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FHIR IG Statistics: Measure/CMS159FHIRDepressionRemissionatTwelveMonths

Packagegov.healthit.ecqi.ecqms
Resource TypeMeasure
IdCMS159FHIRDepressionRemissionatTwelveMonths
FHIR VersionR4
Sourcehttp://ecqi.healthit.gov/ecqms/https://build.fhir.org/ig/cqframework/ecqm-content-qicore-2025/Measure-CMS159FHIRDepressionRemissionatTwelveMonths.html
URLhttps://madie.cms.gov/Measure/CMS159FHIRDepressionRemissionatTwelveMonths
Version0.3.000
Statusactive
Date2025-07-15T13:37:41+00:00
NameCMS159FHIRDepressionRemissionatTwelveMonths
TitleDepression Remission at Twelve MonthsFHIR
DescriptionThe percentage of adolescent patients 12 to 17 years of age and adult patients 18 years of age or older with major depression or dysthymia who reached remission 12 months (+/- 60 days) after an index event
CopyrightCopyright MN Community Measurement, 2025. All rights reserved. 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. MN Community Measurement disclaims all liability for the use or accuracy of any third-party codes contained in the specifications. CPT(R) contained in the Measure specifications is copyright 2004-2024 American Medical Association. LOINC(R) copyright 2004-2024 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2024 International Health Terminology Standards Development Organisation. ICD-10 copyright 2024 World Health Organization. All Rights Reserved.

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Narrative

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Metadata
Title Depression Remission at Twelve MonthsFHIR
Version 0.3.000
Short Name CMS159FHIR
GUID (Version Independent) urn:uuid:5df972fb-27e0-4b59-b5f8-b041e6ffc947
GUID (Version Specific) urn:uuid:bdf0219b-209a-4b64-8542-03bc3769157b
CMS Identifier 159FHIR
CMS Consensus Based Entity Identifier 0710e
Effective Period 2026-01-01 through 2026-12-31
Steward (Publisher) MN Community Measurement
Developer MN Community Measurement
Description

The percentage of adolescent patients 12 to 17 years of age and adult patients 18 years of age or older with major depression or dysthymia who reached remission 12 months (+/- 60 days) after an index event
Copyright

Copyright MN Community Measurement, 2025. All rights reserved.

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. MN Community Measurement disclaims all liability for the use or accuracy of any third-party codes contained in the specifications.

CPT(R) contained in the Measure specifications is copyright 2004-2024 American Medical Association. LOINC(R) copyright 2004-2024 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2024 International Health Terminology Standards Development Organisation. ICD-10 copyright 2024 World Health Organization. All Rights Reserved.
Disclaimer

The performance measure is not a clinical guideline and does not establish a standard of medical care, and has not been tested for all potential applications.

THE MEASURES AND SPECIFICATIONS ARE PROVIDED “AS IS” WITHOUT WARRANTY OF ANY KIND.

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

Adults: Depression is a common and treatable mental disorder. During 2013-2016, 8.1% of American adults aged 20 and over had depression in a given 2-week period. Women (10.4%) were almost twice as likely as men (5.5%) to have had depression. The prevalence of depression among adults decreased as family income levels increased. About 80% of adults with depression reported at least some difficulty with work, home, or social activities because of their depression symptoms (Brody et al., 2018).

Depression is a risk factor for development of chronic illnesses such as diabetes and coronary heart disease and adversely affects the course, complications and management of chronic medical illness. Both maladaptive health risk behaviors and psychobiological factors associated with depression may explain depression's negative effect on outcomes of chronic illness (Katon, 2011).

Adolescents and Adults: The Centers for Disease Control and Prevention states that during 2009-2012 an estimated 7.6% of the U.S. population aged 12 and over had depression, including 3% of Americans with severe depressive symptoms. Almost 43% of persons with severe depressive symptoms reported serious difficulties in work, home and social activities, yet only 35% reported having contact with a mental health professional in the past year (Pratt & Brody, 2014). Depression is associated with higher mortality rates in all age groups. Depression is also a leading cause of medical disability, and depressed people lose 5.6 hours of productive work every week when they are depressed, 50% of which is due to absenteeism and short-term disability (Stewart et al., 2003).

