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Your User Friendly Name for MyContentIG Here, published by HL7 International - [Some] Work Group. This guide is not an authorized publication; it is the continuous build for version 0.4.6 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/cqframework/sample-content-ig/ and changes regularly. See the Directory of published versions

Measure: HIV Viral Suppression FHIR Example

Official URL: http://somewhere.org/fhir/uv/mycontentig/Measure/HIVViralSuppressionFHIRExample Version: 0.4.6
Draft as of 2024-05-06 Computable Name: HIVViralSuppressionFHIRExample
Other Identifiers: Short Name: CMS314FHIR (use: usual, ), UUID:b8aa1302-d225-4dc7-9a3b-ffec45976a3e (use: official, ), UUID:2c92808287dd6f640188b022a80a1e8d (use: official, ), Publisher: 314FHIR (use: official, )

Usage:Program: EP/EC

Copyright/Legal: This measure was developed by the Health Resources & Services Administration (HRSA) of the U.S. Department of Health & Human Services (HHS). It is in the public domain.

Citation of HRSA as the source of the original measure is appreciated. Any modified versions may not be represented as approved, endorsed, or authorized by HRSA or HHS. 42 U.S.C. Section 1320b-10. Users of modified versions should clearly explain how they deviate from HRSA’s original measure.

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.

CPT(R) contained in the Measure specifications is copyright 2004-2022 American Medical Association. LOINC(R) is copyright 2004-2022 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2022 International Health Terminology Standards Development Organisation. ICD-10 is copyright 2022 World Health Organization. All Rights Reserved.

Due to technical limitations, registered trademarks are indicated by (R) or [R] and unregistered trademarks are indicated by (TM) or [TM].

Percentage of patients, regardless of age, diagnosed with HIV prior to or during the first 90 days of the measurement period, with an eligible encounter in the first 240 days of the measurement period, whose last HIV viral load test result was less than 200 copies/mL during the measurement period

UNKNOWN

Knowledge Artifact Metadata
Name (machine-readable) HIVViralSuppressionFHIRExample
Title (human-readable) HIV Viral Suppression FHIR Example
Status Draft
Experimental false
Description

Percentage of patients, regardless of age, diagnosed with HIV prior to or during the first 90 days of the measurement period, with an eligible encounter in the first 240 days of the measurement period, whose last HIV viral load test result was less than 200 copies/mL during the measurement period

Purpose

UNKNOWN

Clinical Usage HIV viral load data should be captured either as a numeric value or as a character/text value, depending on whether a given viral load result falls above or below the lab's lower limit of detection. For viral loads at or above the lower limit of detection, the viral load should be captured as a numeric value (expressed as the number of copies/mL). For viral loads below the lower limit of detection, the viral load should be populated with a character/text value equivalent to "Below lower limit of detection." The EHR need not record this character value using this exact wording (for example, the character value could be recorded as "<20 copies/mL" or "not detected"), but values below the lower limit of detection should be documented to allow the submitter to accurately map them to a value of "Below lower limit of detection" for reporting purposes. This eCQM is a patient-based measure. This FHIR-based measure has been derived from the QDM-based measure: CMS314v1. Please refer to the HL7 QI-Core Implementation Guide (http://hl7.org/fhir/us/qicore/index.html) for more information on QI-Core and mapping recommendations from QDM to QI-Core 4.1.1 (http://hl7.org/fhir/us/qicore/qdm-to-qicore.html).
Approval Date 2023-08-14
Effective Period 2024-01-01..2024-12-31
Use Context Program (Details: UsageContextType code program = ' Program ', stated as ' null '): EP/EC
Measure Developer Health Resources & Services Administration: https://www.hrsa.gov/
Measure Steward HL7 International - [Some] Work Group
Steward Contact Details http://hl7.org/Special/committees/[something]
Copyright

This measure was developed by the Health Resources & Services Administration (HRSA) of the U.S. Department of Health & Human Services (HHS). It is in the public domain.

Citation of HRSA as the source of the original measure is appreciated. Any modified versions may not be represented as approved, endorsed, or authorized by HRSA or HHS. 42 U.S.C. Section 1320b-10. Users of modified versions should clearly explain how they deviate from HRSA's original measure.

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.

CPT(R) contained in the Measure specifications is copyright 2004-2022 American Medical Association. LOINC(R) is copyright 2004-2022 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2022 International Health Terminology Standards Development Organisation. ICD-10 is copyright 2022 World Health Organization. All Rights Reserved.

Due to technical limitations, registered trademarks are indicated by (R) or [R] and unregistered trademarks are indicated by (TM) or [TM].

