eCQM QICore Content Subset Implementation Guide
2024.0.0 - CI Build

eCQM QICore Content Subset Implementation Guide, published by cqframework. This guide is not an authorized publication; it is the continuous build for version 2024.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/cqframework/ecqm-content-qicore-2024-subset/ and changes regularly. See the Directory of published versions

Measure: Hospital Harm - Severe HyperglycemiaFHIR

This measure assesses the number of inpatient hospital days for patients age 18 and older with a hyperglycemic event (harm) per the total qualifying inpatient hospital days for that encounter

UNKNOWN

Official URL: https://madie.cms.gov/Measure/HospitalHarmHyperglycemiainHospitalizedPatientsFHIR Version: 0.1.000
Active as of 2024-09-09 Responsible: Centers for Medicare & Medicaid Services (CMS)/a> Computable Name: HospitalHarmHyperglycemiainHospitalizedPatientsFHIR
Other Identifiers: Short Name: CMS871FHIR (use: usual, ), UUID:c44ca609-d795-4715-a8fc-1b0b30e46048 (use: official, ), UUID:c7dbf77f-5869-42a0-b5e6-12e18004d2f4 (use: official, ), Endorser: 3533e (use: official, ), Publisher: 871FHIR (use: official, )

Usage:Venue: EH

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. American Institutes for Research(R), formerly IMPAQ International, disclaims all liability for use or accuracy of any third party codes contained in the specifications.

LOINC(R) copyright 2004-2023 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2023 International Health Terminology Standards Development Organisation. ICD-10 copyright 2023 World Health Organization. All Rights Reserved.
Knowledge Artifact Metadata
Name (machine-readable) HospitalHarmHyperglycemiainHospitalizedPatientsFHIR
Title (human-readable) Hospital Harm - Severe HyperglycemiaFHIR
Status Active
Experimental false
Description

This measure assesses the number of inpatient hospital days for patients age 18 and older with a hyperglycemic event (harm) per the total qualifying inpatient hospital days for that encounter
Purpose

UNKNOWN
Clinical Usage The measure is using mg/dL as the unit of measurement for glucose results. When evaluating for days with a glucose level >300 mg/dL, the first 24-hour period after admission to the hospital is not evaluated to account for potentially poor glucose control outside of the hospital setting or that preceded the start of hospital care. The admission starts in the emergency department (ED) or observation when the transition between the ED encounter, observation encounter, and the inpatient encounter are within an hour or less of each other. This measure evaluates the first 10 days of an eligible inpatient hospitalization in determining eligible days for the denominator and numerator (i.e., the length of stay is truncated to <=10 days when the length exceeds 10 days). Patients admitted for longer length of stays are more likely to have more complex medical conditions. The “Days in Hospitalization” logic within Measure Observation 1 (associated with the denominator), in conjunction with other logic, returns the day number (e.g., day 1 to day 10) for each day within the hospitalization period to determine the eligible hospital days (e.g., from day 2 to day 10). The “Days in Hospitalization” logic within Measure Observation 2 (associated with the numerator), in conjunction with other logic, returns the day number (e.g., day 1 to day 10) for each day within the hospitalization period to determine the eligible hyperglycemic event days (e.g., from day 2 to day 10). Since the measure does not count any hyperglycemic events that occur in the first 24 hours, day 1 is not considered an eligible hospital day for the Measure Observations. Eligible days range from day 2 up to day 10. Although the measure does not count any hyperglycemic events that occur in the first 24 hours as a hyperglycemic event day in Measure Observation 2, the first 24 hours of the encounter is considered day 1. This is because if there was a day during the encounter where a glucose result is not found, the measure evaluates the two days preceding to see if each had a glucose value >=200 mg/dL. The measure allows the first 24 hours of the encounter, i.e., day 1, to be one of the preceding days. Multiple hyperglycemic events can occur during a ‘day’, but this is still considered one hyperglycemic event day. The numerator returns the first eligible encounter that meets the qualifying criteria: an inpatient hospitalization with a hyperglycemic event. Only one numerator is counted per encounter. Note that the Numerator returns the encounters, not days, that meet the criteria. The specimen source for the glucose test is blood, serum, plasma, or interstitial fluid, and can be obtained by a laboratory test, a Point of Care (POC) test, or a continuous glucose monitor (CGM). Glucose test results from urine specimens are not considered. This eCQM is an episode-based measure. An episode is defined as each inpatient hospitalization or encounter that ends during the measurement period. This FHIR-based measure has been derived from the QDM-based measure: CMS871v4. Please refer to the HL7 QI-Core Implementation Guide(https://hl7.org/fhir/us/qicore/STU4.1.1/) for more information on QI-Core and mapping recommendations from QDM to QI-Core4.1.1 (https://hl7.org/fhir/us/qicore/STU4.1.1/qdm-to-qicore.html).
Effective Period 2025-01-01..2025-12-31
Use Context Venue = EH
Measure Developer American Institutes for Research (AIR): https://www.air.org
Measure Steward Centers for Medicare & Medicaid Services (CMS)
Steward Contact Details https://www.cms.gov/
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. American Institutes for Research(R), formerly IMPAQ International, disclaims all liability for use or accuracy of any third party codes contained in the specifications.

