Quality Measure Implementation Guide (STU5)
5.0.0 - release United States of America flag

Quality Measure Implementation Guide (STU5), published by HL7 International / Clinical Quality Information. This guide is not an authorized publication; it is the continuous build for version 5.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/cqf-measures/ and changes regularly. See the Directory of published versions

Measure: EXM124 - Cervical Cancer Screening (Experimental)

Official URL: http://hl7.org/fhir/us/cqfmeasures/Measure/EXM124-FHIR Version: 9.0.000
Active as of 2022-02-22 Computable Name: EXM124
Other Identifiers: http://example.org/fhir/cqi/ecqm/Measure/Identifier/cms#124 (use: official, ), Version Independent: Uniform Resource Identifier (URI)#http://example.org/fhir/us/cqfmeasures/Measure/EXM124-FHIR (use: official, ), Version Specific: Uniform Resource Identifier (URI)#http://example.org/fhir/us/cqfmeasures/Measure/CMS124v7 (use: official, ), Short Name: Cervical Cancer Screening (use: usual, ), http://example.org/fhir/cqi/ecqm/Measure/Identifier/mips#309 (use: official, )

Usage:Venue: EC

Copyright/Legal: This Physician Performance Measure (Measure) and related data specifications were developed by the National Committee for Quality Assurance (NCQA). NCQA is not responsible for any use of the Measure. NCQA makes no representations, warranties, or endorsement about the quality of any organization or physician that uses or reports performance measures and NCQA has no liability to anyone who relies on such measures or specifications. NCQA holds a copyright in the Measure. The Measure can be reproduced and distributed, without modification, for noncommercial purposes (eg, use by healthcare providers in connection with their practices) without obtaining approval from NCQA. Commercial use is defined as the sale, licensing, or distribution of the Measure for commercial gain, or incorporation of the Measure into a product or service that is sold, licensed or distributed for commercial gain. All commercial uses or requests for modification must be approved by NCQA and are subject to a license at the discretion of NCQA. (C) 2012-2017 National Committee for Quality Assurance. All Rights Reserved. Limited proprietary coding is contained in the Measure specifications for user convenience. Users of proprietary code sets should obtain all necessary licenses from the owners of the code sets. NCQA disclaims all liability for use or accuracy of any third party codes contained in the specifications. CPT(R) contained in the Measure specifications is copyright 2004-2017 American Medical Association. LOINC(R) copyright 2004-2017 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R] ) copyright 2004-2017 International Health Terminology Standards Development Organisation. ICD-10 copyright 2017 World Health Organization. All Rights Reserved.

Percentage of women 21-64 years of age who were screened for cervical cancer using either of the following criteria:

  • Women age 21-64 who had cervical cytology performed every 3 years
  • Women age 30-64 who had cervical cytology/human papillomavirus (HPV) co-testing performed every 5 years

This measure has been developed to support improvement in clinical care.

Title: EXM124 - Cervical Cancer Screening
Id: EXM124-FHIR
Version: 9.0.000
Url: EXM124 - Cervical Cancer Screening
Official

124

Version Independent Identifier:

http://example.org/fhir/us/cqfmeasures/Measure/EXM124-FHIR

Version Specific Identifier:

http://example.org/fhir/us/cqfmeasures/Measure/CMS124v7

Short Name Identifier:

Cervical Cancer Screening

Official

309

Effective Period: 2018-01-01..2018-12-31
Experimental: true
Publisher: HL7 International / Clinical Quality Information
Description:

Percentage of women 21-64 years of age who were screened for cervical cancer using either of the following criteria:

  • Women age 21-64 who had cervical cytology performed every 3 years
  • Women age 30-64 who had cervical cytology/human papillomavirus (HPV) co-testing performed every 5 years
Use Context:
code value
venue
Jurisdiction: US
Topic: 57024-2
Purpose:

This measure has been developed to support improvement in clinical care.

Copyright:

This Physician Performance Measure (Measure) and related data specifications were developed by the National Committee for Quality Assurance (NCQA). NCQA is not responsible for any use of the Measure. NCQA makes no representations, warranties, or endorsement about the quality of any organization or physician that uses or reports performance measures and NCQA has no liability to anyone who relies on such measures or specifications. NCQA holds a copyright in the Measure. The Measure can be reproduced and distributed, without modification, for noncommercial purposes (eg, use by healthcare providers in connection with their practices) without obtaining approval from NCQA. Commercial use is defined as the sale, licensing, or distribution of the Measure for commercial gain, or incorporation of the Measure into a product or service that is sold, licensed or distributed for commercial gain. All commercial uses or requests for modification must be approved by NCQA and are subject to a license at the discretion of NCQA. (C) 2012-2017 National Committee for Quality Assurance. All Rights Reserved. Limited proprietary coding is contained in the Measure specifications for user convenience. Users of proprietary code sets should obtain all necessary licenses from the owners of the code sets. NCQA disclaims all liability for use or accuracy of any third party codes contained in the specifications. CPT(R) contained in the Measure specifications is copyright 2004-2017 American Medical Association. LOINC(R) copyright 2004-2017 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R] ) copyright 2004-2017 International Health Terminology Standards Development Organisation. ICD-10 copyright 2017 World Health Organization. All Rights Reserved.

