                                hospitalization

                                                hospitalization.dischargeDisposition

                                        </td>
                                        <td>

                                                     ED

                                        </td>
                                        <td><a href="https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.464.1003.101.12.1085/expansion">ED</a></td>
                                    </tr>

                                    <tr>
                                        <td>Location(<a href="http://hl7.org/fhir/us/qicore/STU4.1.1/StructureDefinition-qicore-location.html">QICoreLocation</a>)</td>
                                        <td>

                                                id

                                                id.value

                                        </td>
                                        <td>

                                        </td>
                                        <td/>
                                    </tr>

                                    <tr>
                                        <td>MedicationAdministration(<a href="http://hl7.org/fhir/us/qicore/STU4.1.1/StructureDefinition-qicore-medicationadministration.html">QICoreMedicationAdministration</a>)</td>
                                        <td>

                                                medication

                                                status

                                                status.value

                                                effective

                                        </td>
                                        <td>

                                                     Fibrinolytic Therapy

                                        </td>
                                        <td><a href="https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.3157.4020/expansion">Fibrinolytic Therapy</a></td>
                                    </tr>

                                    <tr>
                                        <td>Procedure(<a href="http://hl7.org/fhir/us/qicore/STU4.1.1/StructureDefinition-qicore-procedure.html">QICoreProcedure</a>)</td>
                                        <td>

                                                code

                                                performed

                                                status

                                                status.value

                                        </td>
                                        <td>

                                                     Percutaneous Coronary Intervention

                                        </td>
                                        <td><a href="https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.3157.2000.5/expansion">Percutaneous Coronary Intervention</a></td>
                                    </tr>

                                    <tr>
                                        <td>Procedure(<a href="http://hl7.org/fhir/us/qicore/STU4.1.1/StructureDefinition-qicore-procedure.html">QICoreProcedure</a>)</td>
                                        <td>

                                                code

                                                performed

                                                status

                                                status.value

                                        </td>
                                        <td>

                                                     Major Surgical Procedure

                                        </td>
                                        <td><a href="https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.3157.4056/expansion">Major Surgical Procedure</a></td>
                                    </tr>

                                    <tr>
                                        <td>Procedure(<a href="http://hl7.org/fhir/us/qicore/STU4.1.1/StructureDefinition-qicore-procedure.html">QICoreProcedure</a>)</td>
                                        <td>

                                                code

                                                performed

                                                status

                                                status.value

                                        </td>
                                        <td>

                                                     Endotracheal Intubation

                                        </td>
                                        <td><a href="https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1045.69/expansion">Endotracheal Intubation</a></td>
                                    </tr>

                                    <tr>
                                        <td>Procedure(<a href="http://hl7.org/fhir/us/qicore/STU4.1.1/StructureDefinition-qicore-procedure.html">QICoreProcedure</a>)</td>
                                        <td>

                                                code

                                                performed

                                                status

                                                status.value

                                        </td>
                                        <td>

                                                     Insertion or Replacement of Mechanical Circulatory Assist Device

                                        </td>
                                        <td><a href="https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.3157.4052/expansion">Mechanical Circulatory Assist Device</a></td>
                                    </tr>

                                    <tr>
                                        <td>Procedure(<a href="http://hl7.org/fhir/us/qicore/STU4.1.1/StructureDefinition-qicore-procedure.html">QICoreProcedure</a>)</td>
                                        <td>

                                                code

                                                performed

                                                status

                                                status.value

                                        </td>
                                        <td>

                                                     Intracranial or Intraspinal surgery

                                        </td>
                                        <td><a href="https://tx.fhir.org/r4/ValueSet/2.16.840.1.113762.1.4.1170.2-20220218">Intracranial or Intraspinal Surgery</a></td>
                                    </tr>

                                    <tr>
                                        <td>Coverage(<a href="http://hl7.org/fhir/us/qicore/STU4.1.1/StructureDefinition-qicore-coverage.html">QICoreCoverage</a>)</td>
                                        <td>

                                                type

                                                period

                                        </td>
                                        <td>

                                                     Payer Type

                                        </td>
                                        <td><a href="https://vsac.nlm.nih.gov/valueset/2.16.840.1.114222.4.11.3591/expansion">Payer</a></td>
                                    </tr>

                                    <tr>
                                        <td>AllergyIntolerance(<a href="http://hl7.org/fhir/us/qicore/STU4.1.1/StructureDefinition-qicore-allergyintolerance.html">QICoreAllergyIntolerance</a>)</td>
                                        <td>

                                                code

                                                clinicalStatus

                                                onset

                                        </td>
                                        <td>

                                                     Thrombolytic medications

                                        </td>
                                        <td><a href="https://tx.fhir.org/r4/ValueSet/2.16.840.1.113762.1.4.1170.4-20211007">Thrombolytic Therapy Allergen</a></td>
                                    </tr>

                                    <tr>
                                        <td>AdverseEvent(<a href="http://hl7.org/fhir/us/qicore/STU4.1.1/StructureDefinition-qicore-adverseevent.html">QICoreAdverseEvent</a>)</td>
                                        <td>

                                                event

                                                recordedDate

                                                recordedDate.value

                                                actuality

                                                actuality.value

                                        </td>
                                        <td>

                                                     Adverse reaction to thrombolytics

                                        </td>
                                        <td><a href="https://tx.fhir.org/r4/ValueSet/2.16.840.1.113762.1.4.1170.6-20250211">Thrombolytics Adverse Event</a></td>
                                    </tr>

                                    <tr>
                                        <td>Medication(<a href="http://hl7.org/fhir/us/qicore/STU4.1.1/StructureDefinition-qicore-medication.html">QICoreMedication</a>)</td>
                                        <td>

                                                id

                                        </td>
                                        <td>

                                        </td>
                                        <td/>
                                    </tr>

                                    <tr>
                                        <td>MedicationRequest(<a href="http://hl7.org/fhir/us/qicore/STU4.1.1/StructureDefinition-qicore-medicationrequest.html">QICoreMedicationRequest</a>)</td>
                                        <td>

                                                medication.reference

                                                status

                                                status.value

                                                intent

                                                intent.value

                                                authoredOn

                                                authoredOn.value

                                        </td>
                                        <td>

                                        </td>
                                        <td/>
                                    </tr>

                                    <tr>
                                        <td>MedicationRequest(<a href="http://hl7.org/fhir/us/qicore/STU4.1.1/StructureDefinition-qicore-medicationrequest.html">QICoreMedicationRequest</a>)</td>
                                        <td>

                                                medication

                                                status

                                                status.value

                                                intent

                                                intent.value

                                                authoredOn

                                                authoredOn.value

                                        </td>
                                        <td>

                                                     Oral Anticoagulant Medications

                                        </td>
                                        <td><a href="https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.3157.4045/expansion">Anticoagulant Medications, Oral</a></td>
                                    </tr>

                            </table>
                        </td>
                    </tr>

                        <tr>
                            <th scope="row"><b>Direct Reference Codes:</b></th>
                            <td style="padding-left: 4px;">
                                <table class="grid-dict">
                                    <tr>
                                        <th><b>display</b></th>
                                        <th><b>code</b></th>
                                        <th><b>system</b></th>
                                    </tr>

                                        <tr>
                                            <td>Male</td>
                                            <td>M</td>
                                            <td><a href="http://hl7.org/fhir/v3/AdministrativeGender">http://hl7.org/fhir/v3/AdministrativeGender</a></td>
                                        </tr>

                                        <tr>
                                            <td>Female</td>
                                            <td>F</td>
                                            <td><a href="http://hl7.org/fhir/v3/AdministrativeGender">http://hl7.org/fhir/v3/AdministrativeGender</a></td>
                                        </tr>

                                        <tr>
                                            <td>emergency</td>
                                            <td>EMER</td>
                                            <td><a href="http://terminology.hl7.org/7.1.0/CodeSystem-v3-ActCode.html">http://terminology.hl7.org/CodeSystem/v3-ActCode</a></td>
                                        </tr>

                                        <tr>
                                            <td/>
                                            <td>active</td>
                                            <td><a href="http://terminology.hl7.org/7.1.0/CodeSystem-condition-clinical.html">http://terminology.hl7.org/CodeSystem/condition-clinical</a></td>
                                        </tr>

                                        <tr>
                                            <td/>
                                            <td>active</td>
                                            <td><a href="http://terminology.hl7.org/7.1.0/CodeSystem-allergyintolerance-clinical.html">http://terminology.hl7.org/CodeSystem/allergyintolerance-clinical</a></td>
                                        </tr>

                                </table>
                            </td>
                        </tr>

                    <tr>
                        <th scope="row"><b>Logic Definitions:</b></th>
                        <td style="padding-left: 4px;">

                            <table class="grid-dict">
                                <tr>
                                    <th><b>Group</b></th>
                                    <th><b>Scoring</b></th>
                                    <th><b>Population Criteria</b></th>
                                    <th><b>Expression</b></th>
                                </tr>
                                <tr>

                                    <td> 6384fdb64ba3d47c885c02a6 </td>
                                    <td>

                                            <b>Group scoring:</b>

                                                <span>  proportion </span>

                                    </td>

                                    <tr>
                                        <td/>
                                        <td/>
                                        <td>Initial Population</td>
                                        <td>

                                                <pre><code class="language-cql">/***Population Criteria***/

    define &quot;Initial Population&quot;:
      &quot;ED Encounter with STEMI Diagnosis&quot; EDwithSTEMI
        where AgeInYearsAt(date from start of(EDwithSTEMI.period)) &gt;= 18</code></pre>

                                        </td>
                                    </tr>

                                    <tr>
                                        <td/>
                                        <td/>
                                        <td>Denominator</td>
                                        <td>

                                                <pre><code class="language-cql">define &quot;Denominator&quot;:
      &quot;Initial Population&quot;</code></pre>

                                        </td>
                                    </tr>

                                    <tr>
                                        <td/>
                                        <td/>
                                        <td>Denominator Exclusion</td>
                                        <td>

                                                <pre><code class="language-cql">define &quot;Denominator Exclusions&quot;:
      &quot;Allergy or Intolerance to Thrombolytic Medications Overlaps ED Encounter&quot;
        union &quot;Adverse Effect to Thrombolytic Medications Before End of ED Encounter&quot;
        union &quot;Active Exclusion Diagnosis at Start of ED Encounter&quot;
        union &quot;Active Oral Anticoagulant Medication at the Start of ED Encounter&quot;
        union &quot;Exclusion Diagnosis During ED Encounter or Within 24 Hours of ED Encounter Start&quot;
        union &quot;Major Surgical Procedure 21 Days or Less Before Start of or Starts During ED Encounter&quot;
        union &quot;Intubation or Mechanical Circulatory Assist Procedure During ED Encounter or Within 24 Hours of ED Encounter Start&quot;
        union &quot;Active Exclusion Diagnosis Within 90 Days Before or At the Start of ED Encounter&quot;
        union &quot;Intracranial or Intraspinal Procedure 90 Days or Less Before Start of ED Encounter&quot;
        union &quot;ED Encounter with Discharge Disposition as Patient Expired&quot;</code></pre>

                                        </td>
                                    </tr>

                                    <tr>
                                        <td/>
                                        <td/>
                                        <td>Numerator</td>
                                        <td>

                                                <pre><code class="language-cql">define &quot;Numerator&quot;:
      &quot;Fibrinolytic Therapy within 30 Minutes of Arrival&quot;
        union &quot;PCI within 90 Minutes of Arrival&quot;
        union &quot;ED Departure with Transfer to Acute Care Facility Within 45 Minutes of Arrival&quot;</code></pre>

                                        </td>
                                    </tr>

                                    <tr>
                                        <td/>
                                        <td/>
                                        <td>Numerator Exclusion</td>
                                        <td>

                                                None

                                        </td>
                                    </tr>

                                    <tr>
                                        <td/>
                                        <td/>
                                        <td>Denominator Exception</td>
                                        <td>

                                                None

                                        </td>
                                    </tr>

                                </tr>
                            </table>

                    <table class="grid-dict">

                            <tr>
                                <th><b>Library Name</b></th>
                                <th><b>Name</b></th>
                            </tr>
                            <tr>

