CMS FHIR Quality Measure Development IG, published by Centers for Medicare & Medicaid Services (CMS). This guide is not an authorized publication; it is the continuous build for version 0.8.0-cibuild built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/cqframework/cms-qmd/ and changes regularly. See the Directory of published versions

Medications

FHIR defines several medication-related resources, profiled for use in quality improvement artifacts by US Quality Core. For background see the Medication module in the base FHIR specification and the Medication list guidance in US Core.

Medication in the US CQL implementation guide covers active medications and electronically transmitted prescriptions. The patterns below are those specific to quality measurement, principally the positive and negated forms of ordering, administering, and dispensing; see the Pattern Index for the full list.

For MedicationRequest, MedicationAdministration, and MedicationDispense, see also modifier elements, search parameters, and cross-version considerations in that guide.

Two considerations apply throughout. status, intent, and doNotPerform are all modifier elements on MedicationRequest, and where a profile does not fix them the expression must account for every value they may take. And each medication profile is characterized by the medication element, which may be a code or a reference. The category functions isCommunity(), isDischarge(), and hasCategory() are defined in FHIRCommon.

Medication status and intent

FHIRCommon defines status functions for observations, conditions, and allergies, but none for the medication resources, so medication logic has had to test status and intent with inline code lists. This guide defines the missing functions in a MedicationCommon library, following the same conventions FHIRCommon uses — an is prefixed predicate over a single resource, and an unprefixed form that filters a list:

Resource	Functions
MedicationRequest status	isActive(), isOnHold(), isCompleted(), isCancelled(), isStopped(), isDraft(), isEnteredInError(), and the list forms active(), onHold(), completed()
MedicationRequest intent	isOrder(), isPlan(), isProposal(), and isOrderIntent() for any of the order intents, with the list form orderIntent()
MedicationAdministration status	isCompleted(), isInProgress(), isOnHold(), isStopped(), isNotDone(), isEnteredInError(), and the list form completed()
MedicationDispense status	isCompleted(), isInProgress(), isPreparation(), isOnHold(), isCancelled(), isStopped(), isDeclined(), isEnteredInError(), and the list form completed()

isOrderIntent() covers order, original-order, reflex-order, filler-order, and instance-order, which is the set used by the Active Medication Orders expression in USCoreElements; it distinguishes an actual order from a proposal, plan, or option.

NOTE: Nothing in MedicationCommon is US-specific, so the intent is to propose these functions for inclusion in FHIRCommon. Until that happens, measure developers who want to use them can add them to CQMCommon; this guidance will be updated if and when they are available in that library. Note also that no aggregate helpers are defined for the recurring active or completed and in-progress, completed or on-hold combinations, because naming them requires agreement on what they mean — for now the examples below compose the individual predicates.

Medication ordered

US Quality Core defines the US Quality Core MedicationRequest profile to represent medication proposals, plans, and orders, as well as self-reported medications.

define "Antithrombotic Therapy at Discharge":
  [USQualityCore.MedicationRequest: "Antithrombotic Therapy Anticoagulant"] Antithrombotic
    without [USQualityCore.TaskRejected] TaskReject
      such that TaskReject.focus.references(Antithrombotic)
        and TaskReject.code ~ FHIRCommon."Fulfill"
    where (Antithrombotic.isCommunity() or Antithrombotic.isDischarge())
      and (Antithrombotic.isActive() or Antithrombotic.isCompleted())
      and Antithrombotic.isOrder()

Here active and completed identify active or filled prescriptions. The without clause is required because a rejected proposal may be recorded against any request; see Positive requests and rejected proposals. The profile fixes doNotPerform to false where present, so it need not be tested.

