eCQM Content CMS Implementation Guide
2025.7.1 - CI Build
eCQM Content CMS Implementation Guide, published by cqframework. This guide is not an authorized publication; it is the continuous build for version 2025.7.1 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/cqframework/ecqm-content-cms-2025/ and changes regularly. See the Directory of published versions
Official URL: https://madie.cms.gov/Measure/NHSNGlycemicControlHypoglycemiaInitialPopulation | Version: 0.0.001 | |||
Active as of 2025-07-09 | Responsible: Centers for Disease Control and Prevention (CDC) | Computable Name: NHSNGlycemicControlHypoglycemiaInitialPopulation | ||
Other Identifiers: Short Name: NHSNHypoglycemia (use: usual, ), UUID:0d555fb6-f654-418c-a2b3-2dd0c3f0e7b4 (use: official, ), UUID:50ceef3e-0a14-4f4f-8797-ffae8cce7237 (use: official, ) | ||||
Copyright/Legal: 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. |
All inpatient encounters (including ED/Observation visits that end within 1 hour of the start of the inpatient encounter) for patients of all ages where at least one diabetes medication was ordered or administered during the encounter that is during the measurement period.
Metadata | |
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Title | NHSN Glycemic Control Hypoglycemia Initial Population |
Version | 0.0.001 |
Short Name | NHSNHypoglycemia |
GUID (Version Independent) | urn:uuid:0d555fb6-f654-418c-a2b3-2dd0c3f0e7b4 |
GUID (Version Specific) | urn:uuid:50ceef3e-0a14-4f4f-8797-ffae8cce7237 |
Effective Period | 2026-01-01 through 2026-12-31 |
Steward (Publisher) | Centers for Disease Control and Prevention (CDC) |
Developer | Lantana Consulting Group |
Description | All inpatient encounters (including ED/Observation visits that end within 1 hour of the start of the inpatient encounter) for patients of all ages where at least one diabetes medication was ordered or administered during the encounter that is during the measurement period. |
Copyright | 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. |
Disclaimer | Disclaimer This performance measure is not a clinical guideline, does not establish a standard of medical care and has not been tested for all potential applications. THE MEASURES AND SPECIFICATIONS ARE PROVIDED “AS IS” WITHOUT WARRANTY OF ANY KIND. This measure and specifications are subject to further revisions. |
Rationale | The NHSN Glycemic Control module supports an electronic health record (EHR)- and vendor-neutral standard for reporting patient-level, linked medication and blood glucose data for inpatients. These data support calculation of inpatient medication-related hypoglycemia events by the NHSN application, which are then returned as reports to the facility. Inpatient hyperglycemia measurement is being incorporated into a future version of the NHSN Glycemic Control module. The primary objective of the NHSN Glycemic Control Module is to support U.S. hospitals in glycemic control measurement to improve glycemic management and patient safety. As additional data are collected by NHSN, an additional objective will be to facilitate inter-facility benchmarking of glycemic control metrics across U.S. hospitals and evaluate national-level trends of glycemic control metrics over time. The IP dQM provides the initial population, FHIR line-level and supplement data necessary for calculating the module metrics. |
Measure Group (Rate) (ID: Group_1) | |
Basis | Encounter |
Scoring | Cohort |
Type | Process |
Initial Population |
ID: InitialPopulation_1
Description: All inpatient encounters, as well as ED and OBS encounters that end within 1 hour of the start of the inpatient encounter, for patients of all ages where at least one diabetes medication was ordered or administered during the encounter that is during the measurement period. Logic Definition: Initial Population |
Supplemental Data Elements | |
Supplemental Data Element |
ID: sde-encounter-locations
Usage Code: Supplemental Data Description: SDE Encounter Locations Logic Definition: SDE Encounter Locations |
Supplemental Data Element |
ID: sde-location
Usage Code: Supplemental Data Description: SDE Location Logic Definition: SDE Location |
Supplemental Data Element |
ID: sde-medication
Usage Code: Supplemental Data Description: SDE Medication Logic Definition: SDE Medication |
Supplemental Data Element |
ID: sde-blood-glucose-observation
Usage Code: Supplemental Data Description: SDE Blood Glucose Observation Logic Definition: SDE Blood Glucose Observation |
Supplemental Data Element |
ID: sde-chief-complaint
Usage Code: Supplemental Data Description: SDE Chief Complaint Logic Definition: SDE Chief Complaint |
Supplemental Data Element |
ID: sde-condition
Usage Code: Supplemental Data Description: SDE Condition Logic Definition: SDE Condition |
Supplemental Data Element |
ID: sde-coverage
Usage Code: Supplemental Data Description: SDE Coverage Logic Definition: SDE Coverage |
Supplemental Data Element |
ID: sde-initial-population-encounters
Usage Code: Supplemental Data Description: SDE Initial Population Encounters Logic Definition: SDE Initial Population Encounters |
Supplemental Data Element |
