Cervical Cancer Screening - Quality Measure Implementation Guide v2.0.0-ballot

Quality Measure Implementation Guide, published by HL7 International / Clinical Quality Information. This guide is not an authorized publication; it is the continuous build for version 2.0.0-ballot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/fhir-cqm/ and changes regularly. See the Directory of published versions

Measure: Cervical Cancer Screening (Experimental)

Official URL: http://hl7.org/fhir/uv/cqm/Measure/CCSComponent	Version: 0.0.001	Highlight text changes?
Standards status: Informative Active as of 2025-08-13		Computable Name: CCSComponent
Other Identifiers: Version Independent: Uniform Resource Identifier (URI)#http://example.org/fhir/us/cqm/Measure/CCSComponent (use: official, ), Version Specific: Uniform Resource Identifier (URI)#http://example.org/fhir/us/cqm/Measure/130v10 (use: official, ), Short Name: Colorectal Cancer Screening (use: usual, ), OID:2.16.840.1.113883.4.642.40.61.29.2
Usage: Clinical Venue: EC

This is only an example.

Metadata

Title Cervical Cancer Screening

Version 0.0.001

Short Name Colorectal Cancer Screening

GUID (Version Independent) http://example.org/fhir/us/cqm/Measure/CCSComponent

GUID (Version Specific) http://example.org/fhir/us/cqm/Measure/130v10

Identifier urn:oid:2.16.840.1.113883.4.642.40.61.29.2

Effective Period 2022-01-01 through 2022-12-31

Experimental true

Use Context Clinical Venue = EC

Jurisdiction 001 from http://unstats.un.org/unsd/methods/m49/m49.htm

Steward (Publisher) HL7 International / Clinical Quality Information

Description

This is only an example.

Measure Basis boolean

Measure Scoring Proportion

Improvement Notation increase from http://terminology.hl7.org/CodeSystem/measure-improvement-notation

Measure Type process from http://terminology.hl7.org/CodeSystem/measure-type

Measure Group (Rate) (ID: primary)

Supplemental Data Elements

Supplemental Data Element ID: 4d3fff25-29d7-4e61-9fdd-a02a85c1472f
Usage Code: Supplemental Data
Description: No description provided
Logic Definition: SDE Ethnicity

Supplemental Data Element ID: 4732f9d3-e4c9-4a24-ab3c-9247a55d73ef
Usage Code: Supplemental Data
Description: No description provided
Logic Definition: SDE Payer

Supplemental Data Element ID: 523c2619-71c6-4e60-83f8-3d8eeef75398
Usage Code: Supplemental Data
Description: No description provided
Logic Definition: SDE Race

Supplemental Data Element ID: 336d1356-61a7-4220-9635-ffc50b90af2f
Usage Code: Supplemental Data
Description: No description provided
Logic Definition: SDE Sex

Measure Logic

Primary Library CCS Component Library

Contents Population Criteria
Logic Definitions
Terminology
Dependencies
Data Requirements
Parameters

Population Criteria

Measure Group (Rate) (ID: primary)

Logic Definitions

Logic Definition Library Name: AdultOutpatientEncounters

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'

Logic Definition Library Name: 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"
    )

Logic Definition Library Name: AdvancedIllnessandFrailtyExclusion

define "Has Criteria Indicating Frailty":
  //Ask Bryn about devices
      	exists ( [DeviceRequest: "Frailty Device"] FrailtyDeviceOrder
      			where FrailtyDeviceOrder.authoredOn during "Measurement Period"
      	)
          // DeviceUseStatement has a known issue with the publication tooling
          // so it is removed to allow this IG to publish until that is fixed
      		//or exists ( [DeviceUseStatement: "Frailty Device"] FrailtyDeviceUse
      		//		where Global."Normalize Interval"(FrailtyDeviceUse.timing) overlaps "Measurement Period"
      		//)
      		or exists ( [Condition: "Frailty Diagnosis"] FrailtyDiagnosis
      				where Global."Prevalence Period"(FrailtyDiagnosis) overlaps "Measurement Period"
      		)
      		or exists ( [Encounter: "Frailty Encounter"] FrailtyEncounter
      				where FrailtyEncounter.period overlaps "Measurement Period"
      		)
      		or exists ( [Observation: "Frailty Symptom"] FrailtySymptomObservation
      				where Global."Normalize Interval"(FrailtySymptomObservation.effective) overlaps "Measurement Period"
      		)