                                    <td>SupplementalDataElements</td>

                                    <td>SDE Sex</td>

                            </tr>
                            <tr>

                                    <td/>
                                    <td>
                                        <pre class="highlight language-cql"><code class="language-cql">define &quot;SDE Sex&quot;:
      case
          when Patient.gender = 'male' then &quot;M&quot;
          when Patient.gender = 'female' then &quot;F&quot;
          else null
        end</code></pre>
                                    </td>

                            </tr>

                            <tr>
                                <th><b>Library Name</b></th>
                                <th><b>Name</b></th>
                            </tr>
                            <tr>

                                    <td>AppropriateTreatmentforSTEMIFHIR</td>

                                    <td>SDE Sex</td>

                            </tr>
                            <tr>

                                    <td/>
                                    <td>
                                        <pre class="highlight language-cql"><code class="language-cql">define &quot;SDE Sex&quot;:
      SDE.&quot;SDE Sex&quot;</code></pre>
                                    </td>

                            </tr>

                            <tr>
                                <th><b>Library Name</b></th>
                                <th><b>Name</b></th>
                            </tr>
                            <tr>

                                    <td>AppropriateTreatmentforSTEMIFHIR</td>

                                    <td>ED Encounter with Encounter Diagnosis of STEMI</td>

                            </tr>
                            <tr>

                                    <td/>
                                    <td>
                                        <pre class="highlight language-cql"><code class="language-cql">define &quot;ED Encounter with Encounter Diagnosis of STEMI&quot;:
      [&quot;Encounter&quot;: &quot;ED&quot;] EDEncounter
        where EDEncounter.status = 'finished'
          and EDEncounter.class ~ &quot;EMER&quot;
          and ( EDEncounter.reasonCode in &quot;STEMI&quot;
              or exists ( ( EDEncounter.encounterDiagnosis ( ) ) EncDiagnosis
                  where EncDiagnosis.code in &quot;STEMI&quot;
              )
          )
          and EDEncounter.period during &quot;Measurement Period&quot;</code></pre>
                                    </td>

                            </tr>

                            <tr>
                                <th><b>Library Name</b></th>
                                <th><b>Name</b></th>
                            </tr>
                            <tr>

                                    <td>AppropriateTreatmentforSTEMIFHIR</td>

                                    <td>ED Encounter with Diagnosis of STEMI</td>

                            </tr>
                            <tr>

                                    <td/>
                                    <td>
                                        <pre class="highlight language-cql"><code class="language-cql">define &quot;ED Encounter with Diagnosis of STEMI&quot;:
      [&quot;Encounter&quot;: &quot;ED&quot;] EDEncounter
        with [&quot;Condition&quot;: &quot;STEMI&quot;] DxSTEMI
          such that DxSTEMI.clinicalStatus ~ QICoreCommon.&quot;active&quot;
            and EDEncounter.status = 'finished'
            and EDEncounter.class ~ &quot;EMER&quot;
            and DxSTEMI.prevalenceInterval ( ) starts during EDEncounter.period
            and EDEncounter.period during day of &quot;Measurement Period&quot;</code></pre>
                                    </td>

                            </tr>

                            <tr>
                                <th><b>Library Name</b></th>
                                <th><b>Name</b></th>
                            </tr>
                            <tr>

                                    <td>AppropriateTreatmentforSTEMIFHIR</td>

                                    <td>ED Encounter with STEMI Diagnosis</td>

                            </tr>
                            <tr>

                                    <td/>
                                    <td>
                                        <pre class="highlight language-cql"><code class="language-cql">define &quot;ED Encounter with STEMI Diagnosis&quot;:
      &quot;ED Encounter with Encounter Diagnosis of STEMI&quot;
        union &quot;ED Encounter with Diagnosis of STEMI&quot;</code></pre>
                                    </td>

                            </tr>

                            <tr>
                                <th><b>Library Name</b></th>
                                <th><b>Name</b></th>
                            </tr>
                            <tr>

                                    <td>AppropriateTreatmentforSTEMIFHIR</td>

                                    <td>Fibrinolytic Therapy within 30 Minutes of Arrival</td>

                            </tr>
                            <tr>

                                    <td/>
                                    <td>
                                        <pre class="highlight language-cql"><code class="language-cql">/*Did not include a status of active as any diagnosis that resolves during the ED visit would not be counted*/

    define &quot;Fibrinolytic Therapy within 30 Minutes of Arrival&quot;:
      &quot;ED Encounter with STEMI Diagnosis&quot; EDwithSTEMI
        with [&quot;MedicationAdministration&quot;: &quot;Fibrinolytic Therapy&quot;] Fibrinolytic
          such that Fibrinolytic.status = 'completed'
            and start of ( Fibrinolytic.effective.toInterval ( ) ) 30 minutes or less after EDwithSTEMI.currentemergencyDepartmentArrivalTime ( )</code></pre>
                                    </td>

                            </tr>

                            <tr>
                                <th><b>Library Name</b></th>
                                <th><b>Name</b></th>
                            </tr>
                            <tr>

                                    <td>AppropriateTreatmentforSTEMIFHIR</td>

                                    <td>PCI within 90 Minutes of Arrival</td>

                            </tr>
                            <tr>

                                    <td/>
                                    <td>
                                        <pre class="highlight language-cql"><code class="language-cql">define &quot;PCI within 90 Minutes of Arrival&quot;:
      &quot;ED Encounter with STEMI Diagnosis&quot; EDwithSTEMI
        with [&quot;Procedure&quot;: &quot;Percutaneous Coronary Intervention&quot;] PCI
          such that PCI.performed.toInterval ( ) starts 90 minutes or less after EDwithSTEMI.currentemergencyDepartmentArrivalTime ( )
            and PCI.status = 'completed'</code></pre>
                                    </td>

                            </tr>

                            <tr>
                                <th><b>Library Name</b></th>
                                <th><b>Name</b></th>
                            </tr>
                            <tr>

                                    <td>AppropriateTreatmentforSTEMIFHIR</td>

                                    <td>ED Departure with Transfer to Acute Care Facility Within 45 Minutes of Arrival</td>

                            </tr>
                            <tr>

                                    <td/>
                                    <td>
                                        <pre class="highlight language-cql"><code class="language-cql">define &quot;ED Departure with Transfer to Acute Care Facility Within 45 Minutes of Arrival&quot;:
      &quot;ED Encounter with STEMI Diagnosis&quot; EDwithSTEMI
        where ( EDwithSTEMI.period ) ends 45 minutes or less after start of ( EDwithSTEMI.period )
          and EDwithSTEMI.hospitalization.dischargeDisposition in &quot;Discharge To Acute Care Facility&quot;</code></pre>
                                    </td>

                            </tr>

                            <tr>
                                <th><b>Library Name</b></th>
                                <th><b>Name</b></th>
                            </tr>
                            <tr>

                                    <td>AppropriateTreatmentforSTEMIFHIR</td>

                                    <td>Numerator</td>

                            </tr>
                            <tr>

                                    <td/>
                                    <td>
                                        <pre class="highlight language-cql"><code class="language-cql">define &quot;Numerator&quot;:
      &quot;Fibrinolytic Therapy within 30 Minutes of Arrival&quot;
        union &quot;PCI within 90 Minutes of Arrival&quot;
        union &quot;ED Departure with Transfer to Acute Care Facility Within 45 Minutes of Arrival&quot;</code></pre>
                                    </td>

                            </tr>

                            <tr>
                                <th><b>Library Name</b></th>
                                <th><b>Name</b></th>
                            </tr>
                            <tr>

                                    <td>AppropriateTreatmentforSTEMIFHIR</td>

                                    <td>Initial Population</td>

                            </tr>
                            <tr>

                                    <td/>
                                    <td>
                                        <pre class="highlight language-cql"><code class="language-cql">/***Population Criteria***/

    define &quot;Initial Population&quot;:
      &quot;ED Encounter with STEMI Diagnosis&quot; EDwithSTEMI
        where AgeInYearsAt(date from start of(EDwithSTEMI.period)) &gt;= 18</code></pre>
                                    </td>

                            </tr>

                            <tr>
                                <th><b>Library Name</b></th>
                                <th><b>Name</b></th>
                            </tr>
                            <tr>

                                    <td>AppropriateTreatmentforSTEMIFHIR</td>

                                    <td>Denominator</td>

                            </tr>
                            <tr>

                                    <td/>
                                    <td>
                                        <pre class="highlight language-cql"><code class="language-cql">define &quot;Denominator&quot;:
      &quot;Initial Population&quot;</code></pre>
                                    </td>

                            </tr>

                            <tr>
                                <th><b>Library Name</b></th>
                                <th><b>Name</b></th>
                            </tr>
                            <tr>

                                    <td>SupplementalDataElements</td>

                                    <td>SDE Payer</td>

                            </tr>
                            <tr>

                                    <td/>
                                    <td>
                                        <pre class="highlight language-cql"><code class="language-cql">define &quot;SDE Payer&quot;:
      [Coverage: type in &quot;Payer Type&quot;] Payer
        return {
          code: Payer.type,
          period: Payer.period
        }</code></pre>
                                    </td>

                            </tr>

                            <tr>
                                <th><b>Library Name</b></th>
                                <th><b>Name</b></th>
                            </tr>
                            <tr>

                                    <td>AppropriateTreatmentforSTEMIFHIR</td>

                                    <td>SDE Payer</td>

                            </tr>
                            <tr>

                                    <td/>
                                    <td>
                                        <pre class="highlight language-cql"><code class="language-cql">define &quot;SDE Payer&quot;:
      SDE.&quot;SDE Payer&quot;</code></pre>
                                    </td>

                            </tr>

                            <tr>
                                <th><b>Library Name</b></th>
                                <th><b>Name</b></th>
                            </tr>
                            <tr>

                                    <td>SupplementalDataElements</td>

                                    <td>SDE Ethnicity</td>

                            </tr>
                            <tr>

                                    <td/>
                                    <td>
                                        <pre class="highlight language-cql"><code class="language-cql">define &quot;SDE Ethnicity&quot;:
      Patient.ethnicity E
        return Tuple {
          codes: { E.ombCategory } union E.detailed,
          display: E.text
        }</code></pre>
                                    </td>

                            </tr>

                            <tr>
                                <th><b>Library Name</b></th>
                                <th><b>Name</b></th>
                            </tr>
                            <tr>

                                    <td>AppropriateTreatmentforSTEMIFHIR</td>

                                    <td>SDE Ethnicity</td>

                            </tr>
                            <tr>

                                    <td/>
                                    <td>
                                        <pre class="highlight language-cql"><code class="language-cql">define &quot;SDE Ethnicity&quot;:
      SDE.&quot;SDE Ethnicity&quot;</code></pre>
                                    </td>

                            </tr>

                            <tr>
                                <th><b>Library Name</b></th>
                                <th><b>Name</b></th>
                            </tr>
                            <tr>

                                    <td>AppropriateTreatmentforSTEMIFHIR</td>

                                    <td>Allergy or Intolerance to Thrombolytic Medications Overlaps ED Encounter</td>

                            </tr>
                            <tr>

                                    <td/>
                                    <td>
                                        <pre class="highlight language-cql"><code class="language-cql">define &quot;Allergy or Intolerance to Thrombolytic Medications Overlaps ED Encounter&quot;:
      &quot;ED Encounter with STEMI Diagnosis&quot; EDwSTEMI
        with [&quot;AllergyIntolerance&quot;: &quot;Thrombolytic medications&quot;] ThrombolyticAllergy
          such that ThrombolyticAllergy.clinicalStatus ~ QICoreCommon.&quot;allergy-active&quot;
            and ThrombolyticAllergy.onset.toInterval ( ) overlaps ( EDwSTEMI.period )</code></pre>
                                    </td>

                            </tr>

                            <tr>
                                <th><b>Library Name</b></th>
                                <th><b>Name</b></th>
                            </tr>
                            <tr>

                                    <td>AppropriateTreatmentforSTEMIFHIR</td>

                                    <td>Adverse Effect to Thrombolytic Medications Before End of ED Encounter</td>

                            </tr>
                            <tr>

                                    <td/>
                                    <td>
                                        <pre class="highlight language-cql"><code class="language-cql">/*this definition differs from QDM re: timing - cannot use overlaps for a single point in time*/