LOINC(R) copyright 2004-2023 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2023 International Health Terminology Standards Development Organisation. ICD-10 copyright 2023 World Health Organization. All Rights Reserved.
Measure Metadata
Short Name Identifier CMS871FHIR
Version Independent Identifier urn:uuid:c44ca609-d795-4715-a8fc-1b0b30e46048
Version Specific Identifier urn:uuid:c7dbf77f-5869-42a0-b5e6-12e18004d2f4
Publisher (CMS) Identifier 871FHIR
Identifier Endorser/3533e (use: official, )
Version Number 0.1.000
Measure Scoring Ratio
Rationale

Hyperglycemia, i.e., elevated glucose level, is common among hospitalized patients, especially those with preexisting diabetes (Umpierrez et al., 2012) and account for over 30% of noncritically ill hospitalized patients (Korytkowski, 2022). Hyperglycemia can also affect individuals with no prior history of diabetes and may be induced by medications such as steroids, or parenteral (intravenous) or enteral (tube) feeding.

Severe hyperglycemia, i.e., extremely elevated glucose level, is significantly associated with a range of harms, including increased in-hospital mortality, infection rates, and hospital length of stay (Pasquel, et al., 2021; Umpierrez et al., 2012, 2015). Lower rates of inpatient severe hyperglycemia may not only improve care for patients, but also reduce costs for healthcare payers (Krinsley et al., 2016). The rate of hyperglycemia varies across hospitals, suggesting opportunities for improvement in inpatient glycemic management (Seisa et al., 2022; Bersoux et al., 2013). The rate of inpatient hyperglycemia can be considered a marker for quality of hospital care, since inpatient hyperglycemia is largely avoidable with proper glycemic management. The use of evidence-based standardized protocols and insulin management protocols have been shown to improve glycemic control and safety (Leroy et al., 2020; Maynard et al., 2015).

From the Endocrine Society clinical practice guideline on the Management of Hyperglycemia in Hospitalized Patients in Non-critical Care Setting, 2022: Recommendation 1.1 In adults with insulin-treated diabetes hospitalized for noncritical illness who are at high risk of hypoglycemia, we suggest the use of real-time continuous glucose monitoring (CGM) with confirmatory bedside point-of-care blood glucose (POC-BG) monitoring for adjustments in insulin dosing rather than point-of-care blood glucose (POC-BG) testing alone in hospital settings where resources and training are available.
Clinical Recommendation Statement

Multiple guidelines address recommended levels of glycemic control, though these do not define severe hyperglycemia:

From Section 16, Diabetes Care in the Hospital, in the Standards of Medical Care in Diabetes by the American Diabetes Association, (American Diabetes Association, 2023):

16.4 Insulin therapy should be initiated for the treatment of persistent hyperglycemia starting at a threshold ≥180 mg/dL (10.0 mmol/L) (checked on two occasions). Once insulin therapy is started, a target glucose range of 140–180 mg/dL (7.8–10.0 mmol/L) is recommended for most critically ill and noncritically ill patients.

16.5 More stringent goals, such as 110–140 mg/dL (6.1–7.8 mmol/L) or 100–180 mg/dL (5.6–10.0 mmol/L), may be appropriate for selected patients and are acceptable if they can be achieved without significant hypoglycemia.

From the Endocrine Society clinical practice guideline on the Management of Hyperglycemia in Hospitalized Patients in Non-critical Care Setting (2022):

Recommendation 10.1 In adults with no prior history of diabetes hospitalized for noncritical illness with hyperglycemia [defined as blood glucose (BG) > 140 mg/dL (7.8 mmol/L)] during hospitalization, we suggest initial therapy with correctional insulin over scheduled insulin therapy (defined as basal or basal/bolus insulin) to maintain glucose targets in the range of 100 to 180 mg/dL (5.6 to 10.0 mmol/L). For patients with persistent hyperglycemia [≥2 point-of-care blood glucose (POC-BG) measurements ≥ 180 mg/dL (≥10.0 mmol/L) in a 24-hour period on correctional insulin alone], we suggest the addition of scheduled insulin therapy.

Recommendation 10.2 In adults with diabetes treated with diet or noninsulin diabetes medications prior to admission, we suggest initial therapy with correctional insulin or scheduled insulin therapy to maintain glucose targets in the range of 100 to 180 mg/dL (5.6 to 10.0 mmol/L). For hospitalized adults started on correctional insulin alone and with persistent hyperglycemia [≥2 point-of-care blood glucose (POC-BG) measurements ≥ 180 mg/dL in a 24-hour period (≥10.0 mmol/L)], we suggest addition of scheduled insulin therapy. We suggest initiation of scheduled insulin therapy for patients with confirmed admission blood glucose (BG) ≥ 180 mg/dL (≥10.0 mmol/L).

Recommendation 10.3 In adults with insulin-treated diabetes prior to admission who are hospitalized for noncritical illness, we recommend continuation of the scheduled insulin regimen modified for nutritional status and severity of illness to maintain glucose targets in the range of 100 to 180 mg/dL (5.6 to 10.0 mmol/L).

Remarks Reductions in the dose of basal insulin (by 10% to 20%) at time of hospitalization may be required for patients on basal heavy insulin regimens (defined as doses of basal insulin ≥ 0.6 to 1.0 units/kg/day), in which basal insulin is being used inappropriately to cover meal-related excursions in BG.