ID: sde-medication-administration
Usage Code: Supplemental Data Description: SDE Medication Administration Logic Definition: SDE Medication Administration |
Supplemental Data Element |
ID: sde-medication-request
Usage Code: Supplemental Data Description: SDE Medication Request Logic Definition: SDE Medication Request |
Supplemental Data Element |
ID: sde-minimal-patient
Usage Code: Supplemental Data Description: SDE Minimal Patient Logic Definition: SDE Minimal Patient |
Supplemental Data Element |
ID: sde-service-request
Usage Code: Supplemental Data Description: SDE Service Request Logic Definition: SDE Service Request |
Supplemental Data Element |
ID: sde-ethnicity
Usage Code: Supplemental Data Description: SDE Ethnicity Logic Definition: SDE Ethnicity |
Supplemental Data Element |
ID: sde-payer
Usage Code: Supplemental Data Description: SDE Payer Logic Definition: SDE Payer |
Supplemental Data Element |
ID: sde-race
Usage Code: Supplemental Data Description: SDE Race Logic Definition: SDE Race |
Supplemental Data Element |
ID: sde-sex
Usage Code: Supplemental Data Description: SDE Sex Logic Definition: SDE Sex |
Measure Logic | |
Primary Library | NHSNGlycemicControlHypoglycemiaInitialPopulation |
Contents |
Population Criteria
Logic Definitions Terminology Dependencies Data Requirements |
Population Criteria | |
Measure Group (Rate) (ID: Group_1) | |
Initial Population | |
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Initial Population | |
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Logic Definitions | |
Logic Definition | Library Name: SupplementalDataElements |
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Logic Definition | Library Name: SupplementalDataElements |
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Logic Definition | Library Name: SupplementalDataElements |
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Logic Definition | Library Name: SupplementalDataElements |
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Logic Definition | Library Name: CQMCommon |
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Logic Definition | Library Name: CQMCommon |
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Logic Definition | Library Name: FHIRHelpers |
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Logic Definition | Library Name: FHIRHelpers |
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Logic Definition | Library Name: FHIRHelpers |
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Logic Definition | Library Name: FHIRHelpers |
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Logic Definition | Library Name: NHSNGlycemicControlHypoglycemiaInitialPopulation |
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Logic Definition | Library Name: NHSNGlycemicControlHypoglycemiaInitialPopulation |
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Logic Definition | Library Name: NHSNGlycemicControlHypoglycemiaInitialPopulation |
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Logic Definition | Library Name: NHSNGlycemicControlHypoglycemiaInitialPopulation |
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Logic Definition | Library Name: NHSNGlycemicControlHypoglycemiaInitialPopulation |
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Logic Definition | Library Name: NHSNGlycemicControlHypoglycemiaInitialPopulation |
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Logic Definition | Library Name: NHSNGlycemicControlHypoglycemiaInitialPopulation |
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Logic Definition | Library Name: NHSNGlycemicControlHypoglycemiaInitialPopulation |
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Logic Definition | Library Name: NHSNGlycemicControlHypoglycemiaInitialPopulation |
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Logic Definition | Library Name: NHSNGlycemicControlHypoglycemiaInitialPopulation |
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Logic Definition | Library Name: NHSNGlycemicControlHypoglycemiaInitialPopulation |
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Logic Definition | Library Name: NHSNGlycemicControlHypoglycemiaInitialPopulation |
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Logic Definition | Library Name: NHSNGlycemicControlHypoglycemiaInitialPopulation |
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Logic Definition | Library Name: NHSNGlycemicControlHypoglycemiaInitialPopulation |
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Logic Definition | Library Name: NHSNGlycemicControlHypoglycemiaInitialPopulation |
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Logic Definition | Library Name: NHSNGlycemicControlHypoglycemiaInitialPopulation |
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Logic Definition | Library Name: NHSNGlycemicControlHypoglycemiaInitialPopulation |
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Logic Definition | Library Name: NHSNGlycemicControlHypoglycemiaInitialPopulation |
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Logic Definition | Library Name: NHSNGlycemicControlHypoglycemiaInitialPopulation |
