Chronic Disease Surveillance
0.1.0 - CI Build International flag

Chronic Disease Surveillance, published by Clinical Quality Framework. This guide is not an authorized publication; it is the continuous build for version 0.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/cqframework/aphl-chronic-ig/ and changes regularly. See the Directory of published versions

Measure: Seen Patients (Experimental)

Official URL: http://fhir.org/guides/cqf/aphl/chronic-ds/Measure/SeenPatients Version: 0.1.0
Draft as of 2025-09-25 Computable Name: SeenPatients

Seen patients during the measurement period

The Seen Patients cohort measure is defined to provide a baseline for chronic disease surveillance. For each individual in the cohort, supplemental data is collected aligning with the supplemental data defined for other chronic disease surveillance measure usages, allowing for analytics across and between specific measures.

Metadata
Title Seen Patients
Version 0.1.0
Status Draft
Experimental true
Jurisdiction 001 from http://unstats.un.org/unsd/methods/m49/m49.htm
Topic Health Quality Measure Document
Steward (Publisher) Clinical Quality Framework
Description

Seen patients during the measurement period
Purpose

The Seen Patients cohort measure is defined to provide a baseline for chronic disease surveillance. For each individual in the cohort, supplemental data is collected aligning with the supplemental data defined for other chronic disease surveillance measure usages, allowing for analytics across and between specific measures.
Measure Basis boolean
Measure Scoring cohort from http://hl7.org/fhir/measure-scoring
Measure Type process from http://hl7.org/fhir/measure-type
Measure Group (Rate) (ID: group-1)
Initial Population Description:

Seen patients

Criteria: Initial Population
Stratifier Code: Ethnicity
Description: Ethnicity (CDC Value Set)
Stratifier Code: Plan
Description: Payer
Stratifier Code: Race
Description: Race (CDC Value Set)
Stratifier Code: Sex [HL7.v3]
Description: Administrative sex
Stratifier Code: Age
Description: Age Group
Stratifier Code: Food insecurity risk [HVS]
Description: Food insecurity risk status
Supplemental Data Elements
Supplemental Data Element Usage Code: Supplemental Data
Description: Ethnicity (CDC Value Set)
Logic Definition: SDE Ethnicity
Supplemental Data Element Usage Code: Supplemental Data
Description: Payer
Logic Definition: SDE Payer
Supplemental Data Element Usage Code: Supplemental Data
Description: Race (CDC Value Set)
Logic Definition: SDE Race
Supplemental Data Element Usage Code: Supplemental Data
Description: Administrative sex
Logic Definition: SDE Sex
Supplemental Data Element Usage Code: Supplemental Data
Description: Age
Logic Definition: SDE Age
Supplemental Data Element Usage Code: Supplemental Data
Description: State of residence
Logic Definition: SDE State of Residence
Supplemental Data Element Usage Code: Supplemental Data
Description: Postal code of residence
Logic Definition: SDE Postal Code of Residence
Supplemental Data Element Usage Code: Supplemental Data
Description: Food insecurity risk status
Logic Definition: SDE Food Insecurity Risk Status
Measure Logic
Primary Library Seen Patients
Contents Population Criteria
Logic Definitions
Terminology
Dependencies
Data Requirements
Population Criteria
Measure Group (Rate) (ID: group-1)
Initial Population 
define "Initial Population":
  exists (
    [Encounter] E
      where E.period ends during "Measurement Period"
  )
Definition
Stratifier 
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
Definition
Stratifier 
define "SDE Ethnicity":
  SDE."SDE Ethnicity"
Definition
Stratifier 
define "SDE Payer":
  [Coverage: type in "Payer"] Payer
        return {
          code: Payer.type,
          period: Payer.period
        }
Definition
Stratifier 
define "SDE Payer":
  SDE."SDE Payer"
Definition
Stratifier 
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
Definition
Stratifier 
define "SDE Race":
  SDE."SDE Race"
Definition
Stratifier 
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
Definition
Stratifier 
define "SDE Sex":
  SDE."SDE Sex"
Definition
Stratifier 
define "SDE Food Insecurity Risk Status":
  SurveillanceDataElements."Food Insecurity Risk Status"
Definition
Logic Definitions
Logic Definition Library Name: SurveillanceDataElementsFHIR4 
// Jurisdiction of residence (jurisdiction of the patient)
define "Most recent physical home address":
  First(
    Patient.address A
      where A.use = 'home'
        and A.type = 'physical'
      sort by end of period desc
  )
Logic Definition Library Name: SurveillanceDataElementsFHIR4 
define "Postal Code of Residence":
  "Most recent physical home address".postalCode
Logic Definition Library Name: SurveillanceDataElementsFHIR4 
define "State of Residence":
  "Most recent physical home address".state
Logic Definition Library Name: SurveillanceDataElementsFHIR4 
// Jurisdiction of care (jurisdiction of the most recent encounter)
// TODO:
//define "Most recent address of care":