There is no clinically accepted cutoff for severe hyperglycemia. Studies have used thresholds of >140, >180 , >300, >350 and >400 mg/dL, among other values (American Diabetes Association, 2023; Umpierrez et al, 2012, 2015; Jamesen et al., 2015; Donihi et al., 2011; Mendez et al, 2015; Seisa et al., 2022). BGL <180 mg/dL is associated with lower rates of mortality and stroke compared with a target glucose <200 mg/dL (Sathya et al., 2013). Glycemic goals may also differ among hospitalized patients. For inpatient management of hyperglycemia in noncritical care, the expert consensus recommends a target range of 100–180 mg/dL (5.6–10.0 mmol/L) for noncritically ill patients with “new” hyperglycemia as well as people with known diabetes prior to admission. Glycemic levels >250 mg/dL (13.9 mmol/L) may be acceptable in terminally ill patients with short life expectancy. In these individuals, less aggressive insulin regimens to minimize glucosuria, dehydration, and electrolyte disturbances are often more appropriate. (ElSayed et al., 2023). In an older patient with a prior history of severe hypoglycemia, some degree of hyperglycemia may be tolerated to maximize safety. Intensive insulin therapy to target glucose of 100 and 140mg/dLin the ICU didn’t significantly reduce perioperative complications compared with target glucose of 141and180mg/dL after coronary artery bypass surgery (Umpierrez et al., 2015). The current recommendation is to maintain a blood glucose level between 140-180 mg/dL (7.8-10.0 mmol/L) in both cardiac and non-cardiac ICU patients (Sreedharan et al., 2022).

For patients who present with hyperglycemic crises, neurologic status must be monitored closely, with frequent re-examination. Care should be taken to prevent over-correction of hyperglycemia and hyperosmolarity following initial fluid resuscitation of these patients to prevent cerebral edema, which carries a high mortality rate. (Gosmanov et al., 2021).

From the Endocrine Society clinical practice guideline on the Management of Hyperglycemia in Hospitalized Patients in Non-critical Care Setting, 2022: Recommendation 1.1 In adults with insulin-treated diabetes hospitalized for noncritical illness who are at high risk of hypoglycemia, we suggest the use of real-time continuous glucose monitoring (CGM) with confirmatory bedside point-of-care blood glucose (POC-BG) monitoring for adjustments in insulin dosing rather than point-of-care blood glucose (POC-BG) testing alone in hospital settings where resources and training are available.
Guidance

The measure is using mg/dL as the unit of measurement for glucose results.

When evaluating for days with a glucose level >300 mg/dL, the first 24-hour period after admission to the hospital is not evaluated to account for potentially poor glucose control outside of the hospital setting or that preceded the start of hospital care. The admission starts in the emergency department (ED) or observation when the transition between the ED encounter, observation encounter, and the inpatient encounter are within an hour or less of each other.

This measure evaluates the first 10 days of an eligible inpatient hospitalization in determining eligible days for the denominator and numerator (i.e., the length of stay is truncated to <=10 days when the length exceeds 10 days). Patients admitted for longer length of stays are more likely to have more complex medical conditions.

The “Days in Hospitalization” logic within Measure Observation 1 (associated with the denominator), in conjunction with other logic, returns the day number (e.g., day 1 to day 10) for each day within the hospitalization period to determine the eligible hospital days (e.g., from day 2 to day 10).

The “Days in Hospitalization” logic within Measure Observation 2 (associated with the numerator), in conjunction with other logic, returns the day number (e.g., day 1 to day 10) for each day within the hospitalization period to determine the eligible hyperglycemic event days (e.g., from day 2 to day 10).

Since the measure does not count any hyperglycemic events that occur in the first 24 hours, day 1 is not considered an eligible hospital day for the Measure Observations. Eligible days range from day 2 up to day 10.

Although the measure does not count any hyperglycemic events that occur in the first 24 hours as a hyperglycemic event day in Measure Observation 2, the first 24 hours of the encounter is considered day 1. This is because if there was a day during the encounter where a glucose result is not found, the measure evaluates the two days preceding to see if each had a glucose value >=200 mg/dL. The measure allows the first 24 hours of the encounter, i.e., day 1, to be one of the preceding days.

Multiple hyperglycemic events can occur during a ‘day’, but this is still considered one hyperglycemic event day.

The numerator returns the first eligible encounter that meets the qualifying criteria: an inpatient hospitalization with a hyperglycemic event. Only one numerator is counted per encounter. Note that the Numerator returns the encounters, not days, that meet the criteria.

The specimen source for the glucose test is blood, serum, plasma, or interstitial fluid, and can be obtained by a laboratory test, a Point of Care (POC) test, or a continuous glucose monitor (CGM). Glucose test results from urine specimens are not considered.

This eCQM is an episode-based measure. An episode is defined as each inpatient hospitalization or encounter that ends during the measurement period.

This FHIR-based measure has been derived from the QDM-based measure: CMS871v4.