Adolescents: In 2014, an estimated 2.8 million adolescents aged 12 to 17 in the United States had at least one major depressive episode (MDE) in the past year (Center for Behavioral Health Statistics and Quality, 2015). The 2013 Youth Risk Behavior Survey of students in grades 9 to 12 indicated that during the past 12 months 39.1% (F) and 20.8% (M) indicated feeling sad or hopeless almost every day for at least 2 weeks, planned suicide attempt 16.9% (F) and 10.3% (M), with attempted suicide 10.6% (F) and 5.4% (M) (Kann et al., 2014). Adolescent-onset depression is associated with chronic depression in adulthood. Many mental health conditions (anxiety, bipolar, depression, eating disorders, and substance abuse) are evident by age 14. The 12-month prevalence of MDEs increased from 8.7% in 2005 to 11.3% in 2014 in adolescents and from 8.8% to 9.6% in young adults (both P < .001). The increase was larger and statistically significant only in the age range of 12 to 20 years. The trends remained significant after adjustment for substance use disorders and sociodemographic factors (Mojtabai et al., 2016). Mental health care contacts overall did not change over time; however, the use of specialty mental health providers increased in adolescents and young adults, and the use of prescription medications and inpatient hospitalizations increased in adolescents (Mojtabai et al., 2016).
Clinical Recommendation Statement

Adults:

Recommendations and algorithm notations supporting depression outcomes and duration of treatment according to Institute for Clinical Systems Improvement Health Care Guideline (Trangle et al., 2016):

Recommendation: Clinicians should establish and maintain follow-up with patients. Appropriate, reliable follow-up is highly correlated with improved response and remission scores. It is also correlated with the improved safety and efficacy of medications and helps prevent relapse (Trangle et al., 2016).

Proactive follow-up contacts (in person, telephone) based on the collaborative care model have been shown to significantly lower depression severity (Unutzer et al., 2002). In the available clinical effectiveness trials conducted in real clinical practice settings, even the addition of a care manager leads to modest remission rates (Trivedi et al., 2006; Unutzer et al., 2002). Interventions are critical to educating the patient regarding the importance of preventing relapse, safety and efficacy of medications, and management of potential side effects. Establish and maintain initial follow-up contact intervals (office, phone, other) (Hunkeler et al., 2000; Simon et al., 2000).

The Patient Health Questionnaire-9 (PHQ-9) is an effective monitoring and management tool, and should be used routinely for subsequent visits to monitor treatment outcomes and severity. It can also help the clinician decide if/how to modify the treatment plan (Duffy et al., 2008; Lowe et al., 2004). Using a measurement-based approach to depression care, PHQ-9 results and side effect evaluation should be combined with treatment algorithms to drive patients toward remission. A five-point drop in PHQ-9 score is considered the minimal clinically significant difference (Trivedi, 2009).

The goals of treatment should be to achieve remission, reduce relapse and recurrence, and return to previous level of occupational and psychosocial function.

If using a PHQ-9 tool, remission translates to PHQ-9 score of less than 5 (Kroenke, et al., 2001). Results from the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study showed that remission rates lowered with more treatment steps, but the overall cumulative rate was 67% (Rush et al., 2006).

Response and remission take time. In the STAR*D study, longer times than expected were needed to reach response or remission. In fact, one-third of those who ultimately responded did so after six weeks. Of those who achieved remission by Quick Inventory of Depressive Symptomatology, 50% did so only at or after six weeks of treatment (Trivedi et al., 2006). If the primary care clinician is seeing some improvement, continue working with that patient to augment or increase dosage to reach remission. This can take up to three months.

This measure assesses achievement of remission, which is a desired outcome of effective depression treatment and monitoring.

Adult Depression in Primary Care - Guideline Aims (Trangle et al., 2016):

  • Increase the percentage of patients with major depression or persistent depressive disorder who have improvement in outcomes from treatment for major depression or persistent depressive disorder.
  • Increase the percentage of patients with major depression or persistent depressive disorder who have follow-up to assess for outcomes from treatment.
  • Improve communication between the primary care physician and the mental health care clinician (if patient is co-managed).

Adolescents:

Recommendations supporting depression outcomes and duration of treatment according to American Academy of Child and Adolescent Psychiatry guideline (Birmaher et al., 2007):

  • Treatment of depressive disorders should always include an acute and continuation phase; some children may also require maintenance treatment. The main goal of the acute phase is to achieve response and ultimately full symptomatic remission (definitions below).
  • Each phase of treatment should include psychoeducation, supportive management, and family and school involvement.
  • Education, support, and case management appear to be sufficient treatment for the management of depressed children and adolescents with an uncomplicated or brief depression or with mild psychosocial impairment.
  • For children and adolescents who do not respond to supportive psychotherapy or who have more complicated depressions, a trial with specific types of psychotherapy and/or antidepressants is indicated.