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Logic Definition | Library Name: NHSNGlycemicControlHypoglycemiaInitialPopulation |
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Logic Definition | Library Name: NHSNGlycemicControlHypoglycemiaInitialPopulation |
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Logic Definition | Library Name: NHSNGlycemicControlHypoglycemiaInitialPopulation |
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Logic Definition | Library Name: NHSNGlycemicControlHypoglycemiaInitialPopulation |
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Logic Definition | Library Name: NHSNGlycemicControlHypoglycemiaInitialPopulation |
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Logic Definition | Library Name: NHSNGlycemicControlHypoglycemiaInitialPopulation |
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Logic Definition | Library Name: QICoreCommon |
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Logic Definition | Library Name: QICoreCommon |
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Logic Definition | Library Name: QICoreCommon |
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Logic Definition | Library Name: QICoreCommon |
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Logic Definition | Library Name: QICoreCommon |
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Terminology | |
Code System |
Description: Code system ActCode
Resource: ActCode Canonical URL: http://terminology.hl7.org/CodeSystem/v3-ActCode |
Code System |
Description: Code system SNOMEDCT
Resource: SNOMED CT (all versions) Canonical URL: http://snomed.info/sct |
Code System |
Description: Code system ConditionClinicalStatusCodes
Resource: Condition Clinical Status Codes Canonical URL: http://terminology.hl7.org/CodeSystem/condition-clinical |
Code System |
Description: Code system Diagnosis Role
Resource: Diagnosis Role Canonical URL: http://terminology.hl7.org/CodeSystem/diagnosis-role |
Value Set |
Description: Value set Encounter Inpatient
Resource: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.666.5.307
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.666.5.307 |
Value Set |
Description: Value set Inpatient, Emergency, and Observation Locations
Resource: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1046.265
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1046.265 |
Value Set |
Description: Value set Diabetes Medications
Resource: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1190.58
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1190.58 |
Value Set |
Description: Value set Observation Services
Resource: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1111.143
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1111.143 |
Value Set |
Description: Value set Emergency Department Visit
Resource: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.292
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.292 |
Value Set |
Description: Value set Blood Glucose Laboratory and Point of Care Tests
Resource: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1190.38
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1190.38 |
Value Set |
Description: Value set Payer Type
Resource: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591 |
Direct Reference Code |
Display: inpatient non-acute
Code: NONAC System: http://terminology.hl7.org/CodeSystem/v3-ActCode |
Direct Reference Code |
Display: short stay
Code: SS System: http://terminology.hl7.org/CodeSystem/v3-ActCode |
Direct Reference Code |
Display: inpatient acute
Code: ACUTE System: http://terminology.hl7.org/CodeSystem/v3-ActCode |
Direct Reference Code |
Display: inpatient encounter
Code: IMP System: http://terminology.hl7.org/CodeSystem/v3-ActCode |
Direct Reference Code |
Display: Male (finding)
Code: 248153007 System: http://snomed.info/sct |
Direct Reference Code |
Display: Female (finding)
Code: 248152002 System: http://snomed.info/sct |
Direct Reference Code |
Display: Active
Code: active System: http://terminology.hl7.org/CodeSystem/condition-clinical |
Direct Reference Code |
Display: Recurrence
Code: recurrence System: http://terminology.hl7.org/CodeSystem/condition-clinical |
Direct Reference Code |
Display: Relapse
Code: relapse System: http://terminology.hl7.org/CodeSystem/condition-clinical |
Direct Reference Code |
Display: Chief complaint
Code: CC System: http://terminology.hl7.org/CodeSystem/diagnosis-role |
Dependencies | |
Dependency |
Description: Library FHIRHelpers
Resource: Library/FHIRHelpers|4.4.000
Canonical URL: Library/FHIRHelpers|4.4.000 |
Dependency |
Description: Library QICoreCommon
Resource: Library/QICoreCommon|4.0.000
Canonical URL: Library/QICoreCommon|4.0.000 |
Dependency |
Description: Library CQMCommon
Resource: Library/CQMCommon|4.1.000
Canonical URL: Library/CQMCommon|4.1.000 |
Dependency |
Description: Library QICoreCommon
Resource: Library/QICoreCommon|4.0.000
Canonical URL: Library/QICoreCommon|4.0.000 |
Dependency |
Description: Library FHIRHelpers
Resource: Library/FHIRHelpers|4.4.000
Canonical URL: Library/FHIRHelpers|4.4.000 |
Dependency |
Description: Library SDE
Resource: Library/SupplementalDataElements|5.1.000