Measure Metadata
Short Name Identifier CMS314FHIR
Version Independent Identifier urn:uuid:b8aa1302-d225-4dc7-9a3b-ffec45976a3e
Version Specific Identifier urn:uuid:2c92808287dd6f640188b022a80a1e8d
Publisher (CMS) Identifier 314FHIR
Version Number 0.4.6
Rationale

HIV is a communicable infection that leads to a progressive disease with a long asymptomatic period. Approximately 40,000 persons in the United States are newly infected with HIV each year (Centers for Disease Control and Prevention, 2021, p. 51). Without treatment, most persons develop acquired immunodeficiency syndrome (AIDS) within 10 years of HIV infection.

HIV viral suppression is a long-standing priority outcome among the HIV community in the United States and around the world. The National HIV/AIDS Strategy for the United States from 2022-2025, developed by the White House Office of National AIDS Policy with input from the HIV community across the United States, prioritizes increasing HIV viral suppression rates to 95% (The White House, 2020). The DHHS Panel on Antiretroviral Guidelines for Adults and Adolescents defines viral suppression as a viral load below the lower limits of detection in its guidelines on virologic failure, and it defines viral suppression as a viral load of less than 200 copies/mL as part of its guidelines for the use of antiretroviral therapy to prevent HIV transmission (Panel on Antiretroviral Guidelines for Adults and Adolescents, 2022).

Antiretroviral therapy (ART) delays the progression to AIDS and increases the length of survival. ART reduces HIV-associated morbidity and mortality by maximally inhibiting HIV replication to achieve viral suppression (Hogg et al., 2001; Lundgern et al., 2015). ART has also been shown to reduce transmission of HIV (Rodger et al., 2019). Studies show disparities in rates of viral suppression by race and ethnicity among MSM and among women, with Black and Hispanic or Latino/a study participants having lower rates of viral suppression than White participants (Buchacz et al., 2020; Buchacz et al., 2018; Geter et al., 2018). This measure will help providers direct their attention and quality improvement efforts towards improving HIV viral suppression rates.

Clinical Recommendation Statement

Adult guidelines: "The primary goal of antiretroviral therapy (ART) is to prevent HIV-associated morbidity and mortality. This goal is accomplished by using effective ART to achieve and maintain a plasma HIV-1 RNA (viral load) below the quantification limits of commercially available assays. Durable viral suppression improves immune function and overall quality of life, lowers the risk of both AIDS-defining and non-AIDS–defining complications, and allows persons with HIV to live a lifespan approaching that of persons without HIV" (Panel on Antiretroviral Guidelines for Adults and Adolescents, 2022, p. E-1).

"ART is recommended for all individuals with HIV to reduce the morbidity and mortality associated with HIV infection and to prevent HIV transmission to sexual partners and infants (AI). ART should be initiated as soon as possible after HIV diagnosis (AI)" (Panel on Antiretroviral Guidelines for Adults and Adolescents, 2022, p. E-2).

"The guidelines and the AIDS Clinical Trials Group (ACTG) now define virologic failure as a confirmed viral load >200 copies/mL- a threshold that eliminates most cases of apparent viremia caused by viral load blips or assay variability" (Panel on Antiretroviral Guidelines for Adults and Adolescents, 2022, p. C-6).

"Individuals who are adherent to their ARV regimen and do not harbor resistance mutations to the component drugs can generally achieve suppression 8 to 24 weeks after ART initiation; rarely, in some patients it may take longer" (Panel on Antiretroviral Guidelines for Adults and Adolescents, 2022, p. C-6).

Pediatric guidelines: "Based on accumulated experience with currently available assays, the current definition of virologic suppression is a plasma viral load below the detection limit of the assay used (generally <20 to 75 copies/mL)" (Panel on Antiretroviral Therapy and Medical Management of Children Living with HIV, 2022, p. D-5).

"Temporary viral load elevations ("blips") that are between the level of detection and 200 copies/mL to 500 copies/mL are often detected in adults and children who are on ART; these temporary elevations do not represent virologic failure, as long as the values have returned to below the level of detection when testing is repeated" (Panel on Antiretroviral Therapy and Medical Management of Children Living with HIV, 2022, p. D-5).

