Clinical
Reasoning
This
page
is
part
of
the
FHIR
Specification
(v5.0.0:
R5
-
STU
v6.0.0-ballot3:
Release
6
Ballot
(3rd
Draft)
(see
Ballot
Notes
).
This
is
the
The
current
published
version
in
it's
permanent
home
(it
will
always
be
available
at
this
URL).
is
5.0.0
.
For
a
full
list
of
available
versions,
see
the
Directory
of
published
versions
.
Page
versions:
R5
R4B
R4
|
Work
Group
Clinical
Quality
Information
|
Maturity
Level
:
|
Standards Status : Trial Use |
Note that throughout this section, the following terms are used:
Quality
measures
help
improve
the
quality
of
health
care
through
a
consistent
and
accountable
approach
to
evaluating
care
delivery.
The
Measure
resource
represents
a
structured,
potentially
computable
definition
of
a
health-related
measure
such
as
a
clinical
quality
measure,
public
health
indicator,
or
population
analytics
measure.
The
resource
builds
on
the
general
approach
to
representing
knowledge
artifacts
and
adds
the
metadata
and
structure
information
that
is
specific
to
quality
measures:
Quality
measures
follow
a
generally
general
hierarchical
structure
that
defines:
Population
Groups:
Groups
of
population
criteria
that
define
a
particular
area
of
measurement.
A
given
measure
Measure
may
include
any
number
of
population
groups,
each
with
different
criteria
for
the
various
measure
components.
Population
Quality
Measures
are
often
focused
on
evaluating
from
a
patient
perspective,
but
this
is
not
always
the
case.
The
subject
element
of
the
Measure
indicates
the
intended
subjects
of
a
measure.
If
no
subject
is
specified,
the
measure
subject
is
Patient,
but
Practitioners,
Organizations,
Locations,
or
even
Devices
can
also
be
the
subject
of
a
measure.
The
following
table
provides
a
requirements
mapping
from
the
content
of
an
eMeasure
electronic
Clinical
Quality
Measure
(eCQM)
to
the
elements
defined
in
the
Measure
resource:
|
|
Cardinality | Element | Notes |
|---|---|---|---|
| Title | 0..1 | Measure.title | |
| Identifier | 0..1 | Measure.identifier | identifier type code as http://hl7.org/fhir/cqi/ecqm/Measure/Identifier/cms |
| Version Number | 0..1 | Measure.version | |
| NQF Number | 0..1 | Measure.identifier | identifier type code as http://hl7.org/fhir/cqi/ecqm/Measure/Identifier/nqf |
| GUID | 0..1 | Measure.identifier | identifier type code as http://hl7.org/fhir/cqi/ecqm/Measure/Identifier/guid |
| Measure Steward | 0..1 | Measure.publisher | |
| Measure Developer | 0..1 | Measure.author | |
| Endorser | 0..1 | Measure.endorser | |
| Description | 0..1 | Measure.description | |
| Copyright | 0..1 | Measure.copyright | |
| Reference | 0..* | Measure.relatedArtifact | type.code of citation |
| Disclaimer | 0..1 | disclaimer | String (containing Markdown) |
| Measure Scoring | 0..1 | scoring | Code, e.g. proportion, CV |
| Measure Type | 0..1 | type | Code, e.g. process, outcome |
| Risk Adjustment | 0..1 | riskAdjustment | String |
| Rate Aggregation | 0..1 | rateAggregation | String |
| Rationale | 0..1 | rationale | String (containing Markdown) |
| Clinical Recommendation Statement | 0..1 | clinicalRecommendationStatement | String (containing Markdown) |
| Improvement Notation | 0..1 | improvementNotation | String, e.g. Higher score indicates better quality |
| Definition | 0..1 | definition | String (containing Markdown) |
| Guidance | 0..1 | Measure.usage | String (containing Markdown) |
As
with
other
knowledge
artifacts,
logic
is
included
by
referencing
a
Library
resource.
Although
the
base
resource.The
Library
resource
allows
is
a
general
purpose
container
for
the
measure
clinical
knowledge
artifacts.
