Outcome

Decreased score indicates improvement

define "Initial Population":
  "ED Encounter"
    union "ED Triage"

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 "SDE Sex":
  case
    when Patient.gender = 'male' then "M"
    when Patient.gender = 'female' then "F"
    else null
  end

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

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

define "ED Triage":
  ( [Encounter: "Triage"] EDTriage
      where EDTriage.period ends during day of "Measurement Period"
  )

define "Initial Population":
  "ED Encounter"
    union "ED Triage"

define "Denominator":
  "Initial Population"

define "Time to Treatment Room Greater Than 60 Minutes":
  "Denominator" EDEncounter
    where "EDArrivalTime"(EDEncounter) 61 minutes or more before "EDTreatmentRoomTimeArrivalTime"(EDEncounter)

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

define "Inpatient Encounter":
  [Encounter: "Encounter Inpatient"] EncounterInpatient
		where EncounterInpatient.status = 'finished'
		and EncounterInpatient.period ends during day of "Measurement Period"

define "EDtoIPOrder":
  [ServiceRequest: code in "Decision to Admit to Hospital Inpatient"]

define "Decision to Admit Encounter Order":
  "Denominator" EDEncounter
    with CQMCommon."Inpatient Encounter" EncounterInpatient
      such that "AdmitDecisionUsingEncounterOrder"(EncounterInpatient) 241 minutes or more before "EDDepartureTime"(EDEncounter)

define "AssessmentInED":
  [Observation: "Emergency Department Evaluation"]

define "Decision to Admit Using Assessment":
  "Denominator" EDEncounter
    with CQMCommon."Inpatient Encounter" EncounterInpatient
      such that "AdmitDecisionUsingAssessment"(EncounterInpatient) 241 minutes or more before "EDDepartureTime"(EDEncounter)

define "InpatientOrBedAssignmentEncounterOrder":
  [ServiceRequest: code in "Encounter Inpatient"]
    union [ServiceRequest: "Patient bed assigned (finding)"]

define "Time of Admit Order Or Bed Assignment to Departure Greater Than 241 Minutes":
  "Denominator" EDEncounter
    with CQMCommon."Inpatient Encounter" InpatientEncounter
      such that "AdmitInpatientOrBedAssignmentOrder"(InpatientEncounter) 241 minutes or more before "EDDepartureTime"(EDEncounter)

define "Admitted to Inpatient 241 Minutes or More Before Departure":
  "Denominator" EDEncounter
    with CQMCommon."Inpatient Encounter" Inpatient
      such that "HoldingInEDAfterAdmission"(Inpatient) 241 minutes or more before "EDDepartureTime"(EDEncounter)

define "Boarded Time Greater Than 240 Minutes":
  "Decision to Admit Encounter Order"
    union "Decision to Admit Using Assessment"
    union "Time of Admit Order Or Bed Assignment to Departure Greater Than 241 Minutes"
    union "Admitted to Inpatient 241 Minutes or More Before Departure"

define "ED Observation Encounter Status":
  [Encounter: "Emergency Department Observation"] EDObsEncounter
    with "Denominator" EDEncounter
      such that start of EDObsEncounter.period during EDEncounter.period
        and EDEncounter.status = 'finished'
        and EDObsEncounter.status = 'finished'

define "ED Observation Order Status":
  [ServiceRequest: code in "Emergency Department Observation"] EDObsOrder
    with "Denominator" EDEncounter
      such that EDObsOrder.authoredOn during EDEncounter.period
        and EDEncounter.status = 'finished'
        and EDObsOrder.status = 'active'

define "ED Observation Status":
  ( "ED Observation Encounter Status"
    union "ED Observation Order Status" ) EDObservation
    with ( "Denominator" ) EDStay
      such that EDObservation.period during EDStay.period
        or ( EDObservation.authoredOn during EDStay.period )

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

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

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" EDO
          where ( EDO.period starts during EDStay.period
              or EDO.authoredOn during EDStay.period
          )
      )
  )

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

define "Stratification 1: Pediatric With No Mental Health Diagnosis":
  ( "ED Encounter or Triage of Patients Less Than 18 Years" EDEncounter
      let ConditionCode: EDEncounter.principalDiagnosis ( ).code
      where not ( ConditionCode in "Mental Health Diagnosis without Substance Use Disorders" )
  )

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

define "Stratification 4: Adult With Mental Health Diagnosis":
  ( "ED Encounter or Triage of Patients 18 Years and Older" EDEncounter
      let ConditionCode: EDEncounter.principalDiagnosis ( ).code
      where ( ConditionCode in "Mental Health Diagnosis without Substance Use Disorders" )
  )

define "Stratification 2: Adult With No Mental Health Diagnosis":
  ( "ED Encounter or Triage of Patients 18 Years and Older" EDEncounter
      let ConditionCode: EDEncounter.principalDiagnosis ( ).code
      where not ( ConditionCode in "Mental Health Diagnosis without Substance Use Disorders" )
  )

define "SDE Payer":
  [Coverage: type in "Payer Type"] Payer
    return {
      code: Payer.type,
      period: Payer.period
    }

