Proportion

Process

Increased score indicates improvement

define "Initial Population":
  AHA."Is Adults With Two Qualifying Outpatient Encounters and One Heart Failure Outpatient Encounter During the Measurement Period"

define "Denominator":
  "Initial Population"
    and exists AHA."Heart Failure Outpatient Encounter with History of Moderate or Severe LVSD"

define "Denominator Exclusions":
  AHA."Has Heart Transplant"
    or AHA."Has Heart Transplant Complications"
    or AHA."Has Left Ventricular Assist Device"
    or AHA."Has Left Ventricular Assist Device Complications"

define "Numerator":
  "Has Beta Blocker Therapy for LVSD Ordered"
    or "Is Currently Taking Beta Blocker Therapy for LVSD"

/*
@commentedOuf: Temporary removal of "Has Medical or Patient Reason for Not Ordering Beta Blocker for LVSD"
@commentedOufReason: Negation issue noted in https://github.com/cqframework/cql-execution/issues/296, which is tied to https://oncprojectracking.healthit.gov/support/browse/BONNIEMAT-1455
*/


define "Denominator Exceptions":
  "Has Consecutive Heart Rates Less than 50"
    //or "Has Medical or Patient Reason for Not Ordering Beta Blocker for LVSD"*/or "Has Arrhythmia Diagnosis"
    
    or "Has Hypotension Diagnosis"
    or "Has Asthma Diagnosis"
    or "Has Diagnosis of Allergy or Intolerance to Beta Blocker Therapy"
    or "Has Bradycardia Diagnosis"
    or "Has Allergy or Intolerance to Beta Blocker Therapy Ingredient"
    or "Atrioventricular Block without Cardiac Pacer"

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"

/*
@description: Returns certain finished encounter types that overlap a Heart Failure condition and are during the measurement period: 
                * care services in long term residential facility (http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1014)
                * home healthcare services (http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1016)
                * nursing facility visits (http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1012)
                * office visits (http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1001)
                * outpatient consolutations (http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1008)
*/   
define "Heart Failure Outpatient Encounter":
  ( [Encounter: "Care Services in Long Term Residential Facility"]
      union [Encounter: "Home Healthcare Services"]
      union [Encounter: "Nursing Facility Visit"]
      union [Encounter: "Office Visit"] 
      union [Encounter: "Outpatient Consultation"]
     ) QualifyingEncounter
    with [Condition: "Heart Failure"] HeartFailure
      such that HeartFailure.prevalenceInterval() overlaps QualifyingEncounter.period  
        and HeartFailure.isConfirmedActiveDiagnosis()
    where QualifyingEncounter.period during day of "Measurement Period"
      and QualifyingEncounter.isFinished()

/*
@description: Returns a union  of the following:
                * Observations where the final, amended or correction ejection fraction result is <= 40
                * Moderate or Severe LVSD conditions where the diagnosis has been confirmed as active
*/  
define "Moderate or Severe LVSD Findings":
  ( [Observation: "Ejection Fraction"] EjectionFraction
      where EjectionFraction.value as Quantity <= 40 '%'
        and EjectionFraction.status in {'final', 'amended', 'corrected'} 
   )
   union ( 
           ( [Condition: "Moderate or Severe LVSD"]
             union ( [Condition: "Left ventricular systolic dysfunction (disorder)"] LVSDDiagnosis
                       where LVSDDiagnosis.severity in "Moderate or Severe" )
            ) ModerateOrSevereLVSD   
            where ModerateOrSevereLVSD.isConfirmedActiveDiagnosis()
          )