Recommendations supporting depression outcomes and duration of treatment according to Guidelines for Adolescent Depression in Primary Care (Zuckerbrot et al., 2018 (Part I), Zuckerbrot et al., 2018 (Part II)):

  • Mild depression: consider a period of active support and monitoring before starting other evidence-based treatment
  • Moderate or severe major clinical depression or complicating factors: -- consultation with mental health specialist with agreed upon roles -- evidence based treatment (cognitive behavioral therapy or interpersonal psychotherapy and/or antidepressant selective serotonin reuptake inhibitors)
  • Monitor for adverse effects during antidepressant therapy -- clinical worsening, suicidality, unusual changes in behavior
  • Systematic and regular tracking of goals and outcomes -- improvement in functioning status and resolution of depressive symptoms Regardless of the length of treatment, all patients should be monitored on a monthly basis for 6 to 12 months after the full resolution of symptoms.
Guidance (Usage) When an index assessment is conducted with PHQ-9M, the follow-up assessment can use either a PHQ-9M or PHQ-9. This eCQM is a patient-based measure. This FHIR-based measure has been derived from the QDM-based measure: CMS159v13 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-Core 4.1.1 (https://hl7.org/fhir/us/qicore/STU4.1.1/qdm-to-qicore.html). Note: There are issues related to Stratification in QMIG STU 3 that were addressed in QMIG STU 4. MADiE needs updated to use the technical correction introduced in QMIG STU 4. Refer to https://oncprojectracking.healthit.gov/support/browse/BONNIEMAT-1489. Furthermore, there are issues related to human readable generation of stratification. Refer to https://github.com/cqframework/sample-content-ig/issues/70. Until such time that these issues can be addressed within the tooling, stratification logic has been commented out in this measure.
Measure Group (Rate) (ID: Group_1)
Basis boolean
Scoring Proportion
Type Outcome
Rate Aggregation None
Improvement Notation Increased score indicates improvement
Initial Population ID: InitialPopulation_1
Description:

Adolescent patients 12 to 17 years of age and adult patients 18 years of age and older with a diagnosis of major depression or dysthymia and an initial PHQ-9 or PHQ-9M score greater than nine during the index event. Patients may be assessed using PHQ-9 or PHQ-9M on the same date or up to 7 days prior to the encounter (index event)

Logic Definition: Initial Population
Denominator ID: Denominator_1
Description:

Equals Initial Population

Logic Definition: Denominator
Denominator Exclusion ID: DenominatorExclusion_1
Description:

- Patients who died any time prior to the end of the measure assessment period - Patients who received hospice or palliative care services between the start of the denominator period and the end of the measurement assessment period - Patients with a diagnosis of bipolar disorder any time prior to the end of the measure assessment period - Patients with a diagnosis of personality disorder emotionally labile any time prior to the end of the measure assessment period - Patients with a diagnosis of schizophrenia or psychotic disorder any time prior to the end of the measure assessment period - Patients with a diagnosis of pervasive developmental disorder (e.g., autism spectrum disorder) any time prior to the end of the measure assessment period

Logic Definition: Denominator Exclusions
Numerator ID: Numerator_1
Description:

Adolescent patients 12 to 17 years of age and adult patients 18 years of age and older who achieved remission at twelve months as demonstrated by the most recent twelve month (+/- 60 days) PHQ-9 or PHQ-9M score of less than five