Measure Population Criteria (ID: 64873a03be23a058642d5816)
Initial Population ID: DF999E50-BAB8-409F-922D-E8FA0E0BD92E
Description:

All patients, regardless of age, diagnosed with HIV prior to or during the first 90 days of the measurement period with at least one eligible encounter in the first 240 days of the measurement period

Logic Definition: Initial Population
Denominator ID: 2D69A89B-E60C-4878-B1DD-9F27450D603B
Description:

Equals Initial Population

Logic Definition: Denominator
Denominator Exclusion ID: 02767a1a-3174-47b6-8c31-84e10114824f
Description: No description provided
Numerator ID: E492BC05-FD48-4459-8574-5CF67CC14C66
Description:

Patients with a last HIV viral load test result of less than 200 copies/mL during the measurement period

Logic Definition: Numerator
Numerator Exclusion ID: c5d8edbc-2566-4a49-b298-f39723e037c6
Description: No description provided
Denominator Exception ID: 4e8d7586-8625-42d1-9cff-c02d3d4b87f3
Description: No description provided
Population Basis boolean
Scoring Proportion
Type Outcome
Measure Logic
Primary Library HIV Viral Suppression FHIR Example
Dependency Description: Library FHIRHelpers
Resource: http://hl7.org/fhir/Library/FHIRHelpers|4.0.1
Canonical URL: http://hl7.org/fhir/Library/FHIRHelpers|4.0.1
Dependency Description: Library QICoreCommon
Resource: QICore Common Example
Canonical URL: http://somewhere.org/fhir/uv/mycontentig/Library/QICoreCommonExample
Dependency Description: Code system SNOMEDCT
Resource: SNOMED CT (all versions)
Canonical URL: http://snomed.info/sct
Dependency Description: Value set HIV Viral Load
Resource: HIV Viral Load
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.120.12.1002
Dependency Description: Value set HIV
Resource: HIV
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.120.12.1003
Dependency Description: Value set Office Visit
Resource: Office Visit
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1001
Dependency Description: Value set Outpatient Consultation
Resource: Outpatient Consultation
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1008
Dependency Description: Value set Annual Wellness Visit
Resource: Annual Wellness Visit
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.526.3.1240
Dependency Description: Value set Face-to-Face Interaction
Resource: Face-to-Face Interaction
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1048
Dependency Description: Value set Home Healthcare Services
Resource: Home Healthcare Services
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1016
Dependency Description: Value set Preventive Care Services Established Office Visit, 18 and Up
Resource: Preventive Care Services Established Office Visit, 18 and Up
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1025
Dependency Description: Value set Preventive Care Services Initial Office Visit, 18 and Up
Resource: Preventive Care Services Initial Office Visit, 18 and Up
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1023
Dependency Description: Value set Preventive Care Services, Initial Office Visit, 0 to 17
Resource: Preventive Care Services, Initial Office Visit, 0 to 17
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1022
Dependency Description: Value set Preventive Care, Established Office Visit, 0 to 17
Resource: Preventive Care, Established Office Visit, 0 to 17
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1024
Dependency Description: Value set Telephone Visits
Resource: Telephone Visits
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1080
Dependency Description: Value set Preventive Care Services Other
Resource: Preventive Care Services Other
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1030
Direct Reference Code Display: Below threshold level (qualifier value)
Code: 260988000
System: http://snomed.info/sct
Direct Reference Code Display: Not detected (qualifier value)
Code: 260415000
System: http://snomed.info/sct
Parameter Name: Measurement Period
Use: In
Min Cardinality: 0
Max Cardinality: 1
Type: Period
Parameter Name: Numerator
Use: Out
Min Cardinality: 0
Max Cardinality: 1
Type: boolean
Parameter Name: Denominator
Use: Out
Min Cardinality: 0
Max Cardinality: 1
Type: boolean
Parameter Name: Initial Population
Use: Out
Min Cardinality: 0
Max Cardinality: 1
Type: boolean
Measure Logic Data Requirements
Data Requirement Type: Patient
Profile(s): QICore Patient
Data Requirement Type: Observation
Profile(s): QICore Observation
Must Support Elements: code, effective
Code Filter(s):
Path: code
ValueSet: HIV Viral Load
Data Requirement Type: Condition
Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-condition
Must Support Elements: code
Code Filter(s):
Path: code
ValueSet: HIV
Data Requirement Type: Encounter
Profile(s): QICore Encounter
Must Support Elements: type, period
Code Filter(s):
Path: type
ValueSet: Office Visit
Data Requirement Type: Encounter
Profile(s): QICore Encounter
Must Support Elements: type, period
Code Filter(s):
Path: type
ValueSet: Outpatient Consultation