/*
@description: Returns heart failure outpatient encounters that start before the end of a moderate or severe LVSD finding
*/ 
define "Heart Failure Outpatient Encounter with History of Moderate or Severe LVSD":
    "Heart Failure Outpatient Encounter" HFOutpatientEncounter
        with "Moderate or Severe LVSD Findings" LVSDFindings
            such that Coalesce(LVSDFindings.prevalenceInterval(), LVSDFindings.effective.toInterval()) starts before end of HFOutpatientEncounter.period

define "Has Beta Blocker Therapy for LVSD Ordered":
  exists ( [MedicationRequest: "Beta Blocker Therapy for LVSD"] BetaBlockerOrdered
      where BetaBlockerOrdered.isOrderedDuringHeartFailureOutpatientEncounter ( )
  )

define "Is Currently Taking Beta Blocker Therapy for LVSD":
  exists ( ["MedicationRequest": "Beta Blocker Therapy for LVSD"] ActiveBetaBlocker
      where ActiveBetaBlocker.overlapsAfterHeartFailureOutpatientEncounter ( )
  )

define "Numerator":
  "Has Beta Blocker Therapy for LVSD Ordered"
    or "Is Currently Taking Beta Blocker Therapy for LVSD"

/*
@description: Returns certain finished encounter types that occurred during the measurement period: 
                * office visits (http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1001)
                * outpatient consolutations (http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1008)
                * nursing facility visits (http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1012)
                * care services in long term residential facility (http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1014)
                * home healthcare services (http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1016)
                * patient provider interactions (http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.526.3.1012) 
*/          
define "Qualifying Outpatient Encounter During Measurement Period":
    ( [Encounter: "Office Visit"]
        union [Encounter: "Outpatient Consultation"]
        union [Encounter: "Nursing Facility Visit"]
        union [Encounter: "Care Services in Long Term Residential Facility"]
        union [Encounter: "Home Healthcare Services"]
        union [Encounter: "Patient Provider Interaction"] ) ValidEncounter
      where ValidEncounter.period during day of "Measurement Period"
        and ValidEncounter.isFinished()

/*
@description: Returns true if the patient meets the following criteria:
                * 18 years of age or older, has two 
                * Has two Qualifying Outpatient Encounters During Measurement Period
                * Has a Heart Failure Outpatient Encounter
*/           
define "Is Adults With Two Qualifying Outpatient Encounters and One Heart Failure Outpatient Encounter During the Measurement Period":
  AgeInYearsAt(date from start of "Measurement Period") >= 18
    and exists ( "Qualifying Outpatient Encounter During Measurement Period" Encounter1
        with "Qualifying Outpatient Encounter During Measurement Period" Encounter2
          such that Encounter2.id !~ Encounter1.id
    )
    and exists "Heart Failure Outpatient Encounter"

define "Initial Population":
  AHA."Is Adults With Two Qualifying Outpatient Encounters and One Heart Failure Outpatient Encounter During the Measurement Period"

define "Denominator":
  "Initial Population"
    and exists AHA."Heart Failure Outpatient Encounter with History of Moderate or Severe LVSD"

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

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

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

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

/*
@description: Returns completed heart tansplant procedures that start before the end of a heart failure outpatient encounter with history of moderate or severe LVSD
*/ 
define "Has Heart Transplant":
  exists (
          [Procedure: "Heart Transplant"] HeartTransplant
            with "Heart Failure Outpatient Encounter with History of Moderate or Severe LVSD" ModerateOrSevereLVSDHFOutpatientEncounter
              such that HeartTransplant.performed.toInterval() starts before end of ModerateOrSevereLVSDHFOutpatientEncounter.period
            where HeartTransplant.status = 'completed'
          )

/*
@description: Returns true if patient has confirmed heart transplant complications that start before the end of a heart failure outpatient encounter with history of moderate or severe LVSD
*/ 
define "Has Heart Transplant Complications":
  exists ( 
          [Condition: "Heart Transplant Complications"] HeartTransplantComplications
            let diagnosisStart: Coalesce( HeartTransplantComplications.recordedDate, start of HeartTransplantComplications.prevalenceInterval() )  
            with "Heart Failure Outpatient Encounter with History of Moderate or Severe LVSD" ModerateOrSevereLVSDHFOutpatientEncounter
              such that diagnosisStart before end of ModerateOrSevereLVSDHFOutpatientEncounter.period
            where HeartTransplantComplications.isConfirmedActiveDiagnosis()
          )