It
can
be
used
to
reference
any
number
of
libraries,
for
simplicity
describe
and
expose
existing
knowledge
such
as
logic
and
information
model
descriptions,
as
well
as
to
describe
a
collection
of
managing
sharing,
measures
knowledge
artifacts.
Measures
should
reference
only
one
Library,
the
primary
measure
library
,
library,
and
that
library
should
contain
all
the
named
expressions
required
to
define
the
measure
structure.
For
more
information
on
using
libraries
with
CQL
and
FHIR,
refer
to
the
Libraries
topic
in
the
Using
CQL
with
FHIR
Implementation
Guide.
Note that this approach does not preclude sharing of logic between measures, it only requires that that sharing be explicitly done as dependencies within the referenced libraries, rather than allowing a measure to reference multiple libraries directly.
A
measure
can
specify
include
various
types
of
populations,
population
criteria,
depending
on
the
measure
scoring
being
used.
The
following
table
shows
which
population
criteria
types
are
required
(R),
optional
(O),
or
not
permitted
(NP)
for
proportion,
ratio,
and
continuous
variable
measures.
This
table
is
adapted
from
Table
1
from
the
HQMF
Release
1
Normative
specification,
and
Table
2.1
from
in
the
QDM-based
HQMF
IG
Quality
Measure
Implementation
Guide
.
| Measure Scoring | Initial Population | Denominator | Denominator Exclusion | Denominator Exception | Numerator | Numerator Exclusion | Measure Population | Measure Population Exclusion |
|---|---|---|---|---|---|---|---|---|
| Proportion | R | R | O | O | R | O | NP | NP |
| Ratio | R | R | O | NP | R | O | NP | NP |
| Continuous Variable | R | NP | NP | NP | NP | NP | R | O |
| Cohort | R | NP | NP | NP | NP | NP | NP | NP |
| Attestation | O | O | O | O | O | O | O | O |
The
Measure
resource
then
identifies
specific
named
expressions
within
the
referenced
primary
measure
library
that
define
the
criteria
for
each
population.
For
example,
the
following
fragment
illustrates
the
population
criteria
definitions
for
the
CMS146
measure
example:
<group>
<linkId value="CMS146-group-1"/>
<population>
<linkId value="CMS146-group-1-ip"/>
<code>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/measure-population-type"/>
<code value="initial-population"/>
</coding>
</code>
<criteria value="CMS146.InInitialPopulation"/>
</population>
<population>
<linkId value="CMS146-group-1-num"/>
<code>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/measure-population-type"/>
<code value="numerator"/>
</coding>
</code>
<criteria value="CMS146.InNumerator"/>
</population>
<population>
<linkId value="CMS146-group-1-den"/>
<code>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/measure-population-type"/>
<code value="denominator"/>
</coding>
</code>
<criteria value="CMS146.InDenominator"/>
</population>
<population>
<linkId value="CMS146-group-1-denex"/>
<code>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/measure-population-type"/>
<code value="denominator-exclusion"/>
</coding>
</code>
<criteria value="CMS146.InDenominatorExclusions"/>
</population>
</group>
Quality
measures
often
specify
multiple
rates,
with
different
population
crtiteria
for
each
rate.
This
is
different
than
stratifying
the
scores
for
the
same
population.
For
Supplemental
data
are
descriptive
in
nature
and
do
not
represent
an
evidence-based
quality
measures
that
contain
multiple
rates,
the
Measure
will
contain
multiple
group
elements,
where
the
criteria
opportunity,
rather
thay
may
provide
useful
additional
contextual
information
about
a
measure
population,
or
support
quality
program
requirements
such
as
Helth
IT
certifiaction.
Strata
are
specified
once
for
each
group.
The
linkId
attribute
an
integral
component
of
the
group
element
is
used
to
uniquely
identify
the
group
within
the
measure,
as
well
as
within
core
measure
specification.
Each
evidence-based
stratum
represents
significant
clinical
or
policy
rationale
for
subdividing
the
quality
reporting
results.
measure
population.
).
Stratifiers
and
supplemental
data
are
Measure
stratification
is
specified
using
the
stratifier
and
supplementalData
elements
element
of
the
Measure
resource.
Stratification
criteria
are
specified
either
as
a
reference
to
a
CQL
named
expression
within
a
Library
(e.g.