Medication Not Ordered

US Quality Core defines the US Quality Core Medication Not Requested profile to document the reason for not ordering a medication or class of medications. The profile fixes doNotPerform to true, so that element need not be tested.

define "Antithrombotics Prohibited for Reason":
  [USQualityCore.MedicationNotRequested: "Antithrombotic Therapy Anticoagulant"] NoAntithrombotic
    where (NoAntithrombotic.reasonCode in "Medical Reason For Not Providing Treatment"
        or NoAntithrombotic.reasonCode in "Patient Declined")
      and (NoAntithrombotic.isCommunity() or NoAntithrombotic.isDischarge())
      and (NoAntithrombotic.isActive() or NoAntithrombotic.isCompleted())
      and NoAntithrombotic.isOrder()

A prohibition is a different statement from the rejection of a proposal, which uses TaskRejected against the positive request:

define "Antithrombotics Rejected for Reason":
  [USQualityCore.MedicationRequest: "Antithrombotic Therapy Anticoagulant"] Antithrombotic
    with [USQualityCore.TaskRejected] TaskRejected
      such that TaskRejected.focus.references(Antithrombotic)
        and TaskRejected.code ~ FHIRCommon."Fulfill"
        and (TaskRejected.statusReason in "Medical Reason For Not Providing Treatment"
          or TaskRejected.statusReason in "Patient Declined")
    where Antithrombotic.isActive()

Where measure intent accepts either, the two are unioned. A measure may extend the same pattern across the other negation profiles:

define "Exclusion Criteria":
  exists "Antithrombotics Prohibited for Reason"
    or exists "Antithrombotics Rejected for Reason"
    or exists "Antithrombotics Not Administered for Reason"
    or exists "Antithrombotics Not Dispensed for Reason"

Medication administered

US Quality Core defines the US Quality Core MedicationAdministration profile to represent the administration of a medication to a patient. The profile does not fix status, so it must be tested.

define "Antithrombotic Therapy Administration":
  [USQualityCore.MedicationAdministration: "Antithrombotic Therapy Anticoagulant"] VTEMedication
    where VTEMedication.isCompleted()
      and VTEMedication.category ~ FHIRCommon."Inpatient"

Medication not administered

US Quality Core defines the US Quality Core MedicationAdministration Not Done profile to document the reason an administration did not occur. The profile fixes status to not-done, so it need not be tested.

define "Antithrombotic Therapy Not Administered":
  [USQualityCore.MedicationAdministrationNotDone: "Antithrombotic Therapy Anticoagulant"] VTEMedication
    where VTEMedication.category ~ FHIRCommon."Inpatient"
      and (VTEMedication.reasonCode in "Medical Reason For Not Providing Treatment"
        or VTEMedication.reasonCode in "Patient Declined")

Medication dispensed

US Quality Core defines the US Quality Core MedicationDispense profile to represent the fulfillment of a medication request, in either a hospital or a community pharmacy. The profile does not fix status.

define "Antithrombotic Medication Dispensed":
  [USQualityCore.MedicationDispense: "Antithrombotic Therapy Anticoagulant"] MedicationDispense
    where MedicationDispense.isInProgress()
      or MedicationDispense.isCompleted()
      or MedicationDispense.isOnHold()

The in-progress, completed, and on-hold statuses together retrieve any positive dispensing event.

Medication not dispensed

US Quality Core defines the US Quality Core MedicationDispense Declined profile to document the reason a dispense did not occur. The profile fixes status to declined.

define "Antithrombotic Medication Not Dispensed":
  [USQualityCore.MedicationDispenseDeclined: "Antithrombotic Therapy Anticoagulant"] MedicationDispense
    where MedicationDispense.statusReason in "Medical Reason For Not Providing Treatment"
      or MedicationDispense.statusReason in "Patient Declined"

Medication in use

Beyond medications ordered at discharge or administered in hospital, a measure may need medications currently in use outside the hospital, including those not prescribed by a provider.

define "Antithrombotic Therapy Active":
  [USQualityCore.MedicationRequest: "Antithrombotic Therapy Anticoagulant"] Antithrombotic
    where Antithrombotic.isActive()

USCoreElements defines an equivalent Active Medication Orders, which additionally constrains intent to the order intents. Where a measure needs that narrowing, add and Antithrombotic.isOrderIntent().

Self-administered OTCs

Over-the-counter medications the patient takes without a prescription are distinguished by category rather than by code.

define "Cold OTC At Home":
  [USQualityCore.MedicationRequest: "OIA_Cough_Cold_Meds"] CoughCold
    where CoughCold.isCommunity()
      and CoughCold.isActive()
      and CoughCold.isPlan()

isCommunity() reflects the MedicationRequest category indicating that the setting in which the medication is taken, or expected to be taken, is community.