    /*define &quot;Adverse Effect to Thrombolytic Medications Before End of ED Encounter&quot;:
    &quot;ED Encounter with STEMI Diagnosis&quot; EDwSTEMI
        with [AdverseEvent: event in &quot;Thrombolytic medications&quot;] ThrombolyticAdverseEvent
        such that ThrombolyticAdverseEvent.category in &quot;Adverse reaction to thrombolytics&quot;
        and ThrombolyticAdverseEvent.recordedDate before end of ( EDwSTEMI.period )
            and ThrombolyticAdverseEvent.actuality = 'actual'*/
    /*KS Note - not sure we need category in the logic - it is must support, but not sure this brings value to the measure logic*/

    define &quot;Adverse Effect to Thrombolytic Medications Before End of ED Encounter&quot;:
      &quot;ED Encounter with STEMI Diagnosis&quot; EDwSTEMI
        with [AdverseEvent: event in &quot;Adverse reaction to thrombolytics&quot;] ThrombolyticAdverseEvent
          such that ThrombolyticAdverseEvent.recordedDate before end of ( EDwSTEMI.period )
            and ThrombolyticAdverseEvent.actuality = 'actual'</code></pre>
                                    </td>

                            </tr>

                            <tr>
                                <th><b>Library Name</b></th>
                                <th><b>Name</b></th>
                            </tr>
                            <tr>

                                    <td>AppropriateTreatmentforSTEMIFHIR</td>

                                    <td>Active Exclusion Diagnosis at Start of ED Encounter</td>

                            </tr>
                            <tr>

                                    <td/>
                                    <td>
                                        <pre class="highlight language-cql"><code class="language-cql">/***Definitions***/

    define &quot;Active Exclusion Diagnosis at Start of ED Encounter&quot;:
      &quot;ED Encounter with STEMI Diagnosis&quot; EDwithSTEMI
        with ( [&quot;Condition&quot;: &quot;Active Bleeding Excluding Menses or Bleeding Diathesis&quot;]
          union [&quot;Condition&quot;: &quot;Malignant Intracranial Neoplasm Group&quot;]
          union [&quot;Condition&quot;: &quot;Cerebral Vascular Lesion&quot;]
          union [&quot;Condition&quot;: &quot;Dementia&quot;]
          union [&quot;Condition&quot;: &quot;Pregnancy&quot;]
          union [&quot;Condition&quot;: &quot;Allergy to thrombolytics&quot;] ) ActiveExclusionDx
          such that /*ActiveExclusionDx.isActive ()
            and */
          ActiveExclusionDx.prevalenceInterval ( ) overlaps before ( EDwithSTEMI.period )</code></pre>
                                    </td>

                            </tr>

                            <tr>
                                <th><b>Library Name</b></th>
                                <th><b>Name</b></th>
                            </tr>
                            <tr>

                                    <td>AppropriateTreatmentforSTEMIFHIR</td>

                                    <td>Active Oral Anticoagulant Medication at the Start of ED Encounter</td>

                            </tr>
                            <tr>

                                    <td/>
                                    <td>
                                        <pre class="highlight language-cql"><code class="language-cql">define &quot;Active Oral Anticoagulant Medication at the Start of ED Encounter&quot;:
      &quot;ED Encounter with STEMI Diagnosis&quot; EDwithSTEMI
        with [&quot;MedicationRequest&quot;: &quot;Oral Anticoagulant Medications&quot;] OralAnticoagulant
          such that OralAnticoagulant.status = 'active'
            and OralAnticoagulant.intent = 'order'
            and OralAnticoagulant.authoredOn before or on start of EDwithSTEMI.period</code></pre>
                                    </td>

                            </tr>

                            <tr>
                                <th><b>Library Name</b></th>
                                <th><b>Name</b></th>
                            </tr>
                            <tr>

                                    <td>AppropriateTreatmentforSTEMIFHIR</td>

                                    <td>Exclusion Diagnosis During ED Encounter or Within 24 Hours of ED Encounter Start</td>

                            </tr>
                            <tr>

                                    <td/>
                                    <td>
                                        <pre class="highlight language-cql"><code class="language-cql">define &quot;Exclusion Diagnosis During ED Encounter or Within 24 Hours of ED Encounter Start&quot;:
      &quot;ED Encounter with STEMI Diagnosis&quot; EDwithSTEMI
        with ( [&quot;Condition&quot;: &quot;Aortic Dissection and Rupture&quot;]
          union [&quot;Condition&quot;: &quot;Neurologic impairment&quot;]
          union [&quot;Condition&quot;: &quot;Cardiopulmonary Arrest&quot;] ) ExclusionDiagnosis
          such that ( ExclusionDiagnosis.prevalenceInterval ( ) starts during EDwithSTEMI.period )
            or ( ExclusionDiagnosis.prevalenceInterval ( ) starts 24 hours or less before start of EDwithSTEMI.period )</code></pre>
                                    </td>

                            </tr>

                            <tr>
                                <th><b>Library Name</b></th>
                                <th><b>Name</b></th>
                            </tr>
                            <tr>

                                    <td>AppropriateTreatmentforSTEMIFHIR</td>

                                    <td>Major Surgical Procedure 21 Days or Less Before Start of or Starts During ED Encounter</td>

                            </tr>
                            <tr>

                                    <td/>
                                    <td>
                                        <pre class="highlight language-cql"><code class="language-cql">define &quot;Major Surgical Procedure 21 Days or Less Before Start of or Starts During ED Encounter&quot;:
      &quot;ED Encounter with STEMI Diagnosis&quot; EDwithSTEMI
        with [&quot;Procedure&quot;: &quot;Major Surgical Procedure&quot;] MajorSurgery
          such that MajorSurgery.performed.toInterval ( ) starts 21 days or less before start of ( EDwithSTEMI.period )
            and MajorSurgery.status = 'completed'</code></pre>
                                    </td>

                            </tr>

                            <tr>
                                <th><b>Library Name</b></th>
                                <th><b>Name</b></th>
                            </tr>
                            <tr>

                                    <td>AppropriateTreatmentforSTEMIFHIR</td>

                                    <td>Intubation or Mechanical Circulatory Assist Procedure During ED Encounter or Within 24 Hours of ED Encounter Start</td>

                            </tr>
                            <tr>

                                    <td/>
                                    <td>
                                        <pre class="highlight language-cql"><code class="language-cql">define &quot;Intubation or Mechanical Circulatory Assist Procedure During ED Encounter or Within 24 Hours of ED Encounter Start&quot;:
      &quot;ED Encounter with STEMI Diagnosis&quot; EDwithSTEMI
        with ( [&quot;Procedure&quot;: &quot;Endotracheal Intubation&quot;]
          union [&quot;Procedure&quot;: &quot;Insertion or Replacement of Mechanical Circulatory Assist Device&quot;] ) AirwayProcedure
          such that ( ( AirwayProcedure.performed.toInterval ( ) starts during ( EDwithSTEMI.period ) )
              or ( AirwayProcedure.performed.toInterval ( ) starts 24 hours or less before start of ( EDwithSTEMI.period ) )
          )
            and AirwayProcedure.status = 'completed'</code></pre>
                                    </td>

                            </tr>

                            <tr>
                                <th><b>Library Name</b></th>
                                <th><b>Name</b></th>
                            </tr>
                            <tr>

                                    <td>AppropriateTreatmentforSTEMIFHIR</td>

                                    <td>Active Exclusion Diagnosis Within 90 Days Before or At the Start of ED Encounter</td>

                            </tr>
                            <tr>

                                    <td/>
                                    <td>
                                        <pre class="highlight language-cql"><code class="language-cql">/*KS 8-10-23: in CQLIT-389, discussed the impacts of requiring a clinical status of active but the condition could end before the end (during) the ED Visit, which would trigger an inactive status. Decided to not follow the Authoring Patterns and remove the requirement for a clinicalstatus of 'active'  */

    define &quot;Active Exclusion Diagnosis Within 90 Days Before or At the Start of ED Encounter&quot;:
      &quot;ED Encounter with STEMI Diagnosis&quot; EDwSTEMI
        with ( [&quot;Condition&quot;: &quot;Ischemic Stroke&quot;]
          union [&quot;Condition&quot;: &quot;Closed Head and Facial Trauma&quot;]
          union [&quot;Condition&quot;: &quot;Active Peptic Ulcer&quot;]
          union [&quot;Condition&quot;: &quot;Cardiopulmonary Arrest&quot;] ) ExclusionCondition
          such that /* ExclusionCondition.isActive ()
       and */
          ExclusionCondition.prevalenceInterval ( ) starts during Interval[start of ( EDwSTEMI.period ) - 90 days, start of ( EDwSTEMI.period )]</code></pre>
                                    </td>

                            </tr>

                            <tr>
                                <th><b>Library Name</b></th>
                                <th><b>Name</b></th>
                            </tr>
                            <tr>

                                    <td>AppropriateTreatmentforSTEMIFHIR</td>

                                    <td>Intracranial or Intraspinal Procedure 90 Days or Less Before Start of ED Encounter</td>

                            </tr>
                            <tr>

                                    <td/>
                                    <td>
                                        <pre class="highlight language-cql"><code class="language-cql">define &quot;Intracranial or Intraspinal Procedure 90 Days or Less Before Start of ED Encounter&quot;:
      &quot;ED Encounter with STEMI Diagnosis&quot; EDwithSTEMI
        with [&quot;Procedure&quot;: &quot;Intracranial or Intraspinal surgery&quot;] CranialorSpinalSurgery
          such that CranialorSpinalSurgery.performed.toInterval ( ) starts 90 days or less before start of ( EDwithSTEMI.period )
            and CranialorSpinalSurgery.status = 'completed'</code></pre>
                                    </td>

                            </tr>

                            <tr>
                                <th><b>Library Name</b></th>
                                <th><b>Name</b></th>
                            </tr>
                            <tr>

                                    <td>AppropriateTreatmentforSTEMIFHIR</td>

                                    <td>ED Encounter with Discharge Disposition as Patient Expired</td>

                            </tr>
                            <tr>

                                    <td/>
                                    <td>
                                        <pre class="highlight language-cql"><code class="language-cql">define &quot;ED Encounter with Discharge Disposition as Patient Expired&quot;:
      &quot;ED Encounter with STEMI Diagnosis&quot; EDwithSTEMI
        where EDwithSTEMI.hospitalization.dischargeDisposition in &quot;Patient Expired&quot;</code></pre>
                                    </td>

                            </tr>

                            <tr>
                                <th><b>Library Name</b></th>
                                <th><b>Name</b></th>
                            </tr>
                            <tr>

                                    <td>AppropriateTreatmentforSTEMIFHIR</td>

                                    <td>Denominator Exclusions</td>

                            </tr>
                            <tr>

                                    <td/>
                                    <td>
                                        <pre class="highlight language-cql"><code class="language-cql">define &quot;Denominator Exclusions&quot;:
      &quot;Allergy or Intolerance to Thrombolytic Medications Overlaps ED Encounter&quot;
        union &quot;Adverse Effect to Thrombolytic Medications Before End of ED Encounter&quot;
        union &quot;Active Exclusion Diagnosis at Start of ED Encounter&quot;
        union &quot;Active Oral Anticoagulant Medication at the Start of ED Encounter&quot;
        union &quot;Exclusion Diagnosis During ED Encounter or Within 24 Hours of ED Encounter Start&quot;
        union &quot;Major Surgical Procedure 21 Days or Less Before Start of or Starts During ED Encounter&quot;
        union &quot;Intubation or Mechanical Circulatory Assist Procedure During ED Encounter or Within 24 Hours of ED Encounter Start&quot;
        union &quot;Active Exclusion Diagnosis Within 90 Days Before or At the Start of ED Encounter&quot;
        union &quot;Intracranial or Intraspinal Procedure 90 Days or Less Before Start of ED Encounter&quot;
        union &quot;ED Encounter with Discharge Disposition as Patient Expired&quot;</code></pre>
                                    </td>

                            </tr>

                            <tr>
                                <th><b>Library Name</b></th>
                                <th><b>Name</b></th>
                            </tr>
                            <tr>

                                    <td>SupplementalDataElements</td>

                                    <td>SDE Race</td>

                            </tr>
                            <tr>

                                    <td/>
                                    <td>
                                        <pre class="highlight language-cql"><code class="language-cql">define &quot;SDE Race&quot;:
      Patient.race R
        return Tuple {
          codes: R.ombCategory union R.detailed,
          display: R.text
        }</code></pre>
                                    </td>