Logic Definition: Numerator
Supplemental Data Guidance For every patient evaluated by this measure also identify payer, race, ethnicity and sex
Supplemental Data Guidance None
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
Supplemental Data Element ID: sde-ethnicity
Usage Code: Risk Adjustment Factor
Description: SDE Ethnicity
Logic Definition: SDE Ethnicity
Supplemental Data Element ID: sde-payer
Usage Code: Risk Adjustment Factor
Description: SDE Payer
Logic Definition: SDE Payer
Supplemental Data Element ID: sde-race
Usage Code: Risk Adjustment Factor
Description: SDE Race
Logic Definition: SDE Race
Supplemental Data Element ID: sde-sex
Usage Code: Risk Adjustment Factor
Description: SDE Sex
Logic Definition: SDE Sex
Measure Logic
Primary Library CMS159FHIRDepressionRemissionatTwelveMonths
Contents Population Criteria
Logic Definitions
Terminology
Dependencies
Data Requirements
Population Criteria
Measure Group (Rate) (ID: Group_1)
Initial Population 
define "Initial Population":
  AgeInYearsAt(start of("Index Depression Assessment".effective.toInterval())) >= 12
Initial Population 
define "Initial Population":
  AgeInYearsAt(start of("Index Depression Assessment".effective.toInterval())) >= 12
Denominator 
define "Denominator":
  "Initial Population"
Denominator Exclusion 
define "Denominator Exclusions":
  "Has Hospice Services in the Measure Assessment Period"
    or "Has Palliative Care in the Measure Assessment Period"
    or "Patient Expired"
    or "Has Mental Health Disorder Diagnoses"
Numerator 
define "Numerator":
  Last([ObservationScreeningAssessment: "PHQ 9 and PHQ 9M Tools"] DepressionAssessment
      where ToDate(start of DepressionAssessment.effective.toInterval()) during day of "Measure Assessment Period"
        and DepressionAssessment.status in { 'final', 'amended', 'corrected' }
      sort by start of effective.toInterval()
  ).value < 5
Logic Definitions
Logic Definition Library Name: SupplementalDataElements 
define "SDE Sex":
  case
    when Patient.sex = '248153007' then "Male (finding)"
    when Patient.sex = '248152002' then "Female (finding)"
    else null
  end
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: SupplementalDataElements 
define "SDE Ethnicity":
  Patient.ethnicity E
    return Tuple {
      codes: { E.ombCategory } union E.detailed,
      display: E.text
    }
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: CMS159FHIRDepressionRemissionatTwelveMonths 
define "SDE Sex":
  SDE."SDE Sex"
Logic Definition Library Name: CMS159FHIRDepressionRemissionatTwelveMonths 
define "Depression Assessments Greater Than 9":
  [ObservationScreeningAssessment: "PHQ 9 and PHQ 9M Tools"] DepressionAssessment
    where DepressionAssessment.value > 9
      and DepressionAssessment.status in { 'final', 'amended', 'corrected' }
Logic Definition Library Name: CMS159FHIRDepressionRemissionatTwelveMonths 
define "Depression Diagnoses":
  ( ( [ConditionProblemsHealthConcerns: "Major Depression Including Remission"]
      union [ConditionEncounterDiagnosis: "Major Depression Including Remission"]
  )
    union ( [ConditionProblemsHealthConcerns: "Dysthymia"]
        union [ConditionEncounterDiagnosis: "Dysthymia"]
    ) ) Depression
    where Depression.isConfirmedActiveDiagnosis ( )
Logic Definition Library Name: CMS159FHIRDepressionRemissionatTwelveMonths 
define "Denominator Identification Period":
  Interval[start of "Measurement Period" - 14 months, start of "Measurement Period" - 2 months )
Logic Definition Library Name: CMS159FHIRDepressionRemissionatTwelveMonths 
define "Depression Encounter":
  [Encounter: "Contact or Office Visit"] ValidEncounter
    with "Depression Diagnoses" Depression
      such that ValidEncounter.period overlaps Depression.prevalenceInterval ( )
        and ValidEncounter.period ends during day of "Denominator Identification Period"
        and ValidEncounter.status = 'finished'
Logic Definition Library Name: CMS159FHIRDepressionRemissionatTwelveMonths 
define "Index Depression Assessment":
  First("Depression Assessments Greater Than 9" DepressionAssessment