CMS146.AgesUpToNine
),
or
as
FHIR
resource
paths
(e.g.
).
When
the
stratification
criteria
is
an
expression,
the
stratification
will
yield
as
many
result
groups
as
the
expression
returns.
For
example,
if
the
expression
returns
a
boolean,
then
there
would
be
two
stratification
groups:
true
and
false.
When
the
stratification
criteria
is
a
FHIR
resource
path,
there
will
be
as
many
stratification
groups
as
possible
values
for
the
resource
path.
Patient.gender
Patient.deceased
For
example,
specifying
Patient.gender
will
yield
four
stratification
groups
since
FHIR
has
four
gender
codes:
male,
female,
other,
and
unknown.
Supplemental data represent additional information about a person or population beyond what is included in a core measure specification. Supplemental data often contain information specific to the entity primarily accountable for taking action on the measure results, such as provider-specific variables or those associated with a specific payment system. Supplemental data are descriptive in nature and do not represent an evidence-based quality opportunity, rather they may provide useful additional contextual information about a measure population, or support quality program requirements such as Health IT certification.
Some
measure
reporting
programs,
such
as
the
CMS
Eligible
Clinician
Electronic
Clinical
Quality
Measurement
program,
require
specific
supplemental
data
elements
can
also
(SDEs)
to
be
included
in
the
measure
report.
Supplemental
data
are
specified
using
FHIR
resource
paths,
in
which
case
the
supplementalData
element
is
the
result
of
evaluating
that
path
against
the
subject.
Measure
resource.
Like
stratifier
criteria,
supplemental
data
elements
are
specified
either
as
a
reference
to
a
CQL
named
expression
within
a
Library
or
as
FHIR
resource
paths.
For individual-level reports, if the result of evaluating the supplemental data expression for the subject of the report is not a resource, it is reported as a contained Observation resource and included by reference in the supplementalData element of the MeasureReport.
For
summary-level
reports,
supplementalData
is
reported
using
contained
Observation
resources
that
indicate
the
number
of
times
each
value
was
encountered
as
the
supplementalData
for
members
of
the
population.
In
this
case,
the
code
element
of
the
Observation
corresponds
to
the
code
of
the
supplementalData,
and
the
component.code
element
of
the
observation
specifies
the
supplementalData
values
encountered,
and
the
component.value[x]
element
is
specified
as
an
integer
that
represents
the
number
of
times
that
value
was
encountered
in
the
members
of
the
population.
The CMS146 example measure illustrates the stratification and supplemental data described above:
The
data
Quality
measures
often
specify
multiple
rates,
with
different
population
crtiteria
for
each
rate.
This
is
different
than
stratifying
the
scores
for
the
same
population.
For
quality
measures
that
contain
multiple
rates,
the
Measure
will
contain
multiple
group
elements,
where
the
criteria
are
specified
once
for
each
group.
The
linkId
attribute
of
the
primary
library
group
element
is
used
to
uniquely
identify
the
group
within
the
measure,
as
well
as
within
the
quality
reporting
results.
Continuous
variable
measures
may
include
a
measure
observation
section.
This
section
defines
variables
(for
example,
time
from
check-in
to
time
of
antibiotic
administration)
used
to
measure
particular
aspects
of
a
process
or
outcome.
Note
that
measure
observations
are
not
population
criteria
in
that
they
do
not
filter
the
population
in
any
way.
Rather,
measure
observations
are
data
elements,
to
be
collected
from
each
subject
that
satisfies
the
population
criteria,
which
are
used
to
calculate
the
results
for
each
member
of
interest
in
the
population.
The
data
requirements
for
a
measure
represent
the
data
of
interest
as
a
set
of
DataRequirement
elements.
Each
data
requirement
identifies
a
specific
types
type
of
data
along
with
constraints
that
the
data
must
meet.
For
example,
one
data
requirement
for
CMS
146
identifies
FHIR
Condition
resources
that
represent
confirmed
diagnoses
of
acute
pharyngitis.
Other
data
requirements
for
this
measure
include
Encounters,
DiagnosticReports
and
other
FHIR
resources
representing
specific
data
that
is
used
needed
to
calculate
the
measure.
a
valid
measure
score.