// NOTE: Included in eICR
// Occupational Data for Health - Past or Present Job
// http://hl7.org/fhir/us/odh/StructureDefinition-odh-PastOrPresentJob.html
// Observation: LOINC#11341-5, valueCodeableConcept in https://phinvads.cdc.gov/vads/ViewValueSet.action?oid=2.16.840.1.114222.4.11.7186

// Social Determinants of Health (SDOH)
// http://build.fhir.org/ig/HL7/fhir-sdoh-clinicalcare/StructureDefinition-SDOHCC-ObservationScreeningResponse.html
// Food insecurity risk: http://build.fhir.org/ig/HL7/fhir-sdoh-clinicalcare/Observation-SDOHCC-ObservationResponseHungerVitalSignQuestion3Example.html
// Observation: LOINC#88124-3, valueCodeableConcept in https://loinc.org/LL2510-7/ (At risk, No risk)
define "Food Insecurity Risk Status":
  First(
    [Observation: "Food insecurity risk [HVS]"] O
      sort by issued desc
  ).value as CodeableConcept
Logic Definition Library Name: SurveillanceDataElementsFHIR4 
// Age
define "Age":
  AgeInYearsAt(end of "Measurement Period")
Logic Definition Library Name: SupplementalDataElementsFHIR4 
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: SupplementalDataElementsFHIR4 
define "SDE Payer":
  [Coverage: type in "Payer"] Payer
        return {
          code: Payer.type,
          period: Payer.period
        }
Logic Definition Library Name: SupplementalDataElementsFHIR4 
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: SupplementalDataElementsFHIR4 
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
Logic Definition Library Name: SeenPatients 
define "SDE Sex":
  SDE."SDE Sex"
Logic Definition Library Name: SeenPatients 
define "SDE Postal Code of Residence":
  SurveillanceDataElements."Postal Code of Residence"
Logic Definition Library Name: SeenPatients 
define "SDE Payer":
  SDE."SDE Payer"
Logic Definition Library Name: SeenPatients 
define "SDE State of Residence":
  SurveillanceDataElements."State of Residence"
Logic Definition Library Name: SeenPatients 
define "SDE Food Insecurity Risk Status":
  SurveillanceDataElements."Food Insecurity Risk Status"
Logic Definition Library Name: SeenPatients 
define "Initial Population":
  exists (
    [Encounter] E
      where E.period ends during "Measurement Period"
  )
Logic Definition Library Name: SeenPatients 
define "SDE Ethnicity":
  SDE."SDE Ethnicity"
Logic Definition Library Name: SeenPatients 
define "SDE Age":
  SurveillanceDataElements."Age"
Logic Definition Library Name: SeenPatients 
define "SDE Race":
  SDE."SDE Race"
Logic Definition Library Name: FHIRHelpers 
define function ToString(value AdministrativeGender): value.value
Logic Definition Library Name: FHIRHelpers 
define function ToString(value AddressUse): value.value
Logic Definition Library Name: FHIRHelpers 
define function ToString(value AddressType): value.value
Logic Definition Library Name: FHIRHelpers 
define function ToInterval(period FHIR.Period):
    if period is null then
        null
    else
        if period."start" is null then
            Interval(period."start".value, period."end".value]
        else
            Interval[period."start".value, period."end".value]
Logic Definition Library Name: FHIRHelpers 
define function ToString(value uri): value.value
Terminology
Code System Description: Code system LOINC
Resource: Logical Observation Identifiers, Names and Codes (LOINC)
Canonical URL: http://loinc.org
Value Set Description: Value set Payer
Resource: Payer
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591
Direct Reference Code Display: Food insecurity risk [HVS]
Code: 88124-3
System: http://loinc.org
Dependencies
Dependency None
Data Requirements
Data Requirement Type: Patient
Profile(s): Patient
Must Support Elements: use, type, url, extension, value
Data Requirement Type: Coverage
Profile(s): Coverage
Must Support Elements: type, period
Code Filter(s):
Path: type
ValueSet: Payer
Data Requirement Type: Observation
Profile(s): Observation
Must Support Elements: code
Code Filter(s):
Path: code
Code(s): LOINC 88124-3: Food insecurity risk [HVS]
Data Requirement Type: Encounter
Profile(s): Encounter
Must Support Elements: period
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