Please refer to the HL7 QI-Core Implementation Guide(https://hl7.org/fhir/us/qicore/STU4.1.1/) for more information on QI-Core and mapping recommendations from QDM to QI-Core4.1.1 (https://hl7.org/fhir/us/qicore/STU4.1.1/qdm-to-qicore.html).
Supplemental Data Guidance For every patient evaluated by this measure also identify payer, race, ethnicity and sex; SDE Ethnicity SDE Payer SDE Race SDE Sex
Measure Population Criteria (ID: 6501fe8dda013638e7b3dc0d)
Initial Population ID: 9B922C53-7F1B-4AF5-96E6-1A1E4AF7909C
Description:

Inpatient hospitalizations for patients age 18 and older that end during the measurement period, as well as either: - A diagnosis of diabetes that starts before or during the encounter; or - Administration of at least one dose of insulin or any hypoglycemic medication during the encounter; or - Presence of at least one glucose value >=200 mg/dL at any time during the encounter

Logic Definition: Initial Population
Denominator ID: 6402512C-2305-42DC-B5F6-A226B5057B89
Description:

Equals Initial Population

Logic Definition: Denominator
Denominator Exclusion ID: 0F4405D3-B373-4620-A9CC-D29558C39E85
Description:

-Inpatient hospitalizations for patients with a glucose result of >=1000 mg/dL anytime between 1 hour prior to the start of the encounter to 6 hours after the start of the encounter -Inpatient hospitalizations for patients who have comfort care measures ordered or provided during the encounter -Inpatient hospitalizations for patients who have a discharge disposition to home or to a health care facility for hospice care

Logic Definition: Denominator Exclusions
Numerator ID: 340EA45E-2411-4192-9C9D-3DF8D89A1D97
Description:

Inpatient hospitalizations with a hyperglycemic event within the first 10 days of the encounter minus the first 24 hours, and minus the last period before discharge from the hospital if less than 24 hours A hyperglycemic event is defined as: - A day with at least one glucose value >300 mg/dL; OR - A day where a glucose test and result was not found, and it was preceded by two consecutive days where at least one glucose value during each of the two days was >=200 mg/dL

Logic Definition: Numerator
Measure Observation ID: 68900484-66a1-4da3-9b02-1a10a5fd592b
Description: No description provided Logic Definition: Denominator Observations
Measure Observation ID: f1bc37e5-f64f-4ed8-b965-2011f1181225
Description: No description provided Logic Definition: Numerator Observations
Population Basis Encounter
Scoring Ratio
Type Outcome
Rate Aggregation None
Improvement Notation decrease
Supplemental Data Elements
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 HospitalHarmHyperglycemiainHospitalizedPatientsFHIR
Dependency Description: Library SDE
Resource: Library/SupplementalDataElements|3.5.000
Canonical URL: Library/SupplementalDataElements|3.5.000
Dependency Description: Library FHIRHelpers
Resource: Library/FHIRHelpers|4.4.000
Canonical URL: Library/FHIRHelpers|4.4.000
Dependency Description: Library CQMCommon
Resource: Library/CQMCommon|2.2.000
Canonical URL: Library/CQMCommon|2.2.000
Dependency Description: Library QICoreCommon
Resource: Library/QICoreCommon|2.1.000
Canonical URL: Library/QICoreCommon|2.1.000
Dependency Description: Code system AdministrativeGender
Resource: AdministrativeGender
Canonical URL: http://hl7.org/fhir/administrative-gender
Dependency Description: Value set Encounter Inpatient
Resource: Encounter Inpatient
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.666.5.307
Dependency Description: Value set Observation Services
Resource: Observation Services
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1111.143
Dependency Description: Value set Emergency Department Visit
Resource: Emergency Department Visit
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.292
Dependency Description: Value set Diabetes
Resource: Diabetes
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.103.12.1001
Dependency Description: Value set Hypoglycemics Treatment Medications
Resource: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1196.394
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1196.394
Dependency Description: Value set Glucose Lab Test Mass Per Volume
Resource: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1248.34
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1248.34
Dependency Description: Value set Payer Type
Resource: Payer
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591
Direct Reference Code Display: Male
Code: M
System: http://hl7.org/fhir/administrative-gender
Direct Reference Code Display: Female
Code: F
System: http://hl7.org/fhir/administrative-gender
Parameter Name: Measurement Period
Use: In
Min Cardinality: 0
Max Cardinality: 1
Type: Period
Parameter Name: SDE Sex
Use: Out
Min Cardinality: 0
Max Cardinality: 1
Type: Coding
Parameter Name: Numerator
Use: Out
Min Cardinality: 0
Max Cardinality: *
Type: Resource
Parameter Name: Denominator
Use: Out
Min Cardinality: 0
Max Cardinality: *
Type: Resource
Parameter Name: SDE Payer
Use: Out
Min Cardinality: 0
Max Cardinality: *
Type: Resource
Parameter Name: Initial Population
Use: Out
Min Cardinality: 0
Max Cardinality: *
Type: Resource
Parameter Name: SDE Ethnicity
Use: Out
Min Cardinality: 0
Max Cardinality: 1
Type: Resource
Parameter Name: Denominator Exclusions
Use: Out
Min Cardinality: 0
Max Cardinality: *
Type: Resource
Parameter Name: SDE Race
Use: Out
Min Cardinality: 0
Max Cardinality: 1
Type: Resource
Measure Logic Data Requirements
Data Requirement Type: Patient
Profile(s): QICorePatient
Must Support Elements: ethnicity, race
Data Requirement Type: Encounter
Profile(s): QICoreEncounter
Must Support Elements: type, status, status.value, period
Code Filter(s):
Path: type
ValueSet: Observation Services
Path: status.value
Code:
Data Requirement Type: Encounter
Profile(s): QICoreEncounter
Must Support Elements: type, status, status.value, period
Code Filter(s):
Path: type
ValueSet: Emergency Department Visit
Path: status.value
Code:
Data Requirement Type: Encounter
Profile(s): QICoreEncounter
Must Support Elements: type, period, status, status.value, hospitalizationPeriod, encounter
Code Filter(s):
Path: type
ValueSet: Encounter Inpatient
Path: status.value
Code:
Data Requirement Type: Condition
Profile(s): QICoreCondition
Must Support Elements: code
Code Filter(s):
Path: code
ValueSet: Diabetes
Data Requirement Type: MedicationAdministration
Profile(s): QICoreMedicationAdministration
Must Support Elements: medication, status, status.value, effective
Code Filter(s):
Path: medication
ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1196.394
Data Requirement Type: Observation
Profile(s): QICoreObservation
Must Support Elements: code, effective, status, status.value, value, id, id.value
Code Filter(s):
Path: code
ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1248.34
Path: status.value
Code:
Data Requirement Type: Observation
Profile(s): QICoreObservation
Must Support Elements: code, effective, value, status, status.value, id, id.value
Code Filter(s):
Path: code
ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1248.34
Data Requirement Type: Coverage
Profile(s): QICoreCoverage
Must Support Elements: type, period
Code Filter(s):
Path: type
ValueSet: Payer
Measure Logic Definitions
Logic Definition Library Name: SupplementalDataElements 
define "SDE Sex":
  case
    when Patient.gender = 'male' then "M"
    when Patient.gender = 'female' then "F"
    else null
  end
Logic Definition Library Name: HospitalHarmHyperglycemiainHospitalizedPatientsFHIR 
define "SDE Sex":
  SDE."SDE Sex"
Logic Definition Library Name: HospitalHarmHyperglycemiainHospitalizedPatientsFHIR 
define "Qualifying Encounter":
  ["Encounter": "Encounter Inpatient"] InpatientEncounter
    where AgeInYearsAt(date from start of InpatientEncounter.period) >= 18
      and InpatientEncounter.period ends during day of "Measurement Period"
      and InpatientEncounter.status = 'finished'
Logic Definition Library Name: HospitalHarmHyperglycemiainHospitalizedPatientsFHIR 
/**
 * Create paring of encounters to hospitalization period so this calculation can be inspected and the result 
 * can be reused, making the logic faster.*/