                            </tr>

                            <tr>
                                <th><b>Library Name</b></th>
                                <th><b>Name</b></th>
                            </tr>
                            <tr>

                                    <td>AppropriateTreatmentforSTEMIFHIR</td>

                                    <td>SDE Race</td>

                            </tr>
                            <tr>

                                    <td/>
                                    <td>
                                        <pre class="highlight language-cql"><code class="language-cql">define &quot;SDE Race&quot;:
      SDE.&quot;SDE Race&quot;</code></pre>
                                    </td>

                            </tr>

                            <tr>
                                <th><b>Library Name</b></th>
                                <th><b>Name</b></th>
                            </tr>
                            <tr>

                                    <td>FHIRHelpers</td>

                                    <td>ToConcept</td>

                            </tr>
                            <tr>

                                    <td/>
                                    <td>
                                        <pre class="highlight language-cql"><code class="language-cql">/*
    @description: Converts the given FHIR [CodeableConcept](https://hl7.org/fhir/datatypes.html#CodeableConcept) value to a CQL Concept.
    */
    define function ToConcept(concept FHIR.CodeableConcept):
        if concept is null then
            null
        else
            System.Concept {
                codes: concept.coding C return ToCode(C),
                display: concept.text.value
            }</code></pre>
                                    </td>

                            </tr>

                            <tr>
                                <th><b>Library Name</b></th>
                                <th><b>Name</b></th>
                            </tr>
                            <tr>

                                    <td>CQMCommon</td>

                                    <td>encounterDiagnosis</td>

                            </tr>
                            <tr>

                                    <td/>
                                    <td>
                                        <pre class="highlight language-cql"><code class="language-cql">/*
    @description: Returns the Condition resources referenced by the diagnosis element of the Encounter
    */
    define fluent function encounterDiagnosis(Encounter Encounter ):
      Encounter.diagnosis D
        return singleton from ([Condition] C where C.id = D.condition.reference.getId())</code></pre>
                                    </td>

                            </tr>

                            <tr>
                                <th><b>Library Name</b></th>
                                <th><b>Name</b></th>
                            </tr>
                            <tr>

                                    <td>QICoreCommon</td>

                                    <td>getId</td>

                            </tr>
                            <tr>

                                    <td/>
                                    <td>
                                        <pre class="highlight language-cql"><code class="language-cql">/*
    @description: Returns the tail of the given uri (i.e. everything after the last slash in the URI).
    @comment: This function can be used to determine the logical id of a given resource. It can be used in
    a single-server environment to trace references. However, this function does not attempt to resolve
    or distinguish the base of the given url, and so cannot be used safely in multi-server environments.
    */
    define fluent function getId(uri String):
      Last(Split(uri, '/'))</code></pre>
                                    </td>

                            </tr>

                            <tr>
                                <th><b>Library Name</b></th>
                                <th><b>Name</b></th>
                            </tr>
                            <tr>

                                    <td>QICoreCommon</td>

                                    <td>prevalenceInterval</td>

                            </tr>
                            <tr>

                                    <td/>
                                    <td>
                                        <pre class="highlight language-cql"><code class="language-cql">/*
    @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 ~ &quot;active&quot;
      or condition.clinicalStatus ~ &quot;recurrence&quot;
      or condition.clinicalStatus ~ &quot;relapse&quot; then
      Interval[start of condition.onset.toInterval(), end of condition.abatementInterval()]
    else
      Interval[start of condition.onset.toInterval(), end of condition.abatementInterval())</code></pre>
                                    </td>

                            </tr>

                            <tr>
                                <th><b>Library Name</b></th>
                                <th><b>Name</b></th>
                            </tr>
                            <tr>

                                    <td>AppropriateTreatmentforSTEMIFHIR</td>

                                    <td>currentemergencyDepartmentArrivalTime</td>

                            </tr>
                            <tr>

                                    <td/>
                                    <td>
                                        <pre class="highlight language-cql"><code class="language-cql">/*
    @description: Returns the emergency department arrival time for the encounter.
    */

    define fluent function currentemergencyDepartmentArrivalTime(EDEncounter Encounter):
      start of ( singleton from ( ( ( EDEncounter.location ) ) EDLocation
            where CQMCommon.GetLocation ( EDLocation.location ).type in &quot;Emergency Department Visit&quot;
        )
      ).period</code></pre>
                                    </td>

                            </tr>

                            <tr>
                                <th><b>Library Name</b></th>
                                <th><b>Name</b></th>
                            </tr>
                            <tr>

                                    <td>CQMCommon</td>

                                    <td>GetLocation</td>

                            </tr>
                            <tr>

                                    <td/>
                                    <td>
                                        <pre class="highlight language-cql"><code class="language-cql">/*
    @description: Returns the Location resource specified by the given reference
    @deprecated: This function is deprecated. Use the fluent function `getLocation()` instead.
    */
    define function &quot;GetLocation&quot;(reference Reference ):
      singleton from (
        [Location] L where L.id = reference.reference.getId()
      )</code></pre>
                                    </td>

                            </tr>

                            <tr>
                                <th><b>Library Name</b></th>
                                <th><b>Name</b></th>
                            </tr>
                            <tr>

                                    <td>FHIRHelpers</td>

                                    <td>ToString</td>

                            </tr>
                            <tr>

                                    <td/>
                                    <td>
                                        <pre class="highlight language-cql"><code class="language-cql">define function ToString(value uri): value.value</code></pre>
                                    </td>

                            </tr>

                            <tr>
                                <th><b>Library Name</b></th>
                                <th><b>Name</b></th>
                            </tr>
                            <tr>

                                    <td>FHIRHelpers</td>

                                    <td>ToCode</td>

                            </tr>
                            <tr>

                                    <td/>
                                    <td>
                                        <pre class="highlight language-cql"><code class="language-cql">/*
    @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
            }</code></pre>
                                    </td>

                            </tr>

                            <tr>
                                <th><b>Library Name</b></th>
                                <th><b>Name</b></th>
                            </tr>
                            <tr>

                                    <td>QICoreCommon</td>

                                    <td>toInterval</td>

                            </tr>
                            <tr>

                                    <td/>
                                    <td>
                                        <pre class="highlight language-cql"><code class="language-cql">/*
    @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&lt;DateTime&gt;, or Interval&lt;Quantity&gt; 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&lt;DateTime&gt; or Interval&lt;Quantity&gt;.
    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&lt;DateTime, Quantity, Interval&lt;DateTime&gt;, Interval&lt;Quantity&gt;&gt;):
      case
    	  when choice is DateTime then
        	Interval[choice as DateTime, choice as DateTime]
    		when choice is Interval&lt;DateTime&gt; then
      		choice as Interval&lt;DateTime&gt;
    		when choice is Quantity then
    		  Interval[Patient.birthDate + (choice as Quantity),
    			  Patient.birthDate + (choice as Quantity) + 1 year)
    		when choice is Interval&lt;Quantity&gt; then
    		  Interval[Patient.birthDate + (choice.low as Quantity),
    			  Patient.birthDate + (choice.high as Quantity) + 1 year)
    		else
    			null as Interval&lt;DateTime&gt;
    	end</code></pre>
                                    </td>

                            </tr>

                        </table>
                    </td>
                </tr>

        </table>
    </div>
      </text>
      <contained>
        <Library>
          <id value="effective-data-requirements"/>
          <extension
                     url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-directReferenceCode">
            <valueCoding>
              <system value="http://hl7.org/fhir/v3/AdministrativeGender"/>
              <code value="M"/>
              <display value="Male"/>
            </valueCoding>
          </extension>
          <extension
                     url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-directReferenceCode">
            <valueCoding>
              <system value="http://hl7.org/fhir/v3/AdministrativeGender"/>
              <code value="F"/>
              <display value="Female"/>
            </valueCoding>
          </extension>
          <extension
                     url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-directReferenceCode">
            <valueCoding>
              <system value="http://terminology.hl7.org/CodeSystem/v3-ActCode"/>
              <code value="EMER"/>
              <display value="emergency"/>
            </valueCoding>
          </extension>
          <extension
                     url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-directReferenceCode">
            <valueCoding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/condition-clinical"/>
              <code value="active"/>
            </valueCoding>
          </extension>
          <extension
                     url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-directReferenceCode">
            <valueCoding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/allergyintolerance-clinical"/>
              <code value="active"/>
            </valueCoding>
          </extension>
          <extension
                     url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
            <extension url="libraryName">
              <valueString value="SupplementalDataElements"/>
            </extension>
            <extension url="name">
              <valueString value="SDE Sex"/>
            </extension>
            <extension url="statement">
              <valueString
                           value="define &quot;SDE Sex&quot;:
      case
          when Patient.gender = 'male' then &quot;M&quot;
          when Patient.gender = 'female' then &quot;F&quot;
          else null
        end"/>
            </extension>
            <extension url="displaySequence">
              <valueInteger value="0"/>
            </extension>
          </extension>
          <extension
                     url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
            <extension url="libraryName">
              <valueString value="AppropriateTreatmentforSTEMIFHIR"/>
            </extension>
            <extension url="name">
              <valueString value="SDE Sex"/>
            </extension>
            <extension url="statement">
              <valueString
                           value="define &quot;SDE Sex&quot;:
      SDE.&quot;SDE Sex&quot;"/>
            </extension>
            <extension url="displaySequence">
              <valueInteger value="1"/>
            </extension>
          </extension>
          <extension
                     url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
            <extension url="libraryName">
              <valueString value="AppropriateTreatmentforSTEMIFHIR"/>
            </extension>
            <extension url="name">
              <valueString
                           value="ED Encounter with Encounter Diagnosis of STEMI"/>
            </extension>
            <extension url="statement">
              <valueString
                           value="define &quot;ED Encounter with Encounter Diagnosis of STEMI&quot;:
      [&quot;Encounter&quot;: &quot;ED&quot;] EDEncounter
        where EDEncounter.status = 'finished'
          and EDEncounter.class ~ &quot;EMER&quot;
          and ( EDEncounter.reasonCode in &quot;STEMI&quot;
              or exists ( ( EDEncounter.encounterDiagnosis ( ) ) EncDiagnosis
                  where EncDiagnosis.code in &quot;STEMI&quot;
              )
          )
          and EDEncounter.period during &quot;Measurement Period&quot;"/>
            </extension>
            <extension url="displaySequence">
              <valueInteger value="2"/>
            </extension>
          </extension>
          <extension
                     url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
            <extension url="libraryName">
              <valueString value="AppropriateTreatmentforSTEMIFHIR"/>
            </extension>
            <extension url="name">
              <valueString value="ED Encounter with Diagnosis of STEMI"/>
            </extension>
            <extension url="statement">
              <valueString
                           value="define &quot;ED Encounter with Diagnosis of STEMI&quot;:
      [&quot;Encounter&quot;: &quot;ED&quot;] EDEncounter
        with [&quot;Condition&quot;: &quot;STEMI&quot;] DxSTEMI
          such that DxSTEMI.clinicalStatus ~ QICoreCommon.&quot;active&quot;
            and EDEncounter.status = 'finished'
            and EDEncounter.class ~ &quot;EMER&quot;
            and DxSTEMI.prevalenceInterval ( ) starts during EDEncounter.period
            and EDEncounter.period during day of &quot;Measurement Period&quot;"/>
            </extension>
            <extension url="displaySequence">
              <valueInteger value="3"/>
            </extension>
          </extension>
          <extension
                     url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
            <extension url="libraryName">
              <valueString value="AppropriateTreatmentforSTEMIFHIR"/>
            </extension>
            <extension url="name">
              <valueString value="ED Encounter with STEMI Diagnosis"/>
            </extension>
            <extension url="statement">
              <valueString
                           value="define &quot;ED Encounter with STEMI Diagnosis&quot;:
      &quot;ED Encounter with Encounter Diagnosis of STEMI&quot;
        union &quot;ED Encounter with Diagnosis of STEMI&quot;"/>
            </extension>
            <extension url="displaySequence">
              <valueInteger value="4"/>
            </extension>
          </extension>
          <extension
                     url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
            <extension url="libraryName">
              <valueString value="AppropriateTreatmentforSTEMIFHIR"/>
            </extension>
            <extension url="name">
              <valueString
                           value="Fibrinolytic Therapy within 30 Minutes of Arrival"/>
            </extension>
            <extension url="statement">
              <valueString
                           value="/*Did not include a status of active as any diagnosis that resolves during the ED visit would not be counted*/