Specifying the data criteria in this way enables the following use cases:
Data
criteria
can
be
specified
statically,
or
they
can
be
inferred
from
the
expressions
referenced
by
the
measure.
The
$data-requirements
operation
can
be
invoked
to
retrieve
the
aggregate
data
requirements
for
the
measure.
This
approach
has
two
advantages:
module-definition
library.
The
Health
Quality
In
addition
to
multiple
rate
measures,
the
Measure
Format
(HQMF)
defines
resource
allows
for
composite
measures
to
be
built
by
referencing
existing
measures.
For
example,
public
health
indicators
may
be
defined
and
combined
in
multiple
ways
by
different
public
health
agencies:
In
the
electronic
representation
above
example,
two
different
agencies
are
able
to
make
use
of
an
eMeasure
but
does
not
define
the
same
definitions
in
different
ways
by
using
composite
measures.
For
a
mechanism
for
invoking
an
eMeasure.
more
complete
treatment
of
composite
measures,
refer
to
the
Quality
Measure
implementation
guide.
FHIR
defines
both
the
representation
of
resources
and
a
general
mechanism
for
interacting
with
them
via
the
OperationDefinition
resource.
Prior
sections
of
this
specification
topic
described
the
Measure
representation
of
an
eMeasure,
quality
measure,
this
section
describes
the
$evaluate-measure
operation
that
is
used
to
invoke
an
eMeasure
and
obtain
request
the
results.
results
of
calculating
a
Quality
Measure.
FHIR defines a standard set of common interactions that include read, update, delete and search. In addition, FHIR defines a standard set of extended operations that can be performed on resources, resource types and system wide. The standard operations include profile validation, concept translation and value set expansion. FHIR also supports custom operations via the FHIR OperationDefinition resource. This resource offers a means to create a formal definition of a custom operation that can be performed on a FHIR server. For the purposes of measure evaluation we define a new custom operation with a code of $evaluate-measure .
The $evaluate-measure operation has the following properties:
The effect of invoking the $evaluate-measure operation is to calculate the quality measure according to the supplied parameters and to return a MeasureReport resource through which the results will be made available. Note that because measure calculation might not be instantaneous, the MeasureReport resource provides a mechanism to handle long running calculations.
GET
[base]/Measure/$evaluate-measure?measure=CMS146&periodStart=2014&periodEnd=2014
GET
[base]/Measure/CMS146/$evaluate-measure?periodStart=2014&periodEnd=2014
The
above
examples
show
how
to
obtain
the
results
of
evaluating
the
eMeasure
measure
with
id
"CMS146"
for
all
patients
over
a
measurement
period
that
consists
of
all
of
2014.
Some
items
of
note:
[base]/Measure
which
is
the
type
of
resource
and
specifies
the
[base]/Measure/CMS146
which
is
the
Measure
instance
that
represents
that
measure
so
there's
no
need
to
also
include
a
reference
to
the
HTTP
GET
method
is
used
since
the
$evaluate-measure
operation
is
idempotent
[base]
is
used
as
a
shortcut
for
the
base
URI
of
the
FHIR
server
The
next
example
demonstrates
how
to
obtain
the
results
of
evaluating
the
eMeasure
measure
with
id
"CMS146"
for
the
patient
with
id
"124"
over
a
measurement
period
that
consists
of
the
first
three
months
of
2014.
GET
[base]/Basic/CMS146/$evaluate-measure?subject=124&periodStart=2014-01&periodEnd=2014-03
When
electronic
Clinical
Quality
Measures
(eCQMs)
are
represented
with
the
Health
Quality
Measure
Format
(HQMF),
a
single
HQMF
document
The
MeasureReport
resource
represents
both
the
results
of
calculating
a
measure
itself
and
the
request.
Meanwhile,
the
responses
are
represented
as
Quality
Reporting
Document
Architecture
(QRDA)
documents.
QRDA
documents
come
in
two
flavors:
Category
I
for
individual
patient
reports
and
Category
III
for
population
reports.
When
eCQMs
are
represented
with
FHIR
resources,
the
measure
is
represented
as
a
specific
subject
or
group
of
subjects.