      with "Depression Encounter" DepressionEncounter
        such that DepressionAssessment.effective.toInterval() during day of Interval[ToDate((start of DepressionEncounter.period) - 7 days), 
        end of DepressionEncounter.period]
      sort by start of effective.toInterval()
  )
Logic Definition Library Name: CMS159FHIRDepressionRemissionatTwelveMonths 
define "Measure Assessment Period":
  "Index Depression Assessment" FirstIndexAssessment
    let YearAfterIndexAssessment: date from start of FirstIndexAssessment.effective.toInterval ( ) + 12 months
    return Interval[YearAfterIndexAssessment - 60 days, YearAfterIndexAssessment + 60 days]
Logic Definition Library Name: CMS159FHIRDepressionRemissionatTwelveMonths 
define "Numerator":
  Last([ObservationScreeningAssessment: "PHQ 9 and PHQ 9M Tools"] DepressionAssessment
      where ToDate(start of DepressionAssessment.effective.toInterval()) during day of "Measure Assessment Period"
        and DepressionAssessment.status in { 'final', 'amended', 'corrected' }
      sort by start of effective.toInterval()
  ).value < 5
Logic Definition Library Name: CMS159FHIRDepressionRemissionatTwelveMonths 
define "Initial Population":
  AgeInYearsAt(start of("Index Depression Assessment".effective.toInterval())) >= 12
Logic Definition Library Name: CMS159FHIRDepressionRemissionatTwelveMonths 
define "Denominator":
  "Initial Population"
Logic Definition Library Name: CMS159FHIRDepressionRemissionatTwelveMonths 
define "SDE Payer":
  SDE."SDE Payer"
Logic Definition Library Name: CMS159FHIRDepressionRemissionatTwelveMonths 
define "Initial Population":
  AgeInYearsAt(start of("Index Depression Assessment".effective.toInterval())) >= 12
Logic Definition Library Name: CMS159FHIRDepressionRemissionatTwelveMonths 
define "SDE Ethnicity":
  SDE."SDE Ethnicity"
Logic Definition Library Name: CMS159FHIRDepressionRemissionatTwelveMonths 
define "Has Hospice Services in the Measure Assessment Period":
  exists ( [Encounter: "Encounter Inpatient"] InpatientEncounter
      where ( InpatientEncounter.hospitalization.dischargeDisposition ~ "Discharge to home for hospice care (procedure)"
          or InpatientEncounter.hospitalization.dischargeDisposition ~ "Discharge to healthcare facility for hospice care (procedure)"
      )
        and InpatientEncounter.period ends during day of Interval[start of "Denominator Identification Period", end of "Measure Assessment Period"]
        and InpatientEncounter.status = 'finished'
  )
    or exists ( [Encounter: "Hospice Encounter"] HospiceEncounter
        where HospiceEncounter.period overlaps day of Interval[start of "Denominator Identification Period", end of "Measure Assessment Period"]
          and not ( HospiceEncounter.status in { 'cancelled', 'entered-in-error', 'unknown' } )
    )
    or exists ( [ObservationScreeningAssessment: "Hospice care [Minimum Data Set]"] HospiceAssessment
        where HospiceAssessment.value ~ "Yes (qualifier value)"
          and HospiceAssessment.effective.toInterval ( ) overlaps day of Interval[start of "Denominator Identification Period", end of "Measure Assessment Period"]
          and HospiceAssessment.status in { 'final', 'amended', 'corrected' }
    )
    or exists ( [ServiceRequest: "Hospice Care Ambulatory"] HospiceOrder
        where HospiceOrder.authoredOn during day of Interval[start of "Denominator Identification Period", end of "Measure Assessment Period"]
          and HospiceOrder.status in { 'active', 'completed' }
          and HospiceOrder.intent in { 'order', 'original-order', 'reflex-order', 'filler-order', 'instance-order' }
          and HospiceOrder.doNotPerform is not true
    )
    or exists ( [Procedure: "Hospice Care Ambulatory"] HospicePerformed
        where HospicePerformed.performed.toInterval ( ) overlaps day of Interval[start of "Denominator Identification Period", end of "Measure Assessment Period"]
          and not ( HospicePerformed.status in { 'not-done', 'entered-in-error', 'unknown' } )
    )
    or exists ( ( [ConditionProblemsHealthConcerns: "Hospice Diagnosis"]