    define &quot;Fibrinolytic Therapy within 30 Minutes of Arrival&quot;:
      &quot;ED Encounter with STEMI Diagnosis&quot; EDwithSTEMI
        with [&quot;MedicationAdministration&quot;: &quot;Fibrinolytic Therapy&quot;] Fibrinolytic
          such that Fibrinolytic.status = 'completed'
            and start of ( Fibrinolytic.effective.toInterval ( ) ) 30 minutes or less after EDwithSTEMI.currentemergencyDepartmentArrivalTime ( )"/>
            </extension>
            <extension url="displaySequence">
              <valueInteger value="5"/>
            </extension>
          </extension>
          <extension
                     url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
            <extension url="libraryName">
              <valueString value="AppropriateTreatmentforSTEMIFHIR"/>
            </extension>
            <extension url="name">
              <valueString value="PCI within 90 Minutes of Arrival"/>
            </extension>
            <extension url="statement">
              <valueString
                           value="define &quot;PCI within 90 Minutes of Arrival&quot;:
      &quot;ED Encounter with STEMI Diagnosis&quot; EDwithSTEMI
        with [&quot;Procedure&quot;: &quot;Percutaneous Coronary Intervention&quot;] PCI
          such that PCI.performed.toInterval ( ) starts 90 minutes or less after EDwithSTEMI.currentemergencyDepartmentArrivalTime ( )
            and PCI.status = 'completed'"/>
            </extension>
            <extension url="displaySequence">
              <valueInteger value="6"/>
            </extension>
          </extension>
          <extension
                     url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
            <extension url="libraryName">
              <valueString value="AppropriateTreatmentforSTEMIFHIR"/>
            </extension>
            <extension url="name">
              <valueString
                           value="ED Departure with Transfer to Acute Care Facility Within 45 Minutes of Arrival"/>
            </extension>
            <extension url="statement">
              <valueString
                           value="define &quot;ED Departure with Transfer to Acute Care Facility Within 45 Minutes of Arrival&quot;:
      &quot;ED Encounter with STEMI Diagnosis&quot; EDwithSTEMI
        where ( EDwithSTEMI.period ) ends 45 minutes or less after start of ( EDwithSTEMI.period )
          and EDwithSTEMI.hospitalization.dischargeDisposition in &quot;Discharge To Acute Care Facility&quot;"/>
            </extension>
            <extension url="displaySequence">
              <valueInteger value="7"/>
            </extension>
          </extension>
          <extension
                     url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
            <extension url="libraryName">
              <valueString value="AppropriateTreatmentforSTEMIFHIR"/>
            </extension>
            <extension url="name">
              <valueString value="Numerator"/>
            </extension>
            <extension url="statement">
              <valueString
                           value="define &quot;Numerator&quot;:
      &quot;Fibrinolytic Therapy within 30 Minutes of Arrival&quot;
        union &quot;PCI within 90 Minutes of Arrival&quot;
        union &quot;ED Departure with Transfer to Acute Care Facility Within 45 Minutes of Arrival&quot;"/>
            </extension>
            <extension url="displaySequence">
              <valueInteger value="8"/>
            </extension>
          </extension>
          <extension
                     url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
            <extension url="libraryName">
              <valueString value="AppropriateTreatmentforSTEMIFHIR"/>
            </extension>
            <extension url="name">
              <valueString value="Initial Population"/>
            </extension>
            <extension url="statement">
              <valueString
                           value="/***Population Criteria***/

    define &quot;Initial Population&quot;:
      &quot;ED Encounter with STEMI Diagnosis&quot; EDwithSTEMI
        where AgeInYearsAt(date from start of(EDwithSTEMI.period)) &gt;= 18"/>
            </extension>
            <extension url="displaySequence">
              <valueInteger value="9"/>
            </extension>
          </extension>
          <extension
                     url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
            <extension url="libraryName">
              <valueString value="AppropriateTreatmentforSTEMIFHIR"/>
            </extension>
            <extension url="name">
              <valueString value="Denominator"/>
            </extension>
            <extension url="statement">
              <valueString
                           value="define &quot;Denominator&quot;:
      &quot;Initial Population&quot;"/>
            </extension>
            <extension url="displaySequence">
              <valueInteger value="10"/>
            </extension>
          </extension>
          <extension
                     url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
            <extension url="libraryName">
              <valueString value="SupplementalDataElements"/>
            </extension>
            <extension url="name">
              <valueString value="SDE Payer"/>
            </extension>
            <extension url="statement">
              <valueString
                           value="define &quot;SDE Payer&quot;:
      [Coverage: type in &quot;Payer Type&quot;] Payer
        return {
          code: Payer.type,
          period: Payer.period
        }"/>
            </extension>
            <extension url="displaySequence">
              <valueInteger value="11"/>
            </extension>
          </extension>
          <extension
                     url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
            <extension url="libraryName">
              <valueString value="AppropriateTreatmentforSTEMIFHIR"/>
            </extension>
            <extension url="name">
              <valueString value="SDE Payer"/>
            </extension>
            <extension url="statement">
              <valueString
                           value="define &quot;SDE Payer&quot;:
      SDE.&quot;SDE Payer&quot;"/>
            </extension>
            <extension url="displaySequence">
              <valueInteger value="12"/>
            </extension>
          </extension>
          <extension
                     url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
            <extension url="libraryName">
              <valueString value="SupplementalDataElements"/>
            </extension>
            <extension url="name">
              <valueString value="SDE Ethnicity"/>
            </extension>
            <extension url="statement">
              <valueString
                           value="define &quot;SDE Ethnicity&quot;:
      Patient.ethnicity E
        return Tuple {
          codes: { E.ombCategory } union E.detailed,
          display: E.text
        }"/>
            </extension>
            <extension url="displaySequence">
              <valueInteger value="13"/>
            </extension>
          </extension>
          <extension
                     url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
            <extension url="libraryName">
              <valueString value="AppropriateTreatmentforSTEMIFHIR"/>
            </extension>
            <extension url="name">
              <valueString value="SDE Ethnicity"/>
            </extension>
            <extension url="statement">
              <valueString
                           value="define &quot;SDE Ethnicity&quot;:
      SDE.&quot;SDE Ethnicity&quot;"/>
            </extension>
            <extension url="displaySequence">
              <valueInteger value="14"/>
            </extension>
          </extension>
          <extension
                     url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
            <extension url="libraryName">
              <valueString value="AppropriateTreatmentforSTEMIFHIR"/>
            </extension>
            <extension url="name">
              <valueString
                           value="Allergy or Intolerance to Thrombolytic Medications Overlaps ED Encounter"/>
            </extension>
            <extension url="statement">
              <valueString
                           value="define &quot;Allergy or Intolerance to Thrombolytic Medications Overlaps ED Encounter&quot;:
      &quot;ED Encounter with STEMI Diagnosis&quot; EDwSTEMI
        with [&quot;AllergyIntolerance&quot;: &quot;Thrombolytic medications&quot;] ThrombolyticAllergy
          such that ThrombolyticAllergy.clinicalStatus ~ QICoreCommon.&quot;allergy-active&quot;
            and ThrombolyticAllergy.onset.toInterval ( ) overlaps ( EDwSTEMI.period )"/>
            </extension>
            <extension url="displaySequence">
              <valueInteger value="15"/>
            </extension>
          </extension>
          <extension
                     url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
            <extension url="libraryName">
              <valueString value="AppropriateTreatmentforSTEMIFHIR"/>
            </extension>
            <extension url="name">
              <valueString
                           value="Adverse Effect to Thrombolytic Medications Before End of ED Encounter"/>
            </extension>
            <extension url="statement">
              <valueString
                           value="/*this definition differs from QDM re: timing - cannot use overlaps for a single point in time*/

    /*define &quot;Adverse Effect to Thrombolytic Medications Before End of ED Encounter&quot;:
    &quot;ED Encounter with STEMI Diagnosis&quot; EDwSTEMI
        with [AdverseEvent: event in &quot;Thrombolytic medications&quot;] ThrombolyticAdverseEvent
        such that ThrombolyticAdverseEvent.category in &quot;Adverse reaction to thrombolytics&quot;
        and ThrombolyticAdverseEvent.recordedDate before end of ( EDwSTEMI.period )
            and ThrombolyticAdverseEvent.actuality = 'actual'*/
    /*KS Note - not sure we need category in the logic - it is must support, but not sure this brings value to the measure logic*/

    define &quot;Adverse Effect to Thrombolytic Medications Before End of ED Encounter&quot;:
      &quot;ED Encounter with STEMI Diagnosis&quot; EDwSTEMI
        with [AdverseEvent: event in &quot;Adverse reaction to thrombolytics&quot;] ThrombolyticAdverseEvent
          such that ThrombolyticAdverseEvent.recordedDate before end of ( EDwSTEMI.period )
            and ThrombolyticAdverseEvent.actuality = 'actual'"/>
            </extension>
            <extension url="displaySequence">
              <valueInteger value="16"/>
            </extension>
          </extension>
          <extension
                     url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
            <extension url="libraryName">
              <valueString value="AppropriateTreatmentforSTEMIFHIR"/>
            </extension>
            <extension url="name">
              <valueString
                           value="Active Exclusion Diagnosis at Start of ED Encounter"/>
            </extension>
            <extension url="statement">
              <valueString
                           value="/***Definitions***/