Data Requirement Type: Encounter
Profile(s): QICore Encounter
Must Support Elements: type, period
Code Filter(s):
Path: type
ValueSet: Annual Wellness Visit
Data Requirement Type: Encounter
Profile(s): QICore Encounter
Must Support Elements: type, period
Code Filter(s):
Path: type
ValueSet: Face-to-Face Interaction
Data Requirement Type: Encounter
Profile(s): QICore Encounter
Must Support Elements: type, period
Code Filter(s):
Path: type
ValueSet: Home Healthcare Services
Data Requirement Type: Encounter
Profile(s): QICore Encounter
Must Support Elements: type, period
Code Filter(s):
Path: type
ValueSet: Preventive Care Services Established Office Visit, 18 and Up
Data Requirement Type: Encounter
Profile(s): QICore Encounter
Must Support Elements: type, period
Code Filter(s):
Path: type
ValueSet: Preventive Care Services Initial Office Visit, 18 and Up
Data Requirement Type: Encounter
Profile(s): QICore Encounter
Must Support Elements: type, period
Code Filter(s):
Path: type
ValueSet: Preventive Care Services, Initial Office Visit, 0 to 17
Data Requirement Type: Encounter
Profile(s): QICore Encounter
Must Support Elements: type, period
Code Filter(s):
Path: type
ValueSet: Preventive Care, Established Office Visit, 0 to 17
Data Requirement Type: Encounter
Profile(s): QICore Encounter
Must Support Elements: type, period
Code Filter(s):
Path: type
ValueSet: Telephone Visits
Data Requirement Type: Encounter
Profile(s): QICore Encounter
Must Support Elements: type, period
Code Filter(s):
Path: type
ValueSet: Preventive Care Services Other
Measure Logic Definitions
Logic Definition Library Name: HIVViralSuppressionFHIRExample
define "Most Recent Viral Load Test During Measurement Period":
  Last(["Observation": "HIV Viral Load"] ViralLoad
      where QICoreCommon."Latest"(ViralLoad.effective) during day of "Measurement Period"
      sort by start of QICoreCommon."ToInterval"(effective)
  )
Logic Definition Library Name: HIVViralSuppressionFHIRExample
define "Numerator":
  "Most Recent Viral Load Test During Measurement Period".value < 200 '{copies}/mL'
    or "Most Recent Viral Load Test During Measurement Period".value ~ "Below threshold level (qualifier value)"
    or "Most Recent Viral Load Test During Measurement Period".value ~ "Not detected (qualifier value)"
Logic Definition Library Name: HIVViralSuppressionFHIRExample
define "Has Active HIV Diagnosis Before or in First 90 Days of Measurement Period":
  exists ["Condition": "HIV"] HIVDx
    where QICoreCommon."ToPrevalenceInterval" ( HIVDx ) starts before day of ( start of "Measurement Period" + 90 days )
Logic Definition Library Name: HIVViralSuppressionFHIRExample
define "Has Qualifying Encounter During First 240 Days of Measurement Period":
  exists ( ["Encounter": "Office Visit"]
    union ["Encounter": "Outpatient Consultation"]
    union ["Encounter": "Annual Wellness Visit"]
    union ["Encounter": "Face-to-Face Interaction"]
    union ["Encounter": "Home Healthcare Services"]
    union ["Encounter": "Preventive Care Services Established Office Visit, 18 and Up"]
    union ["Encounter": "Preventive Care Services Initial Office Visit, 18 and Up"]
    union ["Encounter": "Preventive Care Services, Initial Office Visit, 0 to 17"]
    union ["Encounter": "Preventive Care, Established Office Visit, 0 to 17"]
    union ["Encounter": "Telephone Visits"]
    union ["Encounter": "Preventive Care Services Other"] ) QualifyingEncounter
    where QualifyingEncounter.period during day of Interval[start of "Measurement Period", start of "Measurement Period" + 240 days]
Logic Definition Library Name: HIVViralSuppressionFHIRExample
define "Initial Population":
  "Has Active HIV Diagnosis Before or in First 90 Days of Measurement Period"
    and "Has Qualifying Encounter During First 240 Days of Measurement Period"
Logic Definition Library Name: HIVViralSuppressionFHIRExample
define "Denominator":
  "Initial Population"
Logic Definition Library Name: QICoreCommonExample
/*
@description: Given an interval, returns the ending point if the interval has an ending boundary specified,
otherwise, returns the starting point
@deprecated: This function is deprecated. Use the fluent function `latest()` instead
*/
define function "Latest"(choice Choice<DateTime, Quantity, Interval<DateTime>, Interval<Quantity>> ):
  (choice.toInterval()) period
    return
      if (HasEnd(period)) then end of period
      else start of period
Logic Definition Library Name: QICoreCommonExample
/*
@description: Normalizes a value that is a choice of timing-valued types to an equivalent interval
@comment: Normalizes a choice type of DateTime, Quanitty, Interval<DateTime>, or Interval<Quantity> types
to an equivalent interval. This selection of choice types is a superset of the majority of choice types that are used as possible
representations for timing-valued elements in QICore, allowing this function to be used across any resource.
The input can be provided as a DateTime, Quantity, Interval<DateTime> or Interval<Quantity>.