Disclaimer:

The performance Measure is not a clinical guideline and does not establish a standard of medical care, and has not been tested for all potential applications. THE MEASURE AND SPECIFICATIONS ARE PROVIDED "AS IS" 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].

Basis: boolean
Scoring:

Proportion

Type:

process

Rationale:

Breast cancer is one of the most common types of cancers, accounting for 15 percent of all new cancer diagnoses in the U.S. (Howlader et al, 2016). In 2013, over 3 million women were estimated to be living with breast cancer in the U.S. and it is estimated that 12 percent of women will be diagnosed with breast cancer at some point during their lifetime (Howlader et al, 2016). While there are other factors that affect a woman's risk of developing breast cancer, advancing age is a primary risk factor. Breast cancer is most frequently diagnosed among women ages 55-64; the median age at diagnosis is 62 years (Howlader et al, 2016). The chance of a woman being diagnosed with breast cancer in a given year increases with age. By age 40, the chances are 1 in 235; by age 50 it becomes 1 in 54; by age 60, it is 1 in 25 (National Business Group on Health, 2011). In the U.S., costs associated with a diagnosis of breast cancer range from $451 to $2,520, factoring in continued testing, multiple office visits and procedures. The total costs related to breast cancer add up to nearly $7 billion per year in the U.S., including $2 billion spent on late-stage treatment (National Business Group on Health, 2011). If breast cancer is detected through mammography screening and diagnosed in its earliest stages, treatment may be less expensive (Feig, 2011).

Clinical recommendation statement:

The U.S. Preventive Services Task Force (USPSTF) recommends biennial screening mammography for women aged 50-74 years (B recommendation).
The decision to start screening mammography in women prior to age 50 years should be an individual one. Women who place a higher value on the potential benefit than the potential harms may choose to begin biennial screening between the ages of 40 and 49 years (C recommendation). (USPSTF, 2016) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening mammography in women aged 75 years or older (I statement). (USPSTF, 2016) The USPSTF concludes that the current evidence is insufficient to assess the benefits and harms of digital breast tomosynthesis (DBT) as a primary screening method for breast cancer (I Statement). (USPSTF, 2016)
The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of adjunctive screening for breast cancer using breast ultrasonography, magnetic resonance imaging, DBT, or other methods in women identified to have dense breasts on an otherwise negative screening mammogram (I statement). (USPSTF, 2016)

Improvement Notation:

Increased score indicates improvement

Guidance (Usage):

To ensure the measure is only looking for a cervical cytology test only after a woman turns 21 years of age, the youngest age in the initial population is 23. Patient self-report for procedures as well as diagnostic studies should be recorded in 'Procedure, Performed' template or 'Diagnostic Study, Performed' template in QRDA-1. Include only cytology and HPV "co-testing"; in co-testing, both cytology and HPV tests are performed (i.e., the samples are collected and both tests are ordered, regardless of the cytology result) on the same date of service. Do not include reflex testing. In addition, if the medical record indicates the HPV test was performed only after determining the cytology result, this is considered reflex testing and does not meet criteria for the measure.

Population Criteria:
Initial Population:

Women 23-64 years of age with a visit during the measurement period

Numerator:

Women with one or more screenings for cervical cancer. Appropriate screenings are defined by any one of the following criteria:

  • Cervical cytology performed during the measurement period or the two years prior to the measurement period for women who are at least 21 years old at the time of the test
  • Cervical human papillomavirus (HPV) testing performed during the measurement period or the four years prior to the measurement period for women who are 30 years or older at the time of the test
Denominator:

Equals Initial Population

Denominator Exclusion:

Women who had a hysterectomy with no residual cervix or a congenital absence of cervix. Exclude patients who are in hospice care for any part of the measurement period. Exclude patients receiving palliative care during the measurement period.