    define &quot;Active Exclusion Diagnosis at Start of ED Encounter&quot;:
      &quot;ED Encounter with STEMI Diagnosis&quot; EDwithSTEMI
        with ( [&quot;Condition&quot;: &quot;Active Bleeding Excluding Menses or Bleeding Diathesis&quot;]
          union [&quot;Condition&quot;: &quot;Malignant Intracranial Neoplasm Group&quot;]
          union [&quot;Condition&quot;: &quot;Cerebral Vascular Lesion&quot;]
          union [&quot;Condition&quot;: &quot;Dementia&quot;]
          union [&quot;Condition&quot;: &quot;Pregnancy&quot;]
          union [&quot;Condition&quot;: &quot;Allergy to thrombolytics&quot;] ) ActiveExclusionDx
          such that /*ActiveExclusionDx.isActive ()
            and */
          ActiveExclusionDx.prevalenceInterval ( ) overlaps before ( EDwithSTEMI.period )"/>
            </extension>
            <extension url="displaySequence">
              <valueInteger value="17"/>
            </extension>
          </extension>
          <extension
                     url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
            <extension url="libraryName">
              <valueString value="AppropriateTreatmentforSTEMIFHIR"/>
            </extension>
            <extension url="name">
              <valueString
                           value="Active Oral Anticoagulant Medication at the Start of ED Encounter"/>
            </extension>
            <extension url="statement">
              <valueString
                           value="define &quot;Active Oral Anticoagulant Medication at the Start of ED Encounter&quot;:
      &quot;ED Encounter with STEMI Diagnosis&quot; EDwithSTEMI
        with [&quot;MedicationRequest&quot;: &quot;Oral Anticoagulant Medications&quot;] OralAnticoagulant
          such that OralAnticoagulant.status = 'active'
            and OralAnticoagulant.intent = 'order'
            and OralAnticoagulant.authoredOn before or on start of EDwithSTEMI.period"/>
            </extension>
            <extension url="displaySequence">
              <valueInteger value="18"/>
            </extension>
          </extension>
          <extension
                     url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
            <extension url="libraryName">
              <valueString value="AppropriateTreatmentforSTEMIFHIR"/>
            </extension>
            <extension url="name">
              <valueString
                           value="Exclusion Diagnosis During ED Encounter or Within 24 Hours of ED Encounter Start"/>
            </extension>
            <extension url="statement">
              <valueString
                           value="define &quot;Exclusion Diagnosis During ED Encounter or Within 24 Hours of ED Encounter Start&quot;:
      &quot;ED Encounter with STEMI Diagnosis&quot; EDwithSTEMI
        with ( [&quot;Condition&quot;: &quot;Aortic Dissection and Rupture&quot;]
          union [&quot;Condition&quot;: &quot;Neurologic impairment&quot;]
          union [&quot;Condition&quot;: &quot;Cardiopulmonary Arrest&quot;] ) ExclusionDiagnosis
          such that ( ExclusionDiagnosis.prevalenceInterval ( ) starts during EDwithSTEMI.period )
            or ( ExclusionDiagnosis.prevalenceInterval ( ) starts 24 hours or less before start of EDwithSTEMI.period )"/>
            </extension>
            <extension url="displaySequence">
              <valueInteger value="19"/>
            </extension>
          </extension>
          <extension
                     url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
            <extension url="libraryName">
              <valueString value="AppropriateTreatmentforSTEMIFHIR"/>
            </extension>
            <extension url="name">
              <valueString
                           value="Major Surgical Procedure 21 Days or Less Before Start of or Starts During ED Encounter"/>
            </extension>
            <extension url="statement">
              <valueString
                           value="define &quot;Major Surgical Procedure 21 Days or Less Before Start of or Starts During ED Encounter&quot;:
      &quot;ED Encounter with STEMI Diagnosis&quot; EDwithSTEMI
        with [&quot;Procedure&quot;: &quot;Major Surgical Procedure&quot;] MajorSurgery
          such that MajorSurgery.performed.toInterval ( ) starts 21 days or less before start of ( EDwithSTEMI.period )
            and MajorSurgery.status = 'completed'"/>
            </extension>
            <extension url="displaySequence">
              <valueInteger value="20"/>
            </extension>
          </extension>
          <extension
                     url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
            <extension url="libraryName">
              <valueString value="AppropriateTreatmentforSTEMIFHIR"/>
            </extension>
            <extension url="name">
              <valueString
                           value="Intubation or Mechanical Circulatory Assist Procedure During ED Encounter or Within 24 Hours of ED Encounter Start"/>
            </extension>
            <extension url="statement">
              <valueString
                           value="define &quot;Intubation or Mechanical Circulatory Assist Procedure During ED Encounter or Within 24 Hours of ED Encounter Start&quot;:
      &quot;ED Encounter with STEMI Diagnosis&quot; EDwithSTEMI
        with ( [&quot;Procedure&quot;: &quot;Endotracheal Intubation&quot;]
          union [&quot;Procedure&quot;: &quot;Insertion or Replacement of Mechanical Circulatory Assist Device&quot;] ) AirwayProcedure
          such that ( ( AirwayProcedure.performed.toInterval ( ) starts during ( EDwithSTEMI.period ) )
              or ( AirwayProcedure.performed.toInterval ( ) starts 24 hours or less before start of ( EDwithSTEMI.period ) )
          )
            and AirwayProcedure.status = 'completed'"/>
            </extension>
            <extension url="displaySequence">
              <valueInteger value="21"/>
            </extension>
          </extension>
          <extension
                     url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
            <extension url="libraryName">
              <valueString value="AppropriateTreatmentforSTEMIFHIR"/>
            </extension>
            <extension url="name">
              <valueString
                           value="Active Exclusion Diagnosis Within 90 Days Before or At the Start of ED Encounter"/>
            </extension>
            <extension url="statement">
              <valueString
                           value="/*KS 8-10-23: in CQLIT-389, discussed the impacts of requiring a clinical status of active but the condition could end before the end (during) the ED Visit, which would trigger an inactive status. Decided to not follow the Authoring Patterns and remove the requirement for a clinicalstatus of 'active'  */

    define &quot;Active Exclusion Diagnosis Within 90 Days Before or At the Start of ED Encounter&quot;:
      &quot;ED Encounter with STEMI Diagnosis&quot; EDwSTEMI
        with ( [&quot;Condition&quot;: &quot;Ischemic Stroke&quot;]
          union [&quot;Condition&quot;: &quot;Closed Head and Facial Trauma&quot;]
          union [&quot;Condition&quot;: &quot;Active Peptic Ulcer&quot;]
          union [&quot;Condition&quot;: &quot;Cardiopulmonary Arrest&quot;] ) ExclusionCondition
          such that /* ExclusionCondition.isActive ()
       and */
          ExclusionCondition.prevalenceInterval ( ) starts during Interval[start of ( EDwSTEMI.period ) - 90 days, start of ( EDwSTEMI.period )]"/>
            </extension>
            <extension url="displaySequence">
              <valueInteger value="22"/>
            </extension>
          </extension>
          <extension
                     url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
            <extension url="libraryName">
              <valueString value="AppropriateTreatmentforSTEMIFHIR"/>
            </extension>
            <extension url="name">
              <valueString
                           value="Intracranial or Intraspinal Procedure 90 Days or Less Before Start of ED Encounter"/>
            </extension>
            <extension url="statement">
              <valueString
                           value="define &quot;Intracranial or Intraspinal Procedure 90 Days or Less Before Start of ED Encounter&quot;:
      &quot;ED Encounter with STEMI Diagnosis&quot; EDwithSTEMI
        with [&quot;Procedure&quot;: &quot;Intracranial or Intraspinal surgery&quot;] CranialorSpinalSurgery
          such that CranialorSpinalSurgery.performed.toInterval ( ) starts 90 days or less before start of ( EDwithSTEMI.period )
            and CranialorSpinalSurgery.status = 'completed'"/>
            </extension>
            <extension url="displaySequence">
              <valueInteger value="23"/>
            </extension>
          </extension>
          <extension
                     url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
            <extension url="libraryName">
              <valueString value="AppropriateTreatmentforSTEMIFHIR"/>
            </extension>
            <extension url="name">
              <valueString
                           value="ED Encounter with Discharge Disposition as Patient Expired"/>
            </extension>
            <extension url="statement">
              <valueString
                           value="define &quot;ED Encounter with Discharge Disposition as Patient Expired&quot;:
      &quot;ED Encounter with STEMI Diagnosis&quot; EDwithSTEMI
        where EDwithSTEMI.hospitalization.dischargeDisposition in &quot;Patient Expired&quot;"/>
            </extension>
            <extension url="displaySequence">
              <valueInteger value="24"/>
            </extension>
          </extension>
          <extension
                     url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
            <extension url="libraryName">
              <valueString value="AppropriateTreatmentforSTEMIFHIR"/>
            </extension>
            <extension url="name">
              <valueString value="Denominator Exclusions"/>
            </extension>
            <extension url="statement">
              <valueString
                           value="define &quot;Denominator Exclusions&quot;:
      &quot;Allergy or Intolerance to Thrombolytic Medications Overlaps ED Encounter&quot;
        union &quot;Adverse Effect to Thrombolytic Medications Before End of ED Encounter&quot;
        union &quot;Active Exclusion Diagnosis at Start of ED Encounter&quot;
        union &quot;Active Oral Anticoagulant Medication at the Start of ED Encounter&quot;
        union &quot;Exclusion Diagnosis During ED Encounter or Within 24 Hours of ED Encounter Start&quot;
        union &quot;Major Surgical Procedure 21 Days or Less Before Start of or Starts During ED Encounter&quot;
        union &quot;Intubation or Mechanical Circulatory Assist Procedure During ED Encounter or Within 24 Hours of ED Encounter Start&quot;
        union &quot;Active Exclusion Diagnosis Within 90 Days Before or At the Start of ED Encounter&quot;
        union &quot;Intracranial or Intraspinal Procedure 90 Days or Less Before Start of ED Encounter&quot;
        union &quot;ED Encounter with Discharge Disposition as Patient Expired&quot;"/>
            </extension>
            <extension url="displaySequence">
              <valueInteger value="25"/>
            </extension>
          </extension>
          <extension
                     url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
            <extension url="libraryName">
              <valueString value="SupplementalDataElements"/>
            </extension>
            <extension url="name">
              <valueString value="SDE Race"/>
            </extension>
            <extension url="statement">
              <valueString
                           value="define &quot;SDE Race&quot;:
      Patient.race R
        return Tuple {
          codes: R.ombCategory union R.detailed,
          display: R.text
        }"/>
            </extension>
            <extension url="displaySequence">
              <valueInteger value="26"/>
            </extension>
          </extension>
          <extension
                     url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
            <extension url="libraryName">
              <valueString value="AppropriateTreatmentforSTEMIFHIR"/>
            </extension>
            <extension url="name">
              <valueString value="SDE Race"/>
            </extension>
            <extension url="statement">
              <valueString
                           value="define &quot;SDE Race&quot;:
      SDE.&quot;SDE Race&quot;"/>
            </extension>
            <extension url="displaySequence">
              <valueInteger value="27"/>
            </extension>
          </extension>
          <extension
                     url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
            <extension url="libraryName">
              <valueString value="FHIRHelpers"/>
            </extension>
            <extension url="name">
              <valueString value="ToConcept"/>
            </extension>
            <extension url="statement">
              <valueString
                           value="/*
    @description: Converts the given FHIR [CodeableConcept](https://hl7.org/fhir/datatypes.html#CodeableConcept) value to a CQL Concept.
    */
    define function ToConcept(concept FHIR.CodeableConcept):
        if concept is null then
            null
        else
            System.Concept {
                codes: concept.coding C return ToCode(C),
                display: concept.text.value
            }"/>
            </extension>
            <extension url="displaySequence">
              <valueInteger value="28"/>
            </extension>
          </extension>
          <extension
                     url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
            <extension url="libraryName">
              <valueString value="CQMCommon"/>
            </extension>
            <extension url="name">
              <valueString value="encounterDiagnosis"/>
            </extension>
            <extension url="statement">
              <valueString
                           value="/*
    @description: Returns the Condition resources referenced by the diagnosis element of the Encounter
    */
    define fluent function encounterDiagnosis(Encounter Encounter ):
      Encounter.diagnosis D
        return singleton from ([Condition] C where C.id = D.condition.reference.getId())"/>
            </extension>
            <extension url="displaySequence">
              <valueInteger value="29"/>
            </extension>
          </extension>
          <extension
                     url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
            <extension url="libraryName">
              <valueString value="QICoreCommon"/>
            </extension>
            <extension url="name">
              <valueString value="getId"/>
            </extension>
            <extension url="statement">
              <valueString
                           value="/*
    @description: Returns the tail of the given uri (i.e. everything after the last slash in the URI).
    @comment: This function can be used to determine the logical id of a given resource. It can be used in
    a single-server environment to trace references. However, this function does not attempt to resolve
    or distinguish the base of the given url, and so cannot be used safely in multi-server environments.
    */
    define fluent function getId(uri String):
      Last(Split(uri, '/'))"/>
            </extension>
            <extension url="displaySequence">
              <valueInteger value="30"/>
            </extension>
          </extension>
          <extension
                     url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
            <extension url="libraryName">
              <valueString value="QICoreCommon"/>
            </extension>
            <extension url="name">
              <valueString value="prevalenceInterval"/>
            </extension>
            <extension url="statement">
              <valueString
                           value="/*
    @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 ~ &quot;active&quot;
      or condition.clinicalStatus ~ &quot;recurrence&quot;
      or condition.clinicalStatus ~ &quot;relapse&quot; then
      Interval[start of condition.onset.toInterval(), end of condition.abatementInterval()]
    else
      Interval[start of condition.onset.toInterval(), end of condition.abatementInterval())"/>
            </extension>
            <extension url="displaySequence">
              <valueInteger value="31"/>
            </extension>
          </extension>
          <extension
                     url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
            <extension url="libraryName">
              <valueString value="AppropriateTreatmentforSTEMIFHIR"/>
            </extension>
            <extension url="name">
              <valueString value="currentemergencyDepartmentArrivalTime"/>
            </extension>
            <extension url="statement">
              <valueString
                           value="/*
    @description: Returns the emergency department arrival time for the encounter.
    */

