/*
NOTE: For use by March 2026 US Realm Connectathon participants for internal use only. Not for use or distribution in commercial products.
*/
library CMS1264FHIRECATREHQR version '1.1.000'

using USQualityCore version '0.1.0-cibuild'
using USCore version '6.1.0-derived'
using FHIR version '4.0.1'

include hl7.fhir.uv.cql.FHIRHelpers version '4.0.1' called FHIRHelpers
include hl7.fhir.uv.cql.FHIRCommon version '2.0.0' called FHIRCommon
include hl7.fhir.us.cql.USCoreCommon version '2.0.0-ballot' called USCoreCommon
include hl7.fhir.us.cql.USCoreElements version '2.0.0-ballot' called USCoreElements

include USQualityCoreCommon version '0.1.0-cibuild' called USQualityCoreCommon
include SupplementalDataElements version '6.1.000' called SDE
include CQMCommon version '5.1.000' called CQMCommon

codesystem "SNOMEDCT": 'http://snomed.info/sct'
codesystem "RoleCode": 'http://terminology.hl7.org/CodeSystem/v3-RoleCode'

valueset "Mental Health Diagnosis without Substance Use Disorders": 'http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1046.285'
valueset "Decision to Transfer": 'http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1046.286'
valueset "Emergency Department Evaluation and Management Visit": 'http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1010'
valueset "Emergency Department Location": 'http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1046.284'
valueset "Emergency Department Treatment Location": 'http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1046.278'
valueset "Observation Services": 'http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1111.143'
valueset "Triage": 'http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1046.279'

code "Patient left without being seen (finding)": '21541000119102' from "SNOMEDCT" display 'Patient left without being seen (finding)'
code "Emergency room": 'ER' from "RoleCode" display 'Emergency room'
code "Emergency trauma unit": 'ETU' from "RoleCode" display 'Emergency trauma unit'

parameter "Measurement Period" Interval<DateTime>
  default Interval[@2026-01-01T00:00:00.000Z, @2027-01-01T00:00:00.000Z)

context Patient

define "Initial Population":
  "ED Evaluation and Management"
    union "ED Triage Excluding Those Prior To ED Encounters"

define "Denominator":
  "Initial Population"

define "Numerator":
  "Time to Treatment Room Greater Than 60 Minutes"
    union "ED Arrival Left Without Being Seen"
    union "Boarded Time Greater Than 240 Minutes and No Observation Stay"
    union "ED Length of Stay Greater Than 480 Minutes and No Observation Stay"

define "Pediatric With No Mental Health Diagnosis":
  ( "ED Encounter or Triage of Patients Less Than 18 Years" PediatricEDEncounters
      where not ( PediatricEDEncounters.hasPrincipalDiagnosisOf ( "Mental Health Diagnosis without Substance Use Disorders" ) )
  )

define "Adult With No Mental Health Diagnosis":
  ( "ED Encounter or Triage of Patients 18 Years and Older" AdultEDEncounters
      where not ( AdultEDEncounters.hasPrincipalDiagnosisOf ( "Mental Health Diagnosis without Substance Use Disorders" ) )
  )

define "Pediatric With Mental Health Diagnosis":
  ( "ED Encounter or Triage of Patients Less Than 18 Years" PediatricEDEncounters
      where ( PediatricEDEncounters.hasPrincipalDiagnosisOf ( "Mental Health Diagnosis without Substance Use Disorders" ) )
  )

define "Adult With Mental Health Diagnosis":
  ( "ED Encounter or Triage of Patients 18 Years and Older" AdultEDEncounters
      where ( AdultEDEncounters.hasPrincipalDiagnosisOf ( "Mental Health Diagnosis without Substance Use Disorders" ) )
  )

define "Stratification 1":
  "Pediatric With No Mental Health Diagnosis"

define "Stratification 2":
  "Adult With No Mental Health Diagnosis"

define "Stratification 3":
  "Pediatric With Mental Health Diagnosis"

define "Stratification 4":
  "Adult With Mental Health Diagnosis"

define "Boarded Time Greater Than 240 Minutes":
  "Denominator" EDEncounter
    where EDEncounter.TransferDecisionUsingOrder ( ) 241 minutes or more before EDEncounter.edDepartureTime ( )

define "Boarded Time Greater Than 240 Minutes and No Observation Stay":
  ( "Boarded Time Greater Than 240 Minutes" Boarding
      where not exists ( "ED Observation Status" EDObs
          where ( EDObs.period during Boarding.period )
      )
  )

define "ED Arrival Left Without Being Seen":
  "Denominator" EDEncounter
    where EDEncounter.hospitalization.dischargeDisposition ~ "Patient left without being seen (finding)"

define "ED Evaluation and Management":
  [Encounter: "Emergency Department Evaluation and Management Visit"] EDEvalManagementVisit
    where EDEvalManagementVisit.period ends during day of "Measurement Period"
      and EDEvalManagementVisit.status = 'finished'