The
$evaluate
operation
of
the
Measure
resource,
and
the
request
resource
is
an
HTTP
GET
conforming
defined
to
the
OperationDefinition
described
above.
Meanwhile,
the
responses
are
represented
as
MeasureReport
resources.
Like
QRDA,
the
MeasureReport
allows
for
Category
I
(individual),
Category
II
(subject-list),
return
a
MeasureReport.
The
resource
is
capable
of
representing
three
different
levels
of
report:
individual,
subject-list,
and
Category
III
(population)
reports.
summary.
A
MeasureReport
will
contain
one
a
group
of
data
for
each
group
specified
in
the
corresponding
Measure
,
consisting
of
a
set
of
population
elements,
one
for
each
criteria
defined
in
each
group.
The
Measure.group.linkId
and
Measure.group.population.linkId
elements
define
a
linking
id
that
is
used
to
correlate
the
group
and
population
elements
in
the
MeasureReport
back
to
the
corresponding
elements
in
the
Measure.
In
addition,
each
group
will
contain
stratifiers
with
a
value
stratum
for
each
value
defined
by
the
stratifier
criteria,
for
each
criteria
defined
in
the
measure.
The
Measure.group.stratifier.linkId
element
defines
a
linking
id
that
is
used
to
correlate
the
stratifier
elements
in
the
MeasureReport
back
to
the
corresponding
elements
in
the
Measure.
When
using
a
MeasureReport
resource
to
represent
the
results
of
an
individual
calculation,
the
MeasureReport
SHALL
have
a
type-code
of
"individual"
and
SHALL
have
a
reference
to
the
subject
of
the
report.
In
addition,
the
result
SHOULD
use
the
evaluatedResource
element
to
include
a
reference
references
to
a
Bundle
containing
the
any
subject-specific
resources
that
were
used
to
calculate
the
result.
See
the
MeasureReport
examples
for
a
detailed
illustration
of
how
the
data
elements
involved
in
the
calculation
of
the
measure
are
communicated
through
the
evaluatedResources
element.
As
with
population-level
reports,
the
group
,
population
,
stratifier
,
and
elements
have
a
supplementalData
stratifier
linkId
element
that
defines
a
linking
id
that
is
used
to
correlate
these
elements
in
the
MeasureReport
back
to
the
corresponding
elements
in
the
Measure.
When using a MeasureReport resource to represent a subject-list, the MeasureReport SHALL have a type-code of "subject-list" and if a subject reference is present, it SHALL be a reference to a Group. In addition, the resource SHALL
MeasureReport.group.population.subjectResults
element,
a
reference
to
a
List
resource
that
references
MeasureReport.group.population.subjectReport
element,
references
to
individual-level
MeasureReport
resources
for
the
same
measure
directly.
For
both
options
(measure
reports
provided
directly
using
the
subjectReport
element
or
indirectly
through
a
List
resource
using
the
subjectResults
element),
note
that
for
very
large
populations,
implementations
MAY
decide
to
limit
the
size
of
the
result,
either
by
returning
an
error
indicating
the
request
is
too
costly,
or
by
returning
a
partial
result,
so
long
as
there
is
an
indication
that
the
report
is
only
a
partial
response.
In
addition,
we
are
actively
seeking
feedback
on
how
best
to
approach
evaluation
of
quality
measures
on
large
populations,
including
the
use
of
bulk
data
formats.
In addition, implementations may return a MeasureReport with a status of pending, indicating that the evaluation is in progress. In this case, clients can request the MeasureReport resource until the status changes to complete.
As
part
of
the
evaluation
of
a
Measure
to
produce
a
MeasureReport,
systems
may
report
information
messages,
warnings,
and
errors
using
the
messages
element.
The
messages
can
be
used
to
reference
an
OperationOutcome
resource
describing
issues
that
have
occurred
during
the
evaluation.
Note
that
the
OperationOutcome
resource
referenced
is
typically
contained
within
the
returned
MeasureReport.
FHIR
®©
HL7.org
2011+.
FHIR
R5
hl7.fhir.core#5.0.0
R6
hl7.fhir.core#6.0.0-ballot3
generated
on
Sun,
Mar
26,
2023
15:26+1100.
Tue,
Apr
1,
2025
12:26+1100.
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