        union [ConditionEncounterDiagnosis: "Hospice Diagnosis"] ) HospiceCareDiagnosis
        where HospiceCareDiagnosis.prevalenceInterval ( ) overlaps day of Interval[start of "Denominator Identification Period", end of "Measure Assessment Period"]
          and HospiceCareDiagnosis.isConfirmedActiveDiagnosis ( )
    )
Logic Definition Library Name: CMS159FHIRDepressionRemissionatTwelveMonths 
define "Has Palliative Care in the Measure Assessment Period":
  exists ( [ObservationScreeningAssessment: "Functional Assessment of Chronic Illness Therapy - Palliative Care Questionnaire (FACIT-Pal)"] PalliativeAssessment
      where PalliativeAssessment.effective.toInterval ( ) overlaps day of Interval[start of "Denominator Identification Period", end of "Measure Assessment Period"]
        and PalliativeAssessment.status in { 'final', 'amended', 'corrected' }
  )
    or exists ( ( [ConditionProblemsHealthConcerns: "Palliative Care Diagnosis"]
        union [ConditionEncounterDiagnosis: "Palliative Care Diagnosis"] ) PalliativeDiagnosis
        where PalliativeDiagnosis.prevalenceInterval ( ) overlaps day of Interval[start of "Denominator Identification Period", end of "Measure Assessment Period"]
          and PalliativeDiagnosis.isConfirmedActiveDiagnosis ( )
    )
    or exists ( [Encounter: "Palliative Care Encounter"] PalliativeEncounter
        where PalliativeEncounter.period overlaps day of Interval[start of "Denominator Identification Period", end of "Measure Assessment Period"]
          and PalliativeEncounter.status = 'finished'
    )
    or exists ( [Procedure: "Palliative Care Intervention"] PalliativeIntervention
        where PalliativeIntervention.performed.toInterval ( ) overlaps day of Interval[start of "Denominator Identification Period", end of "Measure Assessment Period"]
          and not ( PalliativeIntervention.status in { 'not-done', 'entered-in-error', 'unknown' } )
    )
Logic Definition Library Name: CMS159FHIRDepressionRemissionatTwelveMonths 
define "Patient Expired":
  Patient.deceased occurs on or before day of end of "Measure Assessment Period"
Logic Definition Library Name: CMS159FHIRDepressionRemissionatTwelveMonths 
define "Has Mental Health Disorder Diagnoses":
  exists ( ( ( [ConditionProblemsHealthConcerns: "Bipolar Disorder"]
        union [ConditionEncounterDiagnosis: "Bipolar Disorder"]
    )
      union ( [ConditionProblemsHealthConcerns: "Personality Disorder Emotionally Labile"]
          union [ConditionEncounterDiagnosis: "Personality Disorder Emotionally Labile"]
      )
      union ( [ConditionProblemsHealthConcerns: "Schizophrenia or Psychotic Disorder"]
          union [ConditionEncounterDiagnosis: "Schizophrenia or Psychotic Disorder"]
      )
      union ( [ConditionProblemsHealthConcerns: "Pervasive Developmental Disorder"]
          union [ConditionEncounterDiagnosis: "Pervasive Developmental Disorder"]
      ) ) MentalHealthDisorderDiagnoses
      where ToDate(start of MentalHealthDisorderDiagnoses.prevalenceInterval()) on or before day of end of "Measure Assessment Period"
        and MentalHealthDisorderDiagnoses.isConfirmedActiveDiagnosis ( )
  )
Logic Definition Library Name: CMS159FHIRDepressionRemissionatTwelveMonths 
define "Denominator Exclusions":
  "Has Hospice Services in the Measure Assessment Period"
    or "Has Palliative Care in the Measure Assessment Period"
    or "Patient Expired"
    or "Has Mental Health Disorder Diagnoses"
Logic Definition Library Name: CMS159FHIRDepressionRemissionatTwelveMonths 
define "SDE Race":
  SDE."SDE Race"
Logic Definition Library Name: CMS159FHIRDepressionRemissionatTwelveMonths 
define fluent function isConfirmedActiveDiagnosis(condition ConditionProblemsHealthConcerns):
  condition.isActive ( )
    and condition.verificationStatus ~ QICoreCommon."confirmed"
Logic Definition Library Name: FHIRHelpers 
define function ToString(value uri): value.value
Logic Definition Library Name: FHIRHelpers 
/*
@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]
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: QICoreCommon 
/* Candidates for FHIRCommon */