define "Encounter with Hospitalization Period":
  "Qualifying Encounter" QualifyingHospitalization
    return Tuple {
      encounter: QualifyingHospitalization,
      hospitalizationPeriod: CQMCommon."HospitalizationWithObservation" ( QualifyingHospitalization )
    }
Logic Definition Library Name: HospitalHarmHyperglycemiainHospitalizedPatientsFHIR 
/**
 * Using the already calculated pairing of hospitalization periods with encounters, filter on ones with 
 * diabetes and return the encounter.*/


define "Encounter with Existing Diabetes Diagnosis":
  "Encounter with Hospitalization Period" Hospitalization
    with ["Condition": "Diabetes"] Diabetes
      such that ( QICoreCommon."ToPrevalenceInterval" ( Diabetes ) starts before end of Hospitalization.hospitalizationPeriod )
    return Hospitalization.encounter
Logic Definition Library Name: HospitalHarmHyperglycemiainHospitalizedPatientsFHIR 
/**
 * Using the already calculated pairing of hospitalization periods with encounters, filter on ones with 
 * hypoglycemic medicatons and return the encounter.*/


define "Encounter with Hypoglycemic Medication":
  from
    "Encounter with Hospitalization Period" Hospitalization,
    ["MedicationAdministration": "Hypoglycemics Treatment Medications"] HypoglycemicMed
    where HypoglycemicMed.status = 'completed'
      and HypoglycemicMed.status != 'not-done'
      and QICoreCommon."ToInterval" ( HypoglycemicMed.effective ) during Hospitalization.hospitalizationPeriod
    return Hospitalization.encounter
Logic Definition Library Name: HospitalHarmHyperglycemiainHospitalizedPatientsFHIR 
/**
 * Using the already calculated pairing of hospitalization periods with encounters, filter on ones with 
 * any elevated (>= 200) blood glucose reading during the hospitalization*/


define "Encounter with Elevated Glucose Greater Than or Equal to 200":
  "Encounter with Hospitalization Period" Hospitalization
    with ["Observation": "Glucose Lab Test Mass Per Volume"] GlucoseTest
      such that QICoreCommon."Earliest" ( GlucoseTest.effective ) during Hospitalization.hospitalizationPeriod
        and GlucoseTest.status in { 'final', 'amended', 'corrected' }
        and GlucoseTest.status != 'cancelled'
        and GlucoseTest.value >= 200 'mg/dL'
    return Hospitalization.encounter
Logic Definition Library Name: HospitalHarmHyperglycemiainHospitalizedPatientsFHIR 
define "Initial Population":
  "Encounter with Existing Diabetes Diagnosis"
    union "Encounter with Hypoglycemic Medication"
    union "Encounter with Elevated Glucose Greater Than or Equal to 200"
Logic Definition Library Name: HospitalHarmHyperglycemiainHospitalizedPatientsFHIR 
define "Denominator":
  "Initial Population"
Logic Definition Library Name: HospitalHarmHyperglycemiainHospitalizedPatientsFHIR 
define "Measurement Population":
  "Denominator"
Logic Definition Library Name: HospitalHarmHyperglycemiainHospitalizedPatientsFHIR 
/***/