Supplemental Data Elements:

SDE Ethnicity

SDE Payer

Race

Sex
Libraries:
EXM124 - Cervical Cancer Screening Library
Terminology and Other Dependencies:
  • Supplemental Data Elements Libraryversion: null2.0.0)
  • http://fhir.org/guides/cqf/common/Library/FHIRHelpers|4.0.1
  • MAT Global Common Functions FHIR Libraryversion: null5.0.000)
  • Adult Outpatient Encounters Common Libraryversion: null2.0.000)
  • Hospice FHIR Libraryversion: null2.0.000)
  • http://snomed.info/sct|http://snomed.info/sct/731000124108/version/201709
  • http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.108.12.1017
  • http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.110.12.1059
  • http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1001
  • http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.526.3.1240
  • http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1025
  • http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1023
  • http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1016
  • http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591
  • http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.666.5.307
  • http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1108.15
  • http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1014
  • Parameters:
    name use min max type
    Measurement Period In 0 1 Period
    SDE Sex Out 0 1 Coding
    Numerator Out 0 1 boolean
    Denominator Out 0 1 boolean
    SDE Payer Out 0 * Resource
    Initial Population Out 0 1 boolean
    SDE Ethnicity Out 0 * Coding
    Denominator Exclusion Out 0 1 boolean
    SDE Race Out 0 * Coding
    DataRequirements:
    Resource Type Resource Elements Valueset Name Valueset
    Coverage(Coverage) period type Payer http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591
    Patient(Patient) extension value url
    Encounter(Encounter) type Office Visit http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1001
    Encounter(Encounter) type Annual Wellness Visit http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.526.3.1240
    Encounter(Encounter) type Preventive Care Services - Established Office Visit, 18 and Up http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1025
    Encounter(Encounter) type Preventive Care Services-Initial Office Visit, 18 and Up http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1023
    Encounter(Encounter) type Home Healthcare Services http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1016
    Encounter(Encounter) period hospitalization hospitalization.dischargeDisposition type status Encounter Inpatient http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.666.5.307
    ServiceRequest(ServiceRequest) code authoredOn intent Hospice care ambulatory http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1108.15
    Procedure(Procedure) code performed status Hospice care ambulatory http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1108.15
    Procedure(Procedure) code performed status Hysterectomy with No Residual Cervix http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1014
    Condition(Condition) code onset
    Observation(Observation) effective code value status Pap Test http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.108.12.1017
    Observation(Observation) effective code value status HPV Test http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.110.12.1059
    Direct Reference Codes:
    display code system
    Discharge to home for hospice care (procedure) 428361000124107 http://snomed.info/sct
    Discharge to healthcare facility for hospice care (procedure) 428371000124100 http://snomed.info/sct
    Congenital absence of cervix (disorder) 37687000 http://snomed.info/sct
    Logic Definitions:
    Group Scoring Population Criteria Expression
    Measure scoring:

    Proportion

    Initial Population
    define "Initial Population":
    	Patient.gender = 'female'
    		and Global."CalendarAgeInYearsAt"(FHIRHelpers.ToDate(Patient.birthDate), start of "Measurement Period") in Interval[23, 64]
    		and exists AdultOutpatientEncounters."Qualifying Encounters"
    Numerator
    //    and NoCervixBirth.clinicalStatus ~ ToConcept(Global."active") because this is an excluion, all statuses are acceptable
    define "Numerator":
    	exists "Cervical Cytology Within 3 Years"
    		or exists "HPV Test Within 5 Years for Women Age 30 and Older"
    Denominator
    define "Denominator":
    	"Initial Population"
    Denominator Exclusion
    define "Denominator Exclusion":
    	Hospice."Has Hospice"
    		or exists "Absence of Cervix"
    Library Name Name
    SupplementalDataElements SDE Sex
    define "SDE Sex":
      case
          when Patient.gender = 'male' then Code { code: 'M', system: 'http://hl7.org/fhir/v3/AdministrativeGender', display: 'Male' }
          when Patient.gender = 'female' then Code { code: 'F', system: 'http://hl7.org/fhir/v3/AdministrativeGender', display: 'Female' }
          else null
        end
    Library Name Name
    EXM124-FHIR SDE Sex
    define "SDE Sex":
      SDE."SDE Sex"
    Library Name Name
    EXM124-FHIR Cervical Cytology Within 3 Years
    define "Cervical Cytology Within 3 Years":
    	[Observation: "Pap Test"] CervicalCytology
    		where CervicalCytology.value is not null
    			and CervicalCytology.status in { 'final', 'amended', 'corrected', 'preliminary' }
    		  and Global."Normalize Interval"(CervicalCytology.effective) ends 3 years or less on or before end of "Measurement Period"
    Library Name Name
    EXM124-FHIR HPV Test Within 5 Years for Women Age 30 and Older
    define "HPV Test Within 5 Years for Women Age 30 and Older":
    	[Observation: "HPV Test"] HPVTest
          where HPVTest.value is not null
            and HPVTest.status in { 'final', 'amended', 'corrected', 'preliminary' }
            and  Global."CalendarAgeInYearsAt"(FHIRHelpers.ToDate(Patient.birthDate), start of Global."Normalize Interval"(HPVTest.effective))>= 30
            and Global."Normalize Interval"(HPVTest.effective) ends 5 years or less on or before end of "Measurement Period"
    Library Name Name
    EXM124-FHIR Numerator
    //    and NoCervixBirth.clinicalStatus ~ ToConcept(Global."active") because this is an excluion, all statuses are acceptable
    define "Numerator":
    	exists "Cervical Cytology Within 3 Years"
    		or exists "HPV Test Within 5 Years for Women Age 30 and Older"
    Library Name Name
    AdultOutpatientEncounters Qualifying Encounters
    define "Qualifying Encounters":
    	(
        [Encounter: "Office Visit"]
      		union [Encounter: "Annual Wellness Visit"]
      		union [Encounter: "Preventive Care Services - Established Office Visit, 18 and Up"]
      		union [Encounter: "Preventive Care Services-Initial Office Visit, 18 and Up"]
      		union [Encounter: "Home Healthcare Services"]
      ) ValidEncounter
    		where ValidEncounter.period during "Measurement Period"
      		and ValidEncounter.status  = 'finished'
    Library Name Name
    EXM124-FHIR Initial Population
    define "Initial Population":
    	Patient.gender = 'female'
    		and Global."CalendarAgeInYearsAt"(FHIRHelpers.ToDate(Patient.birthDate), start of "Measurement Period") in Interval[23, 64]
    		and exists AdultOutpatientEncounters."Qualifying Encounters"
    Library Name Name
    EXM124-FHIR Denominator
    define "Denominator":
    	"Initial Population"
    Library Name Name
    SupplementalDataElements SDE Payer
    define "SDE Payer":
      [Coverage: type in "Payer"] Payer
            return {
              code: Payer.type,
              period: Payer.period
            }
    Library Name Name
    EXM124-FHIR SDE Payer
    define "SDE Payer":
      SDE."SDE Payer"
    Library Name Name
    SupplementalDataElements SDE Ethnicity
    define "SDE Ethnicity":
      (flatten (
          Patient.extension Extension
            where Extension.url = 'http://hl7.org/fhir/us/core/StructureDefinition/us-core-ethnicity'
              return Extension.extension
        )) E
          where E.url = 'ombCategory'
            or E.url = 'detailed'
          return E.value as Coding
    Library Name Name
    EXM124-FHIR SDE Ethnicity
    define "SDE Ethnicity":
      SDE."SDE Ethnicity"
    Library Name Name
    Hospice Has Hospice
    define "Has Hospice":
    	exists (
        [Encounter: "Encounter Inpatient"] DischargeHospice
    			where DischargeHospice.status = 'finished'
    		    and (
    	        DischargeHospice.hospitalization.dischargeDisposition ~ "Discharge to home for hospice care (procedure)"
    				    or DischargeHospice.hospitalization.dischargeDisposition ~ "Discharge to healthcare facility for hospice care (procedure)"
    	    	)
    				and DischargeHospice.period ends during "Measurement Period"
    	)
        or exists (
          [ServiceRequest: "Hospice care ambulatory"] HospiceOrder
            where HospiceOrder.intent = 'order'
                and HospiceOrder.authoredOn in "Measurement Period"
        )
        or exists (
          [Procedure: "Hospice care ambulatory"] HospicePerformed
            where HospicePerformed.status = 'completed'
              and Global."Normalize Interval"(HospicePerformed.performed) overlaps "Measurement Period"
        )
    Library Name Name
    EXM124-FHIR Absence of Cervix
    define "Absence of Cervix":
      ([Procedure: "Hysterectomy with No Residual Cervix"] NoCervixProcedure
       where Global."Normalize Interval"(NoCervixProcedure.performed) ends on or before end of "Measurement Period"
         and NoCervixProcedure.status = 'completed'
         )
      union [Condition : "Congenital absence of cervix (disorder)"] NoCervixBirth
    		where Global."Normalize Interval"(NoCervixBirth.onset) starts on or before end of "Measurement Period"
    Library Name Name
    EXM124-FHIR Denominator Exclusion
    define "Denominator Exclusion":
    	Hospice."Has Hospice"
    		or exists "Absence of Cervix"
    Library Name Name
    SupplementalDataElements SDE Race
    define "SDE Race":
      (flatten (
          Patient.extension Extension
            where Extension.url = 'http://hl7.org/fhir/us/core/StructureDefinition/us-core-race'
              return Extension.extension
        )) E
          where E.url = 'ombCategory'
            or E.url = 'detailed'
          return E.value as Coding
    Library Name Name
    EXM124-FHIR SDE Race
    define "SDE Race":
      SDE."SDE Race"