    define fluent function currentemergencyDepartmentArrivalTime(EDEncounter Encounter):
      start of ( singleton from ( ( ( EDEncounter.location ) ) EDLocation
            where CQMCommon.GetLocation ( EDLocation.location ).type in &quot;Emergency Department Visit&quot;
        )
      ).period"/>
            </extension>
            <extension url="displaySequence">
              <valueInteger value="32"/>
            </extension>
          </extension>
          <extension
                     url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
            <extension url="libraryName">
              <valueString value="CQMCommon"/>
            </extension>
            <extension url="name">
              <valueString value="GetLocation"/>
            </extension>
            <extension url="statement">
              <valueString
                           value="/*
    @description: Returns the Location resource specified by the given reference
    @deprecated: This function is deprecated. Use the fluent function `getLocation()` instead.
    */
    define function &quot;GetLocation&quot;(reference Reference ):
      singleton from (
        [Location] L where L.id = reference.reference.getId()
      )"/>
            </extension>
            <extension url="displaySequence">
              <valueInteger value="33"/>
            </extension>
          </extension>
          <extension
                     url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
            <extension url="libraryName">
              <valueString value="FHIRHelpers"/>
            </extension>
            <extension url="name">
              <valueString value="ToString"/>
            </extension>
            <extension url="statement">
              <valueString
                           value="define function ToString(value uri): value.value"/>
            </extension>
            <extension url="displaySequence">
              <valueInteger value="34"/>
            </extension>
          </extension>
          <extension
                     url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
            <extension url="libraryName">
              <valueString value="FHIRHelpers"/>
            </extension>
            <extension url="name">
              <valueString value="ToCode"/>
            </extension>
            <extension url="statement">
              <valueString
                           value="/*
    @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
            }"/>
            </extension>
            <extension url="displaySequence">
              <valueInteger value="35"/>
            </extension>
          </extension>
          <extension
                     url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
            <extension url="libraryName">
              <valueString value="QICoreCommon"/>
            </extension>
            <extension url="name">
              <valueString value="toInterval"/>
            </extension>
            <extension url="statement">
              <valueString
                           value="/*
    @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&lt;DateTime&gt;, or Interval&lt;Quantity&gt; 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&lt;DateTime&gt; or Interval&lt;Quantity&gt;.
    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&lt;DateTime, Quantity, Interval&lt;DateTime&gt;, Interval&lt;Quantity&gt;&gt;):
      case
    	  when choice is DateTime then
        	Interval[choice as DateTime, choice as DateTime]
    		when choice is Interval&lt;DateTime&gt; then
      		choice as Interval&lt;DateTime&gt;
    		when choice is Quantity then
    		  Interval[Patient.birthDate + (choice as Quantity),
    			  Patient.birthDate + (choice as Quantity) + 1 year)
    		when choice is Interval&lt;Quantity&gt; then
    		  Interval[Patient.birthDate + (choice.low as Quantity),
    			  Patient.birthDate + (choice.high as Quantity) + 1 year)
    		else
    			null as Interval&lt;DateTime&gt;
    	end"/>
            </extension>
            <extension url="displaySequence">
              <valueInteger value="36"/>
            </extension>
          </extension>
          <status value="active"/>
          <type>
            <coding>
              <system value="http://terminology.hl7.org/CodeSystem/library-type"/>
              <code value="module-definition"/>
            </coding>
          </type>
          <relatedArtifact>
            <type value="depends-on"/>
            <display value="Library SDE"/>
            <resource
                      value="http://ecqi.healthit.gov/ecqms/Library/SupplementalDataElements|3.4.000"/>
          </relatedArtifact>
          <relatedArtifact>
            <type value="depends-on"/>
            <display value="Library FHIRHelpers"/>
            <resource
                      value="http://ecqi.healthit.gov/ecqms/Library/FHIRHelpers|4.3.000"/>
          </relatedArtifact>
          <relatedArtifact>
            <type value="depends-on"/>
            <display value="Library CQMCommon"/>
            <resource
                      value="http://ecqi.healthit.gov/ecqms/Library/CQMCommon|1.4.000"/>
          </relatedArtifact>
          <relatedArtifact>
            <type value="depends-on"/>
            <display value="Library QICoreCommon"/>
            <resource
                      value="http://ecqi.healthit.gov/ecqms/Library/QICoreCommon|1.5.000"/>
          </relatedArtifact>
          <relatedArtifact>
            <type value="depends-on"/>
            <display value="Code system AdministrativeGender"/>
            <resource value="http://hl7.org/fhir/v3/AdministrativeGender"/>
          </relatedArtifact>
          <relatedArtifact>
            <type value="depends-on"/>
            <display value="Code system ActCode"/>
            <resource value="http://terminology.hl7.org/CodeSystem/v3-ActCode"/>
          </relatedArtifact>
          <relatedArtifact>
            <type value="depends-on"/>
            <display value="Code system ConditionClinicalStatusCodes"/>
            <resource
                      value="http://terminology.hl7.org/CodeSystem/condition-clinical"/>
          </relatedArtifact>
          <relatedArtifact>
            <type value="depends-on"/>
            <display value="Code system AllergyIntoleranceClinicalStatusCodes"/>
            <resource
                      value="http://terminology.hl7.org/CodeSystem/allergyintolerance-clinical"/>
          </relatedArtifact>
          <relatedArtifact>
            <type value="depends-on"/>
            <display value="Value set ED"/>
            <resource
                      value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1085"/>
          </relatedArtifact>
          <relatedArtifact>
            <type value="depends-on"/>
            <display value="Value set STEMI"/>
            <resource
                      value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.3157.4017"/>
          </relatedArtifact>
          <relatedArtifact>
            <type value="depends-on"/>
            <display value="Value set Fibrinolytic Therapy"/>
            <resource
                      value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.3157.4020"/>
          </relatedArtifact>
          <relatedArtifact>
            <type value="depends-on"/>
            <display value="Value set Emergency Department Visit"/>
            <resource
                      value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.292"/>
          </relatedArtifact>
          <relatedArtifact>
            <type value="depends-on"/>
            <display value="Value set Percutaneous Coronary Intervention"/>
            <resource
                      value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.3157.2000.5"/>
          </relatedArtifact>
          <relatedArtifact>
            <type value="depends-on"/>
            <display value="Value set Discharge To Acute Care Facility"/>
            <resource
                      value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.87"/>
          </relatedArtifact>
          <relatedArtifact>
            <type value="depends-on"/>
            <display value="Value set Payer Type"/>
            <resource
                      value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591"/>
          </relatedArtifact>
          <relatedArtifact>
            <type value="depends-on"/>
            <display value="Value set Thrombolytic medications"/>
            <resource
                      value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1170.4"/>
          </relatedArtifact>
          <relatedArtifact>
            <type value="depends-on"/>
            <display value="Value set Adverse reaction to thrombolytics"/>
            <resource
                      value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1170.6"/>
          </relatedArtifact>
          <relatedArtifact>
            <type value="depends-on"/>
            <display
                     value="Value set Active Bleeding Excluding Menses or Bleeding Diathesis"/>
            <resource
                      value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.3157.4036"/>
          </relatedArtifact>
          <relatedArtifact>
            <type value="depends-on"/>
            <display value="Value set Malignant Intracranial Neoplasm Group"/>
            <resource
                      value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1170.3"/>
          </relatedArtifact>
          <relatedArtifact>
            <type value="depends-on"/>
            <display value="Value set Cerebral Vascular Lesion"/>
            <resource
                      value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.3157.4025"/>
          </relatedArtifact>
          <relatedArtifact>
            <type value="depends-on"/>
            <display value="Value set Dementia"/>
            <resource
                      value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.3157.4043"/>
          </relatedArtifact>
          <relatedArtifact>
            <type value="depends-on"/>
            <display value="Value set Pregnancy"/>
            <resource
                      value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.3157.4055"/>
          </relatedArtifact>
          <relatedArtifact>
            <type value="depends-on"/>
            <display value="Value set Allergy to thrombolytics"/>
            <resource
                      value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1170.5"/>
          </relatedArtifact>
          <relatedArtifact>
            <type value="depends-on"/>
            <display value="Value set Oral Anticoagulant Medications"/>
            <resource
                      value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.3157.4045"/>
          </relatedArtifact>
          <relatedArtifact>
            <type value="depends-on"/>
            <display value="Value set Aortic Dissection and Rupture"/>
            <resource
                      value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.3157.4028"/>
          </relatedArtifact>
          <relatedArtifact>
            <type value="depends-on"/>
            <display value="Value set Neurologic impairment"/>
            <resource
                      value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.114.12.1012"/>
          </relatedArtifact>
          <relatedArtifact>
            <type value="depends-on"/>
            <display value="Value set Cardiopulmonary Arrest"/>
            <resource
                      value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.3157.4048"/>
          </relatedArtifact>
          <relatedArtifact>
            <type value="depends-on"/>
            <display value="Value set Major Surgical Procedure"/>
            <resource
                      value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.3157.4056"/>
          </relatedArtifact>
          <relatedArtifact>
            <type value="depends-on"/>
            <display value="Value set Endotracheal Intubation"/>
            <resource
                      value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1045.69"/>
          </relatedArtifact>
          <relatedArtifact>
            <type value="depends-on"/>
            <display
                     value="Value set Insertion or Replacement of Mechanical Circulatory Assist Device"/>
            <resource
                      value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.3157.4052"/>
          </relatedArtifact>
          <relatedArtifact>
            <type value="depends-on"/>
            <display value="Value set Ischemic Stroke"/>
            <resource
                      value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.104.12.1024"/>
          </relatedArtifact>
          <relatedArtifact>
            <type value="depends-on"/>
            <display value="Value set Closed Head and Facial Trauma"/>
            <resource
                      value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.3157.4026"/>
          </relatedArtifact>
          <relatedArtifact>
            <type value="depends-on"/>
            <display value="Value set Active Peptic Ulcer"/>
            <resource
                      value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.3157.4031"/>
          </relatedArtifact>
          <relatedArtifact>
            <type value="depends-on"/>
            <display value="Value set Intracranial or Intraspinal surgery"/>
            <resource
                      value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1170.2"/>
          </relatedArtifact>
          <relatedArtifact>
            <type value="depends-on"/>
            <display value="Value set Patient Expired"/>
            <resource
                      value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.309"/>
          </relatedArtifact>
          <parameter>
            <name value="Measurement Period"/>
            <use value="in"/>
            <min value="0"/>
            <max value="1"/>
            <type value="Period"/>
          </parameter>
          <parameter>
            <name value="SDE Sex"/>
            <use value="out"/>
            <min value="0"/>
            <max value="1"/>
            <type value="Coding"/>
          </parameter>
          <parameter>
            <name value="Numerator"/>
            <use value="out"/>
            <min value="0"/>
            <max value="*"/>
            <type value="Resource"/>
          </parameter>
          <parameter>
            <name value="Denominator"/>
            <use value="out"/>
            <min value="0"/>
            <max value="*"/>
            <type value="Resource"/>
          </parameter>
          <parameter>
            <name value="SDE Payer"/>
            <use value="out"/>
            <min value="0"/>
            <max value="*"/>
            <type value="Resource"/>
          </parameter>
          <parameter>
            <name value="Initial Population"/>
            <use value="out"/>
            <min value="0"/>
            <max value="*"/>
            <type value="Resource"/>
          </parameter>
          <parameter>
            <name value="SDE Ethnicity"/>
            <use value="out"/>
            <min value="0"/>
            <max value="1"/>
            <type value="Resource"/>
          </parameter>
          <parameter>
            <name value="Denominator Exclusions"/>
            <use value="out"/>
            <min value="0"/>
            <max value="*"/>
            <type value="Resource"/>
          </parameter>
          <parameter>
            <name value="SDE Race"/>
            <use value="out"/>
            <min value="0"/>
            <max value="1"/>
            <type value="Resource"/>
          </parameter>
          <dataRequirement>
            <type value="Patient"/>
            <profile
                     value="http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-patient"/>
            <mustSupport value="ethnicity"/>
            <mustSupport value="race"/>
          </dataRequirement>
          <dataRequirement>
            <type value="Condition"/>
            <profile
                     value="http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-condition"/>
            <mustSupport value="id"/>
            <mustSupport value="id.value"/>
            <mustSupport value="code"/>
          </dataRequirement>
          <dataRequirement>
            <type value="Condition"/>
            <profile
                     value="http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-condition"/>
            <mustSupport value="code"/>
            <mustSupport value="clinicalStatus"/>
            <codeFilter>
              <path value="code"/>
              <valueSet
                        value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.3157.4017"/>
            </codeFilter>
            <codeFilter>
              <path value="clinicalStatus"/>
            </codeFilter>
          </dataRequirement>
          <dataRequirement>
            <type value="Condition"/>
            <profile
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      <url
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            <code value="endorser"/>
          </coding>
        </type>
        <system value="https://madie.cms.gov/measure/nqfId"/>
        <value value="3613e"/>
        <assigner>
          <display value="NQF"/>
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      </identifier>
      <identifier>
        <use value="official"/>
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        <system value="https://madie.cms.gov/measure/cmsId"/>
        <value value="996FHIR"/>
        <assigner>
          <display value="CMS"/>
        </assigner>
      </identifier>
      <version value="0.0.008"/>
      <name value="AppropriateTreatmentforSTEMIFHIR"/>
      <title
             value="Appropriate Treatment for ST-Segment Elevation Myocardial Infarction (STEMI) Patients in the Emergency Department (ED)FHIR"/>
      <status value="draft"/>
      <experimental value="false"/>
      <date value="2023-10-27T08:12:31+00:00"/>
      <publisher value="Centers for Medicare &amp; Medicaid Services (CMS)"/>
      <contact>
        <telecom>
          <system value="url"/>
          <value value="https://www.cms.gov/"/>
        </telecom>
      </contact>
      <description
                   value="Percentage of emergency department (ED) encounters for patients 18 years and older with a diagnosis of ST-segment elevation myocardial infarction (STEMI) that received appropriate treatment, defined as fibrinolytic therapy within 30 minutes of ED arrival, percutaneous coronary intervention (PCI) within 90 minutes of ED arrival, or transfer within 45 minutes of ED arrival"/>
      <purpose value="UNKNOWN"/>
      <usage
             value="This eCQM is an episode-based measure and should be reported for each instance of an ED encounter during the measurement period for patients with a STEMI.