define "Days in Hospitalization":
  "Measurement Population" EligibleInpatientHospitalization
    let period: CQMCommon."HospitalizationWithObservation" ( EligibleInpatientHospitalization ),
    relevantPeriod: "Hospital Days Max 10"(period)
    return Tuple {
      encounter: EligibleInpatientHospitalization,
      hospitalizationPeriod: period,
      relevantPeriod: relevantPeriod,
      relevantDays: "Days In Period"(relevantPeriod)
    }
Logic Definition Library Name: HospitalHarmHyperglycemiainHospitalizedPatientsFHIR 
define "Days with Glucose Results":
  "Days in Hospitalization" InpatientHospitalDays
    return Tuple {
      encounter: InpatientHospitalDays.encounter,
      relevantPeriod: InpatientHospitalDays.relevantPeriod,
      relevantDays: ( InpatientHospitalDays.relevantDays EncounterDay
          return Tuple {
            dayNumber: EncounterDay.dayNumber,
            dayPeriod: EncounterDay.dayPeriod,
            hasSevereResult: exists ( ["Observation": "Glucose Lab Test Mass Per Volume"] GlucoseTest
                where GlucoseTest.status in { 'final', 'amended', 'corrected' }
                  and GlucoseTest.status != 'cancelled'
                  and GlucoseTest.value > 300 'mg/dL'
                  and QICoreCommon."Earliest" ( GlucoseTest.effective ) during EncounterDay.dayPeriod
            ),
            hasElevatedResult: exists ( ["Observation": "Glucose Lab Test Mass Per Volume"] GlucoseTest
                where GlucoseTest.status in { 'final', 'amended', 'corrected' }
                  and GlucoseTest.status != 'cancelled'
                  and GlucoseTest.value >= 200 'mg/dL'
                  and QICoreCommon."Earliest" ( GlucoseTest.effective ) during EncounterDay.dayPeriod
            ),
            hasNoGlucoseTest: not exists ( ["Observation": "Glucose Lab Test Mass Per Volume"] GlucoseTest
                where GlucoseTest.status in { 'final', 'amended', 'corrected' }
                  and GlucoseTest.status != 'cancelled'
                  and QICoreCommon."Earliest" ( GlucoseTest.effective ) during EncounterDay.dayPeriod
            )
          }
      )
    }
Logic Definition Library Name: HospitalHarmHyperglycemiainHospitalizedPatientsFHIR 
/*# hyper days uses "Relevant Encounters With Glucose Result Days" to find if hyper event on each day. Skips 1st day in 'RelevantDays`. Returns boolean based on: Today high result OR Today no result AND Yesterday high result AND 2 days ago high result*/


define "Days with Hyperglycemic Events":
  "Days with Glucose Results" EncounterWithResultDays
    let eligibleEventDays: EncounterWithResultDays.relevantDays EncounterDay
      where EncounterDay.dayNumber > 1
      return Tuple {
        dayIndex: EncounterDay.dayNumber,
        dayPeriod: EncounterDay.dayPeriod,
        hasHyperglycemicEvent: ( EncounterDay.hasSevereResult
            or ( EncounterDay.hasNoGlucoseTest
                and EncounterWithResultDays.relevantDays[EncounterDay.dayNumber - 2].hasElevatedResult
                and EncounterWithResultDays.relevantDays[EncounterDay.dayNumber - 3].hasElevatedResult
            )
        )
      }
    return Tuple {
      encounter: EncounterWithResultDays.encounter,
      relevantPeriod: EncounterWithResultDays.relevantPeriod,
      eligibleEventDays: eligibleEventDays
    }
Logic Definition Library Name: HospitalHarmHyperglycemiainHospitalizedPatientsFHIR 
/***/