/*
@description: Returns true if patient has a completed LVAD placement that starts before the end of a heart failure outpatient encounter with history of moderate or severe LVSD
*/ 
define "Has Left Ventricular Assist Device":
  exists (
            [Procedure: "Left Ventricular Assist Device Placement"] LVADOutpatient
              with "Heart Failure Outpatient Encounter with History of Moderate or Severe LVSD" ModerateOrSevereLVSDHFOutpatientEncounter
                such that LVADOutpatient.performed.toInterval() starts before end of ModerateOrSevereLVSDHFOutpatientEncounter.period
              where LVADOutpatient.status = 'completed'
            )

/*
@description: Returns true if patient has active LVAD complications that start before the end of a heart failure outpatient encounter with history of moderate or severe LVSD
*/ 
define "Has Left Ventricular Assist Device Complications":
  exists (
            [Condition: "Left Ventricular Assist Device Complications"] LVADComplications
              let diagnosisStart: Coalesce( LVADComplications.recordedDate, start of LVADComplications.prevalenceInterval() ) 
              with "Heart Failure Outpatient Encounter with History of Moderate or Severe LVSD" ModerateOrSevereLVSDHFOutpatientEncounter
                such that diagnosisStart before end of ModerateOrSevereLVSDHFOutpatientEncounter.period  
              where LVADComplications.isConfirmedActiveDiagnosis()
          )

define "Denominator Exclusions":
  AHA."Has Heart Transplant"
    or AHA."Has Heart Transplant Complications"
    or AHA."Has Left Ventricular Assist Device"
    or AHA."Has Left Ventricular Assist Device Complications"

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

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

define "Has Consecutive Heart Rates Less than 50":
  exists ( from
      ["observation-heartrate"] HeartRate,
      AHA."Heart Failure Outpatient Encounter with History of Moderate or Severe LVSD" ModerateOrSevereLVSDHFOutpatientEncounter
      let PriorHeartRate: Last(["observation-heartrate"] MostRecentPriorHeartRate
          where MostRecentPriorHeartRate.effective.toInterval() during ModerateOrSevereLVSDHFOutpatientEncounter.period
            and MostRecentPriorHeartRate.effective.toInterval() before HeartRate.effective.toInterval()
          sort by start of effective.toInterval()
      )
      where HeartRate.effective.toInterval ( ) during ModerateOrSevereLVSDHFOutpatientEncounter.period
        and HeartRate.status in { 'final', 'amended', 'corrected' }
        and HeartRate.value < 50 '/min'
        and PriorHeartRate.value < 50 '/min'
      return HeartRate
  )

define "Has Hypotension Diagnosis":
  exists ( ["Condition": "Hypotension"] Hypotension
      where Hypotension.overlapsHeartFailureOutpatientEncounter ( )
        and Hypotension.isConfirmedActiveDiagnosis ( )
  )

define "Has Asthma Diagnosis":
  exists ( [Condition: "Asthma"] Asthma
      where Asthma.overlapsHeartFailureOutpatientEncounter ( )
        and Asthma.isConfirmedActiveDiagnosis ( )
  )

define "Has Diagnosis of Allergy or Intolerance to Beta Blocker Therapy":
  exists ( ( ["Condition": "Allergy to Beta Blocker Therapy"]
      union ["Condition": "Intolerance to Beta Blocker Therapy"] ) BetaBlockerAllergyOrIntoleranceDiagnosis
      where BetaBlockerAllergyOrIntoleranceDiagnosis.overlapsAfterHeartFailureOutpatientEncounter ( )
        and BetaBlockerAllergyOrIntoleranceDiagnosis.isConfirmedActiveDiagnosis ( )
  )

define "Has Bradycardia Diagnosis":
  exists ( [Condition: "Bradycardia"] Bradycardia
      where Bradycardia.overlapsHeartFailureOutpatientEncounter ( )
        and Bradycardia.isConfirmedActiveDiagnosis ( )
  )