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

define "Stratification 3: Pediatric With Mental Health Diagnosis":
  ( "ED Encounter or Triage of Patients Less Than 18 Years" EDEncounter
      let ConditionCode: EDEncounter.principalDiagnosis ( ).code
      where ( ConditionCode in "Mental Health Diagnosis without Substance Use Disorders" )
  )

define "SDE Ethnicity":
  Patient.ethnicity E
    return Tuple {
      codes: { E.ombCategory } union E.detailed,
      display: E.text
    }

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

define "SDE Race":
  Patient.race R
    return Tuple {
      codes: R.ombCategory union R.detailed,
      display: R.text
    }

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

/*
@description: Converts the given [Period](https://hl7.org/fhir/datatypes.html#Period)
value to a CQL DateTime Interval
@comment: If the start value of the given period is unspecified, the starting
boundary of the resulting interval will be open (meaning the start of the interval
is unknown, as opposed to interpreted as the beginning of time).
*/
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]

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

/*
@description: Returns the Location resource specified by the given reference.
*/
define fluent function getLocation(reference Reference ):
  singleton from (
    [Location] L where L.id = reference.reference.getId()
  )

/*
@description: Returns the tail of the given uri (i.e. everything after the last slash in the URI).
@comment: This function can be used to determine the logical id of a given resource. It can be used in
a single-server environment to trace references. However, this function does not attempt to resolve
or distinguish the base of the given url, and so cannot be used safely in multi-server environments.
*/
define fluent function getId(uri String):
  Last(Split(uri, '/'))

/*
@description: Converts the given FHIR [CodeableConcept](https://hl7.org/fhir/datatypes.html#CodeableConcept) value to a CQL Concept.
*/
define function ToConcept(concept FHIR.CodeableConcept):
    if concept is null then
        null
    else
        System.Concept {
            codes: concept.coding C return ToCode(C),
            display: concept.text.value
        }

/*
@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
        }

define function "EDTreatmentRoomTimeArrivalTime"(EDEncounter Encounter):
  Last(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 function "AdmitDecisionUsingEncounterOrder"(InpatientEncounter Encounter):
  Last("EDtoIPOrder" AdmitOrder
      let LastEDVisit: "LastEDEncounter"(InpatientEncounter)
      where AdmitOrder.authoredOn during LastEDVisit.period
        and AdmitOrder.intent ~ 'order'
        and AdmitOrder.status in { 'active', 'completed' }
      return AdmitOrder.authoredOn
      sort ascending
  )

define function "LastEDEncounter"(InpatientEncounter Encounter):
  Last("ED Encounter" EDVisit
      where EDVisit.period starts 1 day or less before or on start of InpatientEncounter.period
        and EDVisit.period starts before start of InpatientEncounter.period
        and EDVisit.period during "Measurement Period"
        and EDVisit.status = 'finished'
      sort by 
      end of period ascending
  )

define function "EDDepartureTime"(EDEncounter Encounter):
  Last(EDEncounter.location Location
      where Location.location.getLocation().type in "Emergency Department Location"
        and 
        end of Location.period is not null
      return 
      end of Location.period
      sort ascending
  )

define function "AdmitDecisionUsingAssessment"(InpatientEncounter Encounter):
  Last("AssessmentInED" EDEvaluation
      let LastEDVisit: "LastEDEncounter"(InpatientEncounter)
      where EDEvaluation.effective.toInterval() starts during LastEDVisit.period
        and EDEvaluation.value as Concept in "Admit Inpatient"
        and EDEvaluation.status in { 'final', 'amended', 'corrected' }
      return start of EDEvaluation.effective.toInterval()
      sort ascending
  )

define function "AdmitInpatientOrBedAssignmentOrder"(InpatientEncounter Encounter):
  Last(("InpatientOrBedAssignmentEncounterOrder") AdmitInpatientOrder
      let LastEDVisit: "LastEDEncounter"(InpatientEncounter)
      where AdmitInpatientOrder.authoredOn during LastEDVisit.period
      return AdmitInpatientOrder.authoredOn
      sort ascending
  )

define function "HoldingInEDAfterAdmission"(InpatientEncounter Encounter):
  Last(CQMCommon."Inpatient Encounter" AdmittedInpatient
      let LastEDVisit: "LastEDEncounter"(InpatientEncounter)
      where start of AdmittedInpatient.period during LastEDVisit.period
      return start of AdmittedInpatient.period
      sort ascending
  )

/*
@description: Returns the condition that is specified as the principal diagnosis for the encounter
*/
define fluent function principalDiagnosis(Encounter Encounter ):
	singleton from ((Encounter.diagnosis D where D.rank = 1 and D.use ~ "Billing") PD
      return singleton from ([Condition] C where C.id = PD.condition.reference.getId())
	)

define function ToString(value uri): value.value