define "Encounter with Hyperglycemic Events":
  "Days with Hyperglycemic Events" HyperglycemicEventDays
    where exists ( HyperglycemicEventDays.eligibleEventDays EligibleEventDay
        where EligibleEventDay.hasHyperglycemicEvent
    )
    return HyperglycemicEventDays.encounter
Logic Definition Library Name: HospitalHarmHyperglycemiainHospitalizedPatientsFHIR 
define "Numerator":
  "Encounter with Hyperglycemic Events"
Logic Definition Library Name: SupplementalDataElements 
define "SDE Payer":
  [Coverage: type in "Payer Type"] Payer
    return {
      code: Payer.type,
      period: Payer.period
    }
Logic Definition Library Name: HospitalHarmHyperglycemiainHospitalizedPatientsFHIR 
define "SDE Payer":
  SDE."SDE Payer"
Logic Definition Library Name: SupplementalDataElements 
define "SDE Ethnicity":
  Patient.ethnicity E
    return Tuple {
      codes: { E.ombCategory } union E.detailed,
      display: E.text
    }
Logic Definition Library Name: HospitalHarmHyperglycemiainHospitalizedPatientsFHIR 
define "SDE Ethnicity":
  SDE."SDE Ethnicity"
Logic Definition Library Name: HospitalHarmHyperglycemiainHospitalizedPatientsFHIR 
define "Glucose Greater Than or Equal to 1000 within 1 Hour Prior To and 6 Hours After Encounter Start":
  from
    "Initial Population" InpatientHospitalization,
    ["Observation": "Glucose Lab Test Mass Per Volume"] GlucoseTest
    let HospitalizationInterval: CQMCommon."HospitalizationWithObservation" ( InpatientHospitalization ),
    GlucoseTestTime: QICoreCommon."Earliest" ( GlucoseTest.effective )
    where GlucoseTest.value as Quantity >= 1000 'mg/dL'
      and GlucoseTest.status in { 'final', 'amended', 'corrected' }
      and GlucoseTestTime during Interval[( start of HospitalizationInterval - 1 hour ), ( start of HospitalizationInterval + 6 hours )]
    return GlucoseTest
Logic Definition Library Name: HospitalHarmHyperglycemiainHospitalizedPatientsFHIR 
define "Glucose Tests Earlier Than Glucose Greater Than or Equal to 1000 within 1 Hour Prior To and 6 Hours After Encounter Start":
  from
    "Initial Population" InpatientHospitalization,
    "Glucose Greater Than or Equal to 1000 within 1 Hour Prior To and 6 Hours After Encounter Start" GlucoseResult1000,
    ["Observation": "Glucose Lab Test Mass Per Volume"] EarlierGlucoseTest
    let HospitalizationInterval: CQMCommon."HospitalizationWithObservation" ( InpatientHospitalization ),
    GlucoseTest1000Time: QICoreCommon."Earliest" ( GlucoseResult1000.effective ),
    EarlierGlucoseTestTime: QICoreCommon."Earliest" ( EarlierGlucoseTest.effective )
    where GlucoseTest1000Time during Interval[( start of HospitalizationInterval - 1 hour ), ( start of HospitalizationInterval + 6 hour )]
      and EarlierGlucoseTestTime during Interval[( start of HospitalizationInterval - 1 hour ), GlucoseTest1000Time )
      and EarlierGlucoseTest.id !~ GlucoseResult1000.id
    return GlucoseResult1000
Logic Definition Library Name: HospitalHarmHyperglycemiainHospitalizedPatientsFHIR 
define "Initial Glucose Greater Than or Equal to 1000 within 1 Hour Prior To and 6 Hours After Encounter Start":
  "Glucose Greater Than or Equal to 1000 within 1 Hour Prior To and 6 Hours After Encounter Start" GlucoseResult1000
    where not ( GlucoseResult1000.id in "Glucose Tests Earlier Than Glucose Greater Than or Equal to 1000 within 1 Hour Prior To and 6 Hours After Encounter Start".id )
Logic Definition Library Name: HospitalHarmHyperglycemiainHospitalizedPatientsFHIR 
define "Encounter with First Glucose Greater Than or Equal to 1000":
  "Initial Population" InpatientHospitalization
    with "Initial Glucose Greater Than or Equal to 1000 within 1 Hour Prior To and 6 Hours After Encounter Start" FirstGlucoseResult
      such that FirstGlucoseResult.value as Quantity >= 1000 'mg/dL'
        and QICoreCommon."Earliest" ( FirstGlucoseResult.effective ) during Interval[( start of CQMCommon."HospitalizationWithObservation" ( InpatientHospitalization ) - 1 hour ), ( start of CQMCommon."HospitalizationWithObservation" ( InpatientHospitalization ) + 6 hours )]
Logic Definition Library Name: HospitalHarmHyperglycemiainHospitalizedPatientsFHIR 
define "Denominator Exclusions":
  "Encounter with First Glucose Greater Than or Equal to 1000"
Logic Definition Library Name: SupplementalDataElements 
define "SDE Race":
  Patient.race R
    return Tuple {
      codes: R.ombCategory union R.detailed,
      display: R.text
    }
Logic Definition Library Name: HospitalHarmHyperglycemiainHospitalizedPatientsFHIR 
define "SDE Race":
  SDE."SDE Race"
Logic Definition Library Name: CQMCommon 
/*
@description: Hospitalization with Observation returns the total interval from the start of any immediately prior emergency department visit through the observation visit to the discharge of the given encounter
@deprecated: This function is deprecated. Use the fluent function `hospitalizationWithObservation()` instead.
*/
define function "HospitalizationWithObservation"(TheEncounter Encounter ):
  TheEncounter Visit
  		let ObsVisit: Last([Encounter: "Observation Services"] LastObs
  				where LastObs.status = 'finished'
            and LastObs.period ends 1 hour or less on or before start of Visit.period
  				sort by end of period
  			),
  			VisitStart: Coalesce(start of ObsVisit.period, start of Visit.period),
  			EDVisit: Last([Encounter: "Emergency Department Visit"] LastED
  				where LastED.status = 'finished'
            and LastED.period ends 1 hour or less on or before VisitStart
  				sort by end of period
  			)
  		return Interval[Coalesce(start of EDVisit.period, VisitStart), end of Visit.period]
Logic Definition Library Name: QICoreCommon 
/*
@description: Returns an interval representing the normalized prevalence period of a given Condition.
@comment: Uses the ToInterval and ToAbatementInterval functions to determine the widest potential interval from
onset to abatement as specified in the given Condition. If the condition is active, or has an abatement date the resulting 
interval will have a closed ending boundary. Otherwise, the resulting interval will have an open ending boundary.
@deprecated: This function is deprecated. Use the `prevalenceInterval()` fluent function instead
*/
define function ToPrevalenceInterval(condition Condition):
if condition.clinicalStatus ~ "active"
  or condition.clinicalStatus ~ "recurrence"
  or condition.clinicalStatus ~ "relapse" then
  Interval[start of ToInterval(condition.onset), end of ToAbatementInterval(condition)]
else
   (end of ToAbatementInterval(condition)) abatementDate
    return if abatementDate is null then
      Interval[start of ToInterval(condition.onset), abatementDate)
    else
      Interval[start of ToInterval(condition.onset), abatementDate]
Logic Definition Library Name: QICoreCommon 
/*
@description: Given an interval, return the starting point if the interval has a starting boundary specified,
otherwise, return the ending point
@deprecated: This function is deprecated. Use the fluent function `earliest()` instead
*/
define function "Earliest"(choice Choice<DateTime, Quantity, Interval<DateTime>, Interval<Quantity>> ):
  (choice.toInterval()) period
    return
      if (HasStart(period)) then start of period
      else end of period
Logic Definition Library Name: HospitalHarmHyperglycemiainHospitalizedPatientsFHIR 
/**
 * Crops an interval to a maximum length of 10 days.*/