    This FHIR-based measure has been derived from the QDM-based measure: CMS996v4.

    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)."/>
      <copyright
                 value="Limited proprietary coding is contained in these specifications for user convenience. Users of proprietary code sets should obtain all necessary licenses from the owners of the code sets.

    This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2022 International Health Terminology Standards Development Organisation. All rights reserved.

    LOINC(R) copyright 2004-2022 Regenstrief Institute, Inc.

    CPT(R) contained in the Measure specifications is copyright 2004-2022 American Medical Association.

    ICD-10 is copyright 2022 World Health Organization. All Rights Reserved."/>
      <approvalDate value="2023-08-17"/>
      <lastReviewDate value="2023-08-17"/>
      <effectivePeriod>
        <start value="2024-01-01"/>
        <end value="2024-12-31"/>
      </effectivePeriod>
      <author>
        <name
              value="Yale New Haven Health Service Corporation/ Center for Outcomes Research and Evaluation"/>
        <telecom>
          <system value="url"/>
          <value value="https://medicine.yale.edu/core/"/>
        </telecom>
      </author>
      <author>
        <name value="The Lewin Group"/>
        <telecom>
          <system value="url"/>
          <value value="https://www.lewin.com/"/>
        </telecom>
      </author>
      <library
               value="http://ecqi.healthit.gov/ecqms/Library/AppropriateTreatmentforSTEMIFHIR"/>
      <disclaimer
                  value="These performance specifications are not clinical guidelines and do not establish a standard of medical care, and have not been tested for all potential applications.

    THE MEASURES AND SPECIFICATIONS ARE PROVIDED &quot;AS IS&quot; WITHOUT WARRANTY OF ANY KIND.

    Due to technical limitations, registered trademarks are indicated by (R) or [R] and unregistered trademarks are indicated by (TM) or [TM]."/>
      <rationale
                 value="Studies have shown that delays in the treatment of acute myocardial infarction (AMI) leads to increased risk of in-hospital mortality and morbidity, with nearly two lives per 1,000 patients lost per hour of delay in treatment (Sohlpour &amp; Yusuf, 2014; Fibrinolytic Therapy Trialists’ Collaborative Group, 1994). For patients receiving fibrinolytic therapy, the American Heart Association (AHA) estimates that 65 lives will be saved per 1,000 patients if treatment is administered within the first hour of symptom onset, and 131 lives will be saved per 1,000 patients treated if fibrinolytic therapy is delivered within the first three hours (O’Connor et al., 2010).
    The total ischemic time—that is, the time from onset of STEMI symptoms to the initiation of some form of reperfusion therapy—is the principal determinant of health outcomes for patients with an AMI, so timely care is essential to minimize disease morbidity and mortality. Primary PCI is the preferred treatment approach, with guidelines recommending initiation of PCI within 120 minutes from first medical contact (O’Gara et al., 2013). In situations where it is unlikely or impossible for a patient to receive primary PCI within the 120-minute timeframe, fibrinolytic therapy may be used for reperfusion and should be rapidly administered to reduce mortality and minimize morbidity; guidelines recommend that fibrinolytic therapy administration occur within 30 minutes of hospital arrival; this may also require rapid transfer for PCI (O’Gara et al., 2013).
    Implementation of an eCQM addressing appropriateness and effectiveness of care for STEMI patients in the ED has the potential to improve the delivery of care furthering alignment with current clinical practice guidelines, while reducing adverse health outcomes such as mortality, bleeding events, and reinfarction. Use of the proposed eCQM could also reduce burden on facilities currently measured using the chart-abstracted Fibrinolytic Therapy Received within 30 Minutes of ED Arrival (OP-2) measure and broaden the population for which performance scores could be publicly reported."/>
      <clinicalRecommendationStatement
                                       value="Primary PCI in STEMI:
    The 2013 ACCF/AHA clinical practice guideline for the management of STEMI recommends that:
    - &quot;Primary PCI should be performed in patients with STEMI and ischemic symptoms of less than 12 hours’ duration.&quot;
    - &quot;Primary PCI should be performed in patients with STEMI and ischemic symptoms of less than 12 hours’ duration who have contraindications to fibrinolytic therapy, irrespective of the time delay from first medical contact.&quot;

    Fibrinolytic Therapy when there is an Anticipated Delay to Performing Primary PCI within 120 Minutes of First Medical Contact:
    The 2013 ACCF/AHA clinical practice guideline for the management of STEMI recommends that:
    - &quot;In the absence of contraindications, fibrinolytic therapy should be given to patients with STEMI and onset of ischemic symptoms within the previous 12 hours when it is anticipated that primary PCI cannot be performed within 120 minutes of first medical contact.”

    Transfer to a PCI-Capable Hospital after Fibrinolytic Therapy:
    The 2013 ACCF/AHA clinical practice guideline for the management of STEMI recommends that:
    - Immediate transfer to a PCI-capable hospital for coronary angiography is recommended for suitable patients with STEMI who develop cardiogenic shock or acute severe HF, irrespective of the time delay from MI onset.
    - Urgent transfer to a PCI-capable hospital for coronary angiography is reasonable for patients with STEMI who demonstrate evidence of failed reperfusion or reocclusion after fibrinolytic therapy.
    - Transfer to a PCI-capable hospital for coronary angiography is reasonable for patients with STEMI who have received fibrinolytic therapy even when hemodynamically stable and with clinical evidence of successful reperfusion. Angiography can be performed as soon as logistically feasible at the receiving hospital, and ideally within 24 hours, but should not be performed within the first 2 to 3 hours after administration of fibrinolytic therapy."/>
      <group id="6384fdb64ba3d47c885c02a6">
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          <description
                       value="All emergency department encounters for patients 18 years and older with a diagnosis of ST-segment elevation myocardial infarction (STEMI)"/>
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                      value="http://terminology.hl7.org/CodeSystem/measure-population"/>
              <code value="denominator"/>
              <display value="Denominator"/>
            </coding>
          </code>
          <description value="Equals Initial Population"/>
          <criteria>
            <language value="text/cql-identifier"/>
            <expression value="Denominator"/>
          </criteria>
        </population>
        <population id="9BDC7445-0BF6-4941-8732-893B185A378E">
          <code>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/measure-population"/>
              <code value="denominator-exclusion"/>
              <display value="Denominator Exclusion"/>
            </coding>
          </code>
          <description
                       value="Patients with the following conditions are excluded from measure denominator:
     • Expired in the ED
     • Bleeding or bleeding diathesis (excluding menses)
     • Intracranial or intraspinal surgery
     • Ischemic stroke
     • Known malignant intracranial neoplasm (primary or metastatic)
     • Known structural cerebral vascular lesion (e.g., AVM)
     • Significant facial and/or closed head trauma
     • Suspected aortic dissection
     •  Peptic ulcer
     •  Cardiopulmonary arrest, including: cardiac arrest, CPR, defibrillation, respiratory arrest, or ventricular fibrillation (V-fib), ventricular tachycardia (VT), or pulseless electrical activity (PEA); or, traumatic or prolonged (&gt;10 minutes) CPR
     • Allergic reaction to alteplase, streptokinase, anistreplase, tenecteplase, or reteplase
     • Intubation, including endotracheal intubation, mechanical ventilation, nasotracheal intubation, or orotracheal intubation
     • Mechanical circulatory assist device placement, including: aortic balloon pump, biventricular assist device, intra-aortic balloon, intra-aortic balloon counterpulsation, intra-aortic counterpulsation balloon pump, left ventricular device, percutaneous ventricular assist device, or ventricular assist device
     • Oral anticoagulant therapy
     • Advanced dementia
     • Pregnancy
     • Internal bleeding
     • Major surgery
     • Severe neurologic impairment (e.g., based on Glasgow coma scale or as indicated by the patient receiving therapeutic hypothermia in the ED)"/>
          <criteria>
            <language value="text/cql-identifier"/>
            <expression value="Denominator Exclusions"/>
          </criteria>
        </population>
        <population id="D66FC17B-ABED-4476-A524-B092500128D9">
          <code>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/measure-population"/>
              <code value="numerator"/>
              <display value="Numerator"/>
            </coding>
          </code>
          <description
                       value="Emergency department encounters with a diagnosis of STEMI:
     - where time from ED arrival to fibrinolysis is 30 minutes or fewer;
    OR
    - where PCI is performed within 90 minutes of arrival for non-transfer patients;
    OR
    - where the patient is transferred within 45 minutes of ED arrival."/>
          <criteria>
            <language value="text/cql-identifier"/>
            <expression value="Numerator"/>
          </criteria>
        </population>
        <population id="dfe4fe2d-fdea-484b-bd77-b2e4bd2523a3">
          <code>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/measure-population"/>
              <code value="numerator-exclusion"/>
              <display value="Numerator Exclusion"/>
            </coding>
          </code>
          <criteria>
            <language value="text/cql-identifier"/>
          </criteria>
        </population>
        <population id="752e3422-6975-4e47-8557-a2cb68f6adad">
          <code>
            <coding>
              <system
                      value="http://terminology.hl7.org/CodeSystem/measure-population"/>
              <code value="denominator-exception"/>
              <display value="Denominator Exception"/>
            </coding>
          </code>
          <criteria>
            <language value="text/cql-identifier"/>
          </criteria>
        </population>
      </group>
      <supplementalData id="sde-ethnicity">
        <usage>
          <coding>
            <system
                    value="http://terminology.hl7.org/CodeSystem/measure-data-usage"/>
            <code value="supplemental-data"/>
          </coding>
        </usage>
        <description value="SDE Ethnicity"/>
        <criteria>
          <language value="text/cql-identifier"/>
          <expression value="SDE Ethnicity"/>
        </criteria>
      </supplementalData>
      <supplementalData id="sde-payer">
        <usage>
          <coding>
            <system
                    value="http://terminology.hl7.org/CodeSystem/measure-data-usage"/>
            <code value="supplemental-data"/>
          </coding>
        </usage>
        <description value="SDE Payer"/>
        <criteria>
          <language value="text/cql-identifier"/>
          <expression value="SDE Payer"/>
        </criteria>
      </supplementalData>
      <supplementalData id="sde-race">
        <usage>
          <coding>
            <system
                    value="http://terminology.hl7.org/CodeSystem/measure-data-usage"/>
            <code value="supplemental-data"/>
          </coding>
        </usage>
        <description value="SDE Race"/>
        <criteria>
          <language value="text/cql-identifier"/>
          <expression value="SDE Race"/>
        </criteria>
      </supplementalData>
      <supplementalData id="sde-sex">
        <usage>
          <coding>
            <system
                    value="http://terminology.hl7.org/CodeSystem/measure-data-usage"/>
            <code value="supplemental-data"/>
          </coding>
        </usage>
        <description value="SDE Sex"/>
        <criteria>
          <language value="text/cql-identifier"/>
          <expression value="SDE Sex"/>
        </criteria>
      </supplementalData>
    </Measure>