The intent of this function is to provide a clear and concise mechanism to treat single
elements that have multiple possible representations as intervals so that logic doesn't have to account
for the variability. More complex calculations (such as medication request period or dispense period
calculation) need specific guidance and consideration. That guidance may make use of this function, but
the focus of this function is on single element calculations where the semantics are unambiguous.
If the input is a DateTime, the result a DateTime Interval beginning and ending on that DateTime.
If the input is a Quantity, the quantity is expected to be a calendar-duration interpreted as an Age,
and the result is a DateTime Interval beginning on the Date the patient turned that age and ending immediately before one year later.
If the input is a DateTime Interval, the result is the input.
If the input is a Quantity Interval, the quantities are expected to be calendar-durations interpreted as an Age, and the result
is a DateTime Interval beginning on the date the patient turned the age given as the start of the quantity interval, and ending
immediately before one year later than the date the patient turned the age given as the end of the quantity interval.
Any other input will reslt in a null DateTime Interval
*/
define fluent function toInterval(choice Choice<DateTime, Quantity, Interval<DateTime>, Interval<Quantity>>):
  case
	  when choice is DateTime then
    	Interval[choice as DateTime, choice as DateTime]
		when choice is Interval<DateTime> then
  		choice as Interval<DateTime>
		when choice is Quantity then
		  Interval[Patient.birthDate + (choice as Quantity),
			  Patient.birthDate + (choice as Quantity) + 1 year)
		when choice is Interval<Quantity> then
		  Interval[Patient.birthDate + (choice.low as Quantity),
			  Patient.birthDate + (choice.high as Quantity) + 1 year)
		else
			null as Interval<DateTime>
	end
Logic Definition Library Name: QICoreCommonExample
/*
@description: Normalizes a value that is a choice of timing-valued types to an equivalent interval
@comment: Normalizes a choice type of DateTime, Quanitty, Interval<DateTime>, or Interval<Quantity> types
to an equivalent interval. This selection of choice types is a superset of the majority of choice types that are used as possible
representations for timing-valued elements in QICore, allowing this function to be used across any resource.
The input can be provided as a DateTime, Quantity, Interval<DateTime> or Interval<Quantity>.
The intent of this function is to provide a clear and concise mechanism to treat single
elements that have multiple possible representations as intervals so that logic doesn't have to account
for the variability. More complex calculations (such as medication request period or dispense period
calculation) need specific guidance and consideration. That guidance may make use of this function, but
the focus of this function is on single element calculations where the semantics are unambiguous.
If the input is a DateTime, the result a DateTime Interval beginning and ending on that DateTime.
If the input is a Quantity, the quantity is expected to be a calendar-duration interpreted as an Age,
and the result is a DateTime Interval beginning on the Date the patient turned that age and ending immediately before one year later.
If the input is a DateTime Interval, the result is the input.
If the input is a Quantity Interval, the quantities are expected to be calendar-durations interpreted as an Age, and the result
is a DateTime Interval beginning on the date the patient turned the age given as the start of the quantity interval, and ending
immediately before one year later than the date the patient turned the age given as the end of the quantity interval.
Any other input will reslt in a null DateTime Interval
@deprecated: This function is deprecated. Use the fluent function `toInterval()` instead
*/
define function ToInterval(choice Choice<DateTime, Quantity, Interval<DateTime>, Interval<Quantity>>):
  case
	  when choice is DateTime then
    	Interval[choice as DateTime, choice as DateTime]
		when choice is Interval<DateTime> then
  		choice as Interval<DateTime>
		when choice is Quantity then
		  Interval[Patient.birthDate + (choice as Quantity),
			  Patient.birthDate + (choice as Quantity) + 1 year)
		when choice is Interval<Quantity> then
		  Interval[Patient.birthDate + (choice.low as Quantity),
			  Patient.birthDate + (choice.high as Quantity) + 1 year)
		when choice is QICore.Timing then
            null as Interval<DateTime>
		else
			null as Interval<DateTime>
	end
Logic Definition Library Name: QICoreCommonExample
/*
@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, the resulting interval will have
a closed ending boundary. If the condition is not active, 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
  Interval[start of ToInterval(condition.onset), end of ToAbatementInterval(condition))
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