2026 US Quality Core Implementation Guide
0.5.0 - cibuild US

2026 US Quality Core Implementation Guide, published by Office of the National Coordinator for Health Information Technology (ONC). This guide is not an authorized publication; it is the continuous build for version 0.5.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/FHIR/us-quality-core/ and changes regularly. See the Directory of published versions

## US Quality Core Patterns (Informational)

> The Clinical Quality Language (CQL) artifacts, ModelInfo, libraries, and patterns referenced on this page are informational content included in this version of US Quality Core to support measure authoring, execution, and reporting tooling. They are not part of the conformance requirements of this guide and may evolve or be removed in future versions.

The US Quality Core patterns described here are adapted from the QI-Core patterns developed through the use of QI-Core profiles in creating CQL-based quality measures and decision support, and are aligned for use with US Quality Core profiles. CMS program measures can be accessed at the Electronic Clinical Quality Improvement (eCQI) Resource Center on HealthIT.gov.

For more information about model information for usage in CQL, refer to the ModelInfo page of this guide.

### Primitives

The USQualityCore ModelInfo represents FHIR primitive elements using the system types directly, so when using USQualityCore, no `.value` accessor is required.

To facilitate implementation in FHIR, references to primitive elements are translated to the FHIR representation using the same `FHIRHelpers` library used for pure-FHIR artifacts, so this library is still required as a runtime, rather than a compile-time dependency for profile-informed authoring models.

In profile-informed authoring, the primitive type is mapped to the CQL type and represented with the CQL type in the model. So, a `FHIR.string` element is modeled as a `System.String`, and the translator maps that to the `FHIR.string` value using the `FHIRHelpers` library.

    include FHIRHelpers version '4.0.1'

Note that the FHIRHelpers version must be consistent with the FHIR version being used.

### Extensions

Extensions in FHIR provide a standard mechanism to describe additional content that is not part of the base FHIR resources. By defining extensions in a uniform way as part of the base specification, FHIR enables extension-based functionality to be introduced through the use of profiles and implementation guidance. US Quality Core includes several extensions related to quality improvement applications.

With profile-informed authoring in USQualityCore, extensions and slices defined in profiles are represented directly as elements in the types. For example:

    define TestSlices:
      [USCoreBloodPressure] BP
        where BP.systolic.value < 140 'mm[Hg]'
          and BP.diastolic.value < 90 'mm[Hg]'

    define TestSimpleExtensions:
      Patient P
        where P.birthsex = 'M'

    define TestComplexExtensions:
      Patient P
        where P.race.ombCategory contains "American Indian or Alaska Native"
          and P.race.detailed contains "Alaska Native"

### Choice Types

FHIR includes the notion of Choice Types, or elements that can be of any of a number of types. For example, the `Patient.deceased` element can be specified as a `Boolean` or as a `DateTime`. Since CQL also supports choice types, these are manifest directly as Choice Types within the ModelInfo.

Where appropriate, USQualityCore profiles restrict choice types to those that are appropriate for the quality improvement use case. For example, The `USQualityCoreConditionProblemsHealthConcerns` profile removes `String` as a possible type for the `onset` element, to communicate the expectation that a computable representation of onset is required for quality improvement applications.

Quality improvement logic must be prepared to deal with choice elements of any of the available types because systems may communicate instances with values of any of these types. To support the most common usages of choice types (for timing elements), the following functions have been defined:

    define fluent function toInterval(choice Choice<DateTime, Quantity, Interval<DateTime>, Interval<Quantity>>):
      case
    	  when choice is DateTime then
        	Interval[choice as DateTime, choice as DateTime]
    		when choice is Interval<DateTime> then
      		choice as Interval<DateTime>
    		when choice is Quantity then
    		  Interval[Patient.birthDate + (choice as Quantity),
    			  Patient.birthDate + (choice as Quantity) + 1 year)
    		when choice is Interval<Quantity> then
    		  Interval[Patient.birthDate + (choice.low as Quantity),
    			  Patient.birthDate + (choice.high as Quantity) + 1 year)
    		else
    			null as Interval<DateTime>
    	end

    define fluent function abatementInterval(condition Condition):
    	if condition.abatement is DateTime then
    	  Interval[condition.abatement as DateTime, condition.abatement as DateTime]
    	else if condition.abatement is Quantity then
    		Interval[Patient.birthDate + (condition.abatement as Quantity),
    			Patient.birthDate + (condition.abatement as Quantity) + 1 year)
    	else if condition.abatement is Interval<Quantity> then
    	  Interval[Patient.birthDate + (condition.abatement.low as Quantity),
    		  Patient.birthDate + (condition.abatement.high as Quantity) + 1 year)
    	else if condition.abatement is Interval<DateTime> then
    	  Interval[condition.abatement.low, condition.abatement.high)
    	else null as Interval<DateTime>

    define fluent function prevalenceInterval(condition Condition):
    if condition.clinicalStatus ~ "active"
      or condition.clinicalStatus ~ "recurrence"
      or condition.clinicalStatus ~ "relapse" then
      Interval[start of ToInterval(condition.onset), end of ToAbatementInterval(condition)]
    else
      Interval[start of ToInterval(condition.onset), end of ToAbatementInterval(condition))

    define fluent function latest(choice Choice<DateTime, Quantity, Interval<DateTime>, Interval<Quantity>> ):
      (choice.toInterval()) period
        return
          if period.hasEnd() then end of period
          else start of period

    define fluent function earliest(choice Choice<DateTime, Quantity, Interval<DateTime>, Interval<Quantity>> ):
      (choice.toInterval()) period
        return
          if period.hasStart() then start of period
          else end of period

Note that these functions make use of the FHIRHelpers library to ensure correct processing.

> NOTE: The examples throughout this topic have been simplified to illustrate specific usage. Refer to the originating context for complete expressions.