define "ED Encounter or Triage of Patients 18 Years and Older":
  "Denominator" EDEncounter
    where AgeInYearsAt(date from start of EDEncounter.period) >= 18

define "ED Encounter or Triage of Patients Less Than 18 Years":
  "Denominator" EDEncounter
    where AgeInYearsAt(date from start of EDEncounter.period) < 18

define "ED Length of Stay Greater Than 480 Minutes":
  "Denominator" EDEncounter
    where EDEncounter.edArrivalTime ( ) 481 minutes or more before EDEncounter.edDepartureTime ( )

define "ED Length of Stay Greater Than 480 Minutes and No Observation Stay":
  ( "ED Length of Stay Greater Than 480 Minutes" EDStay
      where not exists ( "ED Observation Status" EDObs
          where ( EDObs.period during EDStay.period )
      )
  )

define "ED Observation Status":
  [Encounter: "Observation Services"] EDObsEncounter
    with "Denominator" EDStay
      such that EDObsEncounter.period during EDStay.period
        and EDObsEncounter.status = 'finished'

define "ED Triage":
  [Encounter: "Triage"] EDTriage
    where EDTriage.period ends during day of "Measurement Period"
      and EDTriage.status in { 'finished', 'triaged' }

define "ED Triage Excluding Those Prior To ED Encounters":
  "ED Triage" EDTriageinMP
    where not exists ( "ED Evaluation and Management" EDEvalManagementinMP
        where ( ( EDTriageinMP.period overlaps before EDEvalManagementinMP.period )
            or ( EDTriageinMP.period during EDEvalManagementinMP.period )
            or ( EDEvalManagementinMP.period during EDTriageinMP.period )
            or ( EDTriageinMP.period ends 120 minutes or less before start of EDEvalManagementinMP.period )
        )
    )

define "ED Triage Before Evaluation Management":
  "ED Triage" EDTriageinMP
    with "Denominator" EDEncounter
      such that ( ( EDTriageinMP.period overlaps before EDEncounter.period )
          or ( EDTriageinMP.period during EDEncounter.period )
          or ( EDEncounter.period during EDTriageinMP.period )
          or ( EDTriageinMP.period ends 120 minutes or less before start of EDEncounter.period )
      )

define "ED Triage and Evaluation Management":
  "Denominator"
    union "ED Triage Before Evaluation Management"

define "Time to Treatment Room Greater Than 60 Minutes":
  "ED Evaluation and Management" EDEvalManagementinMP
    where EDEvalManagementinMP.edArrivalTime ( ) 61 minutes or more before EDEvalManagementinMP.edTreatmentRoomTimeArrivalTime ( )

define fluent function "edArrivalTime"(EDEncounter Encounter):
  Last("ED Triage and Evaluation Management".location Location
      where exists((Location.location.getLocation().type) LocationType
          where(LocationType in "Emergency Department Location"
              or LocationType ~ "Emergency room"
              or LocationType ~ "Emergency trauma unit"
          )
      )
        and start of Location.period is not null
        and(Location.period ends 120 minutes or less before start of EDEncounter.period
            or Location.period overlaps before EDEncounter.period
            or EDEncounter.period overlaps before Location.period
            or Location.period starts same as start of EDEncounter.period
        )
      return start of Location.period
      sort ascending
  )

define fluent function "edDepartureTime"(EDEncounter Encounter):
  Last("ED Triage and Evaluation Management".location Location
      where exists((Location.location.getLocation().type) LocationType
          where(LocationType in "Emergency Department Location"
              or LocationType ~ "Emergency room"
              or LocationType ~ "Emergency trauma unit"
          )
      )
        and 
        end of Location.period is not null
        and(Location.period ends 120 minutes or less before start of EDEncounter.period
            or Location.period overlaps before EDEncounter.period
            or EDEncounter.period overlaps before Location.period
            or Location.period starts same as start of EDEncounter.period
        )
      return 
      end of Location.period
      sort ascending
  )

define fluent function "edTreatmentRoomTimeArrivalTime"(EDEncounter Encounter):
  First(EDEncounter.location Location
      where Location.location.getLocation().type in "Emergency Department Treatment Location"
        and start of Location.period is not null
      return start of Location.period
      sort ascending
  )

define fluent function "TransferDecisionUsingOrder"(EDEncounter Encounter):
  Last([ServiceRequest: "Decision to Transfer"] TransferOrder
      where TransferOrder.authoredOn during EDEncounter.period
        and TransferOrder.intent = 'order'
        and TransferOrder.status in { 'active', 'completed' }
      return TransferOrder.authoredOn
      sort ascending
  )

define "SDE Ethnicity":
  SDE."SDE Ethnicity"

define "SDE Payer":
  SDE."SDE Payer"

define "SDE Race":
  SDE."SDE Race"

define "SDE Sex":
  SDE."SDE Sex"

Encoded data 

Encoded data