/*
@commentedOut: implies logic
@commentedOutReason: implies not available in cql-execution. Reference https://github.com/cqframework/cql-execution/issues/319.
*/


define "Has Allergy or Intolerance to Beta Blocker Therapy Ingredient":
  exists ( ( [AllergyIntolerance: "Beta Blocker Therapy Ingredient"]
      union [AllergyIntolerance: "Substance with beta adrenergic receptor antagonist mechanism of action (substance)"] ) BetaBlockerAllergyIntolerance
      where BetaBlockerAllergyIntolerance.overlapsAfterHeartFailureOutpatientEncounter ( )
        and ( /*https://oncprojectracking.healthit.gov/support/browse/BONNIEMAT-1771 - issue with implies operator tied to a non-supported feature in cql-exectuion 
                      For cql-execution issue, reference https://github.com/cqframework/cql-execution/issues/319.
                       ( BetaBlockerAllergyIntolerance.clinicalStatus is not null implies 
                             BetaBlockerAllergyIntolerance.clinicalStatus !~ QICoreCommon."allergy-inactive" ) 
                        or */
          BetaBlockerAllergyIntolerance.clinicalStatus ~ QICoreCommon."allergy-active"
        )
  )

define "Has Atrioventricular Block Diagnosis":
  exists ( [Condition: "Atrioventricular Block"] AtrioventricularBlock
      where AtrioventricularBlock.overlapsHeartFailureOutpatientEncounter ( )
        and AtrioventricularBlock.isConfirmedActiveDiagnosis ( )
  )

define "Has Diagnosis of Cardiac Pacer in Situ":
  exists ( ["Condition": "Cardiac Pacer in Situ"] CardiacPacerDiagnosis
      where CardiacPacerDiagnosis.overlapsAfterHeartFailureOutpatientEncounter ( )
        and CardiacPacerDiagnosis.isConfirmedActiveDiagnosis ( )
  )

define "Has Cardiac Pacer Device Implanted":
  exists ( [Procedure: "Cardiac Pacer"] ImplantedCardiacPacer
      with AHA."Heart Failure Outpatient Encounter with History of Moderate or Severe LVSD" ModerateOrSevereLVSDHFOutpatientEncounter
        such that ImplantedCardiacPacer.performed.toInterval ( ) starts before end of ModerateOrSevereLVSDHFOutpatientEncounter.period
      where ImplantedCardiacPacer.status = 'completed'
  )

define "Atrioventricular Block without Cardiac Pacer":
  "Has Atrioventricular Block Diagnosis"
    and not "Has Diagnosis of Cardiac Pacer in Situ"
    and not "Has Cardiac Pacer Device Implanted"

/*
@commentedOuf: Temporary removal of "Has Medical or Patient Reason for Not Ordering Beta Blocker for LVSD"
@commentedOufReason: Negation issue noted in https://github.com/cqframework/cql-execution/issues/296, which is tied to https://oncprojectracking.healthit.gov/support/browse/BONNIEMAT-1455
*/


define "Denominator Exceptions":
  "Has Consecutive Heart Rates Less than 50"
    //or "Has Medical or Patient Reason for Not Ordering Beta Blocker for LVSD"*/or "Has Arrhythmia Diagnosis"
    
    or "Has Hypotension Diagnosis"
    or "Has Asthma Diagnosis"
    or "Has Diagnosis of Allergy or Intolerance to Beta Blocker Therapy"
    or "Has Bradycardia Diagnosis"
    or "Has Allergy or Intolerance to Beta Blocker Therapy Ingredient"
    or "Atrioventricular Block without Cardiac Pacer"

/*
@description: Returns true if the given MedicationRequest is ordered during the heart failure outpatient encounter with history of moderate or severe LVSD at any point
*/
define fluent function isOrderedDuringHeartFailureOutpatientEncounter(MedicationRequest MedicationRequest): 
  exists ( "Heart Failure Outpatient Encounter with History of Moderate or Severe LVSD" ModerateOrSevereLVSDHFOutpatientEncounter
            where MedicationRequest.authoredOn during day of ModerateOrSevereLVSDHFOutpatientEncounter.period
              and MedicationRequest.status in {'active', 'completed'}
              and MedicationRequest.intent in { 'order', 'original-order', 'reflex-order', 'filler-order', 'instance-order' }
              /*Issue: The logic commented out below was added to the logic due to an issue described in the authoring patterns for QI-Core: https://github.com/cqframework/CQL-Formatting-and-Usage-Wiki/wiki/Authoring-Patterns---QICore-v4.1.1#medication-ordered. However, when this logic is present, it causes an issue in Coverage calculation for resources that must be QI-Core compliant, because the inverse cannot be tested for a QI-Core MedicationRequest profile instance. This logic was commented out to achieve 100% Coverage. This requirement is really to handle what would happen if a MedicationRequest instance that could be set to 'false' were provided, but this should not happen within a trusted environment where QI-Core profile instances must be provided.*/
              // and MedicationRequest.doNotPerform is not true 
          )