/*
@description: Returns true if the given condition has a clinical status of active, recurrence, or relapse
*/
define fluent function isActive(condition Choice<"ConditionEncounterDiagnosis", "ConditionProblemsHealthConcerns">):
  condition.clinicalStatus ~ "active"
    or condition.clinicalStatus ~ "recurrence"
    or condition.clinicalStatus ~ "relapse"
Logic Definition Library Name: QICoreCommon 
/*
@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.
If the input is a Timing, an error will be thrown indicating that Timing calculations are not implemented. Any other input will reslt in a null DateTime Interval
*/
define fluent function toInterval(choice Choice<DateTime, Quantity, Interval<DateTime>, Interval<Quantity>, Timing>):
  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 Timing then
      Message(null, true, 'NOT_IMPLEMENTED', 'Error', 'Calculation of an interval from a Timing value is not supported') as Interval<DateTime>
		else
			null as Interval<DateTime>
	end
Terminology
Code System Description: Code system SNOMEDCT
Resource: SNOMED CT (all versions)
Canonical URL: http://snomed.info/sct
Code System Description: Code system ConditionClinicalStatusCodes
Resource: Condition Clinical Status Codes
Canonical URL: http://terminology.hl7.org/CodeSystem/condition-clinical
Code System Description: Code system ConditionVerificationStatusCodes
Resource: ConditionVerificationStatus
Canonical URL: http://terminology.hl7.org/CodeSystem/condition-ver-status
Code System Description: Code system SNOMEDCT
Resource: SNOMED CT (all versions)
Canonical URL: http://snomed.info/sct
Code System Description: Code system LOINC
Resource: Logical Observation Identifiers, Names and Codes (LOINC)
Canonical URL: http://loinc.org
Value Set Description: Value set PHQ 9 and PHQ 9M Tools
Resource: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.67.1.101.1.263
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.67.1.101.1.263
Value Set Description: Value set Contact or Office Visit
Resource: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1080.5
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1080.5
Value Set Description: Value set Major Depression Including Remission
Resource: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.113883.3.67.1.101.3.2444
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.113883.3.67.1.101.3.2444
Value Set Description: Value set Dysthymia
Resource: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.67.1.101.1.254
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.67.1.101.1.254
Value Set Description: Value set Payer Type
Resource: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591
Value Set Description: Value set Encounter Inpatient
Resource: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.666.5.307
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.666.5.307
Value Set Description: Value set Hospice Encounter
Resource: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.1003
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.1003
Value Set Description: Value set Hospice Care Ambulatory
Resource: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.526.3.1584
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.526.3.1584
Value Set Description: Value set Hospice Diagnosis
Resource: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.1165
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.1165
Value Set Description: Value set Palliative Care Diagnosis
Resource: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.1167
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.1167
Value Set Description: Value set Palliative Care Encounter
Resource: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1090
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1090
Value Set Description: Value set Palliative Care Intervention
Resource: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1135
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1135
Value Set Description: Value set Bipolar Disorder
Resource: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.67.1.101.1.128
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.67.1.101.1.128
Value Set Description: Value set Personality Disorder Emotionally Labile
Resource: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.67.1.101.1.246
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.67.1.101.1.246
Value Set Description: Value set Schizophrenia or Psychotic Disorder
Resource: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.105.12.1104
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.105.12.1104
Value Set Description: Value set Pervasive Developmental Disorder
Resource: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.105.12.1152
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.105.12.1152
Direct Reference Code Display: Male (finding)
Code: 248153007
System: http://snomed.info/sct
Direct Reference Code Display: Female (finding)
Code: 248152002
System: http://snomed.info/sct
Direct Reference Code Display: Active
Code: active
System: http://terminology.hl7.org/CodeSystem/condition-clinical
Direct Reference Code Display: Recurrence
Code: recurrence
System: http://terminology.hl7.org/CodeSystem/condition-clinical
Direct Reference Code Display: Relapse
Code: relapse
System: http://terminology.hl7.org/CodeSystem/condition-clinical
Direct Reference Code Display: Confirmed
Code: confirmed
System: http://terminology.hl7.org/CodeSystem/condition-ver-status
Direct Reference Code Display: Discharge to home for hospice care (procedure)
Code: 428361000124107
System: http://snomed.info/sct
Direct Reference Code Display: Discharge to healthcare facility for hospice care (procedure)
Code: 428371000124100
System: http://snomed.info/sct
Direct Reference Code Display: Hospice care [Minimum Data Set]
Code: 45755-6
System: http://loinc.org
Direct Reference Code Display: Yes (qualifier value)
Code: 373066001
System: http://snomed.info/sct
Direct Reference Code Display: Functional Assessment of Chronic Illness Therapy - Palliative Care Questionnaire (FACIT-Pal)
Code: 71007-9
System: http://loinc.org
Dependencies
Dependency Description: Library SDE
Resource: Library/SupplementalDataElements|5.1.000
Canonical URL: Library/SupplementalDataElements|5.1.000
Dependency Description: Library FHIRHelpers
Resource: Library/FHIRHelpers|4.4.000
Canonical URL: Library/FHIRHelpers|4.4.000
Dependency Description: Library FHIRHelpers
Resource: Library/FHIRHelpers|4.4.000
Canonical URL: Library/FHIRHelpers|4.4.000
Dependency Description: Library QICoreCommon
Resource: Library/QICoreCommon|4.0.000
Canonical URL: Library/QICoreCommon|4.0.000
Dependency Description: Library FHIRHelpers
Resource: Library/FHIRHelpers|4.4.000
Canonical URL: Library/FHIRHelpers|4.4.000
Data Requirements