define function "Hospital Days Max 10"(Period Interval<DateTime>):
  Interval[start of Period, Min({ 
    end of Period, start of Period + 10 days }
  )]
Logic Definition Library Name: HospitalHarmHyperglycemiainHospitalizedPatientsFHIR 
/**
 * Creates a list of 24 hour long intervals in an interval paired with the index (1 indexed) to which 24 hour interval it is.*/


define function "Days In Period"(Period Interval<DateTime>):
  ( "Interval To Day Numbers"(Period) ) DayNumber
    let startPeriod: start of Period + ( 24 hours * ( DayNumber - 1 ) ),
    endPeriod: if ( hours between startPeriod and end of Period < 24 ) then startPeriod 
      else start of Period + ( 24 hours * DayNumber )
    return Tuple {
      dayNumber: DayNumber,
      dayPeriod: Interval[startPeriod, endPeriod )
    }
Logic Definition Library Name: HospitalHarmHyperglycemiainHospitalizedPatientsFHIR 
/**
 * Creates a list of integers from 1 to how many days are in the interval. Note, this wont create an index for
 * the final day if it is less than 24 hours. This also includes the first 24 hour period.*/


define function "Interval To Day Numbers"(Period Interval<DateTime>):
  ( expand { Interval[1, duration in days between start of Period and end of Period]} ) DayExpand
    return end of DayExpand
Logic Definition Library Name: HospitalHarmHyperglycemiainHospitalizedPatientsFHIR 
/**
 * Counts the number of eligible days in an encounter. This simply filters and counts the data built in
 * "Relevant Encounters With Hyperglycemic Event Days".*/


define function "Denominator Observations"(QualifyingEncounter Encounter):
  if QualifyingEncounter.id in "Denominator Exclusions".id then singleton from ( "Days with Hyperglycemic Events" EncounterWithEventDays
      where EncounterWithEventDays.encounter = QualifyingEncounter
      return 0
  ) 
    else singleton from ( "Days with Hyperglycemic Events" EncounterWithEventDays
      where EncounterWithEventDays.encounter = QualifyingEncounter
      return Count(EncounterWithEventDays.eligibleEventDays)
  )
Logic Definition Library Name: FHIRHelpers 
define function ToString(value uri): value.value
Logic Definition Library Name: FHIRHelpers 
/*
@description: Converts the given FHIR [Coding](https://hl7.org/fhir/datatypes.html#Coding) value to a CQL Code.
*/
define function ToCode(coding FHIR.Coding):
    if coding is null then
        null
    else
        System.Code {
          code: coding.code.value,
          system: coding.system.value,
          version: coding.version.value,
          display: coding.display.value
        }
Logic Definition Library Name: HospitalHarmHyperglycemiainHospitalizedPatientsFHIR 
/**
 * Counts the number of eligible days with a hyperglycemic event in an encounter. This simply filters and counts the data built in
 * "Relevant Encounters With Hyperglycemic Event Days".*/


define function "Numerator Observations"(QualifyingEncounter Encounter):
  if QualifyingEncounter.id in "Denominator Exclusions".id then singleton from ( "Days with Hyperglycemic Events" EncounterWithEventDays
      where EncounterWithEventDays.encounter = QualifyingEncounter
      return 0
  ) 
    else singleton from ( "Days with Hyperglycemic Events" EncounterWithEventDays
      where EncounterWithEventDays.encounter = QualifyingEncounter
      return Count(EncounterWithEventDays.eligibleEventDays EligibleEventDay
          where EligibleEventDay.hasHyperglycemicEvent
      )
  )
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