/*
@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.
*/
define fluent function prevalenceInterval(condition Condition):
if condition.clinicalStatus ~ "active"
  or condition.clinicalStatus ~ "recurrence"
  or condition.clinicalStatus ~ "relapse" then
  Interval[start of condition.onset.toInterval(), end of condition.abatementInterval()]
else
    (end of condition.abatementInterval()) abatementDate
    return if abatementDate is null then
      Interval[start of condition.onset.toInterval(), abatementDate)
    else
      Interval[start of condition.onset.toInterval(), abatementDate]

/*
@description: Returns true if the given Condition is confirmed as active
*/
define fluent function isConfirmedActiveDiagnosis(condition Condition):
    condition.isActive()
        and condition.verificationStatus ~ QICoreCommon."confirmed"

/* Candidates for FHIRCommon */

/*
@description: Returns true if the given condition has a clinical status of active, recurrence, or relapse
*/
define fluent function isActive(condition Condition):
  condition.clinicalStatus ~ "active"
    or condition.clinicalStatus ~ "recurrence"
    or condition.clinicalStatus ~ "relapse"

/*
@description: Returns true if the given Encounter is finished
*/
define fluent function isFinished(Encounter Encounter):
    Encounter.status = 'finished'

/*
@overloaded
@description: Returns true if the given MedicationRequest overlaps after the day of the heart failure outpatient encounter with history of moderate or severe LVSD
*/                    
define fluent function overlapsAfterHeartFailureOutpatientEncounter(MedicationRequest MedicationRequest): 
  exists ( "Heart Failure Outpatient Encounter with History of Moderate or Severe LVSD" ModerateOrSevereLVSDHFOutpatientEncounter
             where First( ( collapse (MedicationRequest.dosageInstruction.timing.repeat.bounds DoseTime
                                        return DoseTime.toInterval()) ) DrugPeriods
                           sort by start of $this ) overlaps after day of ModerateOrSevereLVSDHFOutpatientEncounter.period 
               and MedicationRequest.status in { 'active', 'completed' } 
               and MedicationRequest.intent in { 'order', 'original-order', 'reflex-order', 'filler-order', 'instance-order' }
               /*Issue: The logic commented out below was added to the logic due to an issue described in the authoring patterns for QI-Core: https://github.com/cqframework/CQL-Formatting-and-Usage-Wiki/wiki/Authoring-Patterns---QICore-v4.1.1#medication-ordered. However, when this logic is present, it causes an issue in Coverage calculation for resources that must be QI-Core compliant, because the inverse cannot be tested for a QI-Core MedicationRequest profile instance. This logic was commented out to achieve 100% Coverage. This requirement is really to handle what would happen if a MedicationRequest instance that could be set to 'false' were provided, but this should not happen within a trusted environment where QI-Core profile instances must be provided.*/
               // and Event.doNotPerform is not true 
          )

define function ToString(value uri): value.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
        }

/*
@description: Returns true if the given Condition overlaps the heart failure outpatient encounter with history of moderate or severe LVSD at any point
*/
define fluent function overlapsHeartFailureOutpatientEncounter(Condition Condition): 
  exists ( "Heart Failure Outpatient Encounter with History of Moderate or Severe LVSD" ModerateOrSevereLVSDHFOutpatientEncounter
            where Condition.prevalenceInterval() overlaps day of ModerateOrSevereLVSDHFOutpatientEncounter.period
              and Condition.isConfirmedActiveDiagnosis()
          )