Logic Definition Library Name: AdvancedIllnessandFrailtyExclusion

define "Outpatient Encounters with Advanced Illness":
  ( [Encounter: "Outpatient"]
      		union [Encounter: "Observation"]
      		union [Encounter: "ED"]
      		union [Encounter: "Nonacute Inpatient"] ) OutpatientEncounter
      		 with [Condition: "Advanced Illness"] AdvancedIllnessDiagnosis
                  such that exists (
                      OutpatientEncounter.diagnosis.condition EncounterDiagnosis
                          where EndsWith(EncounterDiagnosis.reference, AdvancedIllnessDiagnosis.id)
                  )
                  and OutpatientEncounter.period starts 2 years or less on or before
      			end of "Measurement Period"

Logic Definition Library Name: AdvancedIllnessandFrailtyExclusion

define "Inpatient Encounter with Advanced Illness":
  [Encounter: "Acute Inpatient"] InpatientEncounter
      		with [Condition: "Advanced Illness"] AdvancedIllnessDiagnosis
                  such that exists (
                      InpatientEncounter.diagnosis.condition EncounterDiagnosis
                          where EndsWith(EncounterDiagnosis.reference, AdvancedIllnessDiagnosis.id)
                  )
      			and InpatientEncounter.period starts 2 years or less on or before
      			end of "Measurement Period"

Logic Definition Library Name: AdvancedIllnessandFrailtyExclusion

define "Dementia Medications In Year Before or During Measurement Period":
  ["MedicationDispense": "Dementia Medications"] DementiaMed
      		where DementiaMed.whenHandedOver during Interval[
                  ( start of "Measurement Period" - 1 year ), end of "Measurement Period"
              ]

Logic Definition Library Name: AdvancedIllnessandFrailtyExclusion

define "Advanced Illness and Frailty Exclusion Not Including Over Age 80":
  //If the measure does NOT include populations age 80 and older, then use this logic:
      	Global."CalendarAgeInYearsAt"(FHIRHelpers.ToDate(Patient.birthDate), start of "Measurement Period")>= 65
              and "Has Criteria Indicating Frailty"
              and ( Count("Outpatient Encounters with Advanced Illness")>= 2
                  or exists ( "Inpatient Encounter with Advanced Illness" )
                  or exists "Dementia Medications In Year Before or During Measurement Period"
              )

Logic Definition Library Name: AdvancedIllnessandFrailtyExclusion

// start here

define "Long Term Care Periods During Measurement Period":
  ( [Encounter: "Care Services in Long-Term Residential Facility"]
              		union [Encounter: "Nursing Facility Visit"] ) LongTermFacilityEncounter
              		where LongTermFacilityEncounter.period overlaps "Measurement Period"
              		return LongTermFacilityEncounter.period
              			intersect "Measurement Period"

Logic Definition Library Name: AdvancedIllnessandFrailtyExclusion

define "Long Term Care Periods Longer Than 90 Consecutive Days":
  exists ( "Long Term Care Periods During Measurement Period" LongTermCareDuringMP
        where duration in days of LongTermCareDuringMP > 90
    )

Logic Definition Library Name: SupplementalDataElements

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

Logic Definition Library Name: SupplementalDataElements

define "SDE Payer":
  [Coverage: type in "Payer"] Payer
        return {
          code: Payer.type,
          period: Payer.period
        }

Logic Definition Library Name: SupplementalDataElements

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

Logic Definition Library Name: SupplementalDataElements

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