Canonical URL: Library/SupplementalDataElements|5.1.000 |
Dependency |
Description: Library FHIRHelpers
Resource: Library/FHIRHelpers|4.4.000
Canonical URL: Library/FHIRHelpers|4.4.000 |
Dependency |
Description: Library FHIRHelpers
Resource: Library/FHIRHelpers|4.4.000
Canonical URL: Library/FHIRHelpers|4.4.000 |
Data Requirements | |
Data Requirement |
Type: Location
Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-location
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Data Requirement |
Type: Encounter
Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-encounter
Must Support Elements: type, status, status.value, period Code Filter(s): Path: type ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1111.143
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Data Requirement |
Type: Encounter
Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-encounter
Must Support Elements: type, status, status.value, period Code Filter(s): Path: type ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.292
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Data Requirement |
Type: Coverage
Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-coverage
Must Support Elements: period, id, id.value, meta, status, status.value, type, policyHolder, subscriber, subscriberId, subscriberId.value, beneficiary, dependent, dependent.value, relationship, payor, class, order, order.value, network, network.value, subrogation, subrogation.value, contract |
Data Requirement |
Type: Observation
Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-observation-lab
Must Support Elements: code, effective, issued, issued.value, id, id.value, extension, text, referenceRange, component, basedOn, partOf, category, status, status.value, subject, focus, encounter, performer, value, dataAbsentReason, interpretation, note, bodySite, method, specimen, device, hasMember, derivedFrom Code Filter(s): Path: code ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1190.38
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Data Requirement |
Type: Patient
Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-patient
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Data Requirement |
Type: Condition
Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-condition-problems-health-concerns
Must Support Elements: id, id.value, meta, clinicalStatus, verificationStatus, category, severity, code, bodySite, subject, encounter, encounter.reference, encounter.reference.value, onset, stage, evidence, note |
Data Requirement |
Type: Encounter
Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-encounter
Must Support Elements: type, period, class Code Filter(s): Path: type ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.666.5.307
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Data Requirement |
Type: Encounter
Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-encounter
Must Support Elements: type, period, class, location Code Filter(s): Path: type ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.666.5.307
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Data Requirement |
Type: Patient
Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-patient
Must Support Elements: url |
Data Requirement |
Type: ServiceRequest
Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-servicerequest
Must Support Elements: authoredOn, authoredOn.value, id, id.value, meta, instantiatesCanonical, instantiatesUri, basedOn, replaces, requisition, status, status.value, intent, intent.value, category, priority, priority.value, doNotPerform, doNotPerform.value, code, orderDetail, quantity, subject, encounter, occurrence, asNeeded, requester, performerType, performer, locationCode, reasonCode, reasonReference, insurance, bodySite, note, patientInstruction, patientInstruction.value |
Data Requirement |
Type: Patient
Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-patient
Must Support Elements: id, id.value, meta, extension, identifier, active, active.value, name, telecom, gender, gender.value, birthDate, birthDate.value, deceased, address, maritalStatus, multipleBirth, photo, contact, communication, generalPractitioner, managingOrganization, link |
Data Requirement |
Type: Medication
Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-medication
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Data Requirement |
Type: MedicationRequest
Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-medicationrequest
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Data Requirement |
Type: MedicationAdministration
Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-medicationadministration
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Data Requirement |
Type: Coverage
Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-coverage
Must Support Elements: type, period Code Filter(s): Path: type ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591
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Data Requirement |
Type: Patient
Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-patient
Must Support Elements: url, extension |
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