Data Requirement Type: Observation
Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-observation-screening-assessment
Must Support Elements: code, value, status, status.value
Code Filter(s):
Path: code
ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.67.1.101.1.263
Data Requirement Type: Condition
Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-condition-problems-health-concerns
Must Support Elements: code
Code Filter(s):
Path: code
ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.113883.3.67.1.101.3.2444
Data Requirement Type: Condition
Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-condition-encounter-diagnosis
Must Support Elements: code
Code Filter(s):
Path: code
ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.113883.3.67.1.101.3.2444
Data Requirement Type: Condition
Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-condition-problems-health-concerns
Must Support Elements: code
Code Filter(s):
Path: code
ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.67.1.101.1.254
Data Requirement Type: Condition
Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-condition-encounter-diagnosis
Must Support Elements: code
Code Filter(s):
Path: code
ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.67.1.101.1.254
Data Requirement Type: Encounter
Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-encounter
Must Support Elements: type, period, status, status.value
Code Filter(s):
Path: type
ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1080.5
Data Requirement Type: Observation
Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-observation-screening-assessment
Must Support Elements: code, value, status, status.value, effective
Code Filter(s):
Path: code
ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.67.1.101.1.263
Data Requirement Type: Observation
Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-observation-screening-assessment
Must Support Elements: code, effective, status, status.value
Code Filter(s):
Path: code
ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.67.1.101.1.263
Data Requirement Type: Patient
Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-patient
Data Requirement Type: Encounter
Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-encounter
Must Support Elements: type, hospitalization, hospitalization.dischargeDisposition, period, status, status.value
Code Filter(s):
Path: type
ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.666.5.307
Data Requirement Type: Encounter
Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-encounter
Must Support Elements: type, period, status, status.value
Code Filter(s):
Path: type
ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.1003
Data Requirement Type: Observation
Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-observation-screening-assessment
Must Support Elements: code, value, effective, status, status.value
Code Filter(s):
Path: code
Code(s): LOINC 45755-6: Hospice care [Minimum Data Set]
Data Requirement Type: ServiceRequest
Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-servicerequest
Must Support Elements: code, authoredOn, authoredOn.value, status, status.value, intent, intent.value, doNotPerform, doNotPerform.value
Code Filter(s):
Path: code
ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.526.3.1584
Data Requirement Type: Procedure
Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-procedure
Must Support Elements: code, performed, status, status.value
Code Filter(s):
Path: code
ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.526.3.1584
Data Requirement Type: Condition
Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-condition-problems-health-concerns
Must Support Elements: code
Code Filter(s):
Path: code
ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.1165
Data Requirement Type: Condition
Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-condition-encounter-diagnosis
Must Support Elements: code
Code Filter(s):
Path: code
ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.1165
Data Requirement Type: Observation
Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-observation-screening-assessment
Must Support Elements: code, effective, status, status.value
Code Filter(s):
Path: code
Code(s): LOINC 71007-9: Functional Assessment of Chronic Illness Therapy - Palliative Care Questionnaire (FACIT-Pal)
Data Requirement Type: Condition
Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-condition-problems-health-concerns
Must Support Elements: code
Code Filter(s):
Path: code
ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.1167
Data Requirement Type: Condition
Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-condition-encounter-diagnosis
Must Support Elements: code
Code Filter(s):
Path: code
ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.1167
Data Requirement Type: Encounter
Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-encounter
Must Support Elements: type, period, status, status.value
Code Filter(s):
Path: type
ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1090
Data Requirement Type: Procedure
Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-procedure
Must Support Elements: code, performed, status, status.value
Code Filter(s):
Path: code
ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1135
Data Requirement Type: Condition
Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-condition-problems-health-concerns
Must Support Elements: code
Code Filter(s):
Path: code
ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.67.1.101.1.128
Data Requirement Type: Condition
Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-condition-encounter-diagnosis
Must Support Elements: code
Code Filter(s):
Path: code
ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.67.1.101.1.128
Data Requirement Type: Condition
Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-condition-problems-health-concerns
Must Support Elements: code
Code Filter(s):
Path: code
ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.67.1.101.1.246
Data Requirement Type: Condition
Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-condition-encounter-diagnosis
Must Support Elements: code
Code Filter(s):
Path: code
ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.67.1.101.1.246
Data Requirement Type: Condition
Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-condition-problems-health-concerns
Must Support Elements: code
Code Filter(s):
Path: code
ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.105.12.1104
Data Requirement Type: Condition
Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-condition-encounter-diagnosis
Must Support Elements: code
Code Filter(s):
Path: code
ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.105.12.1104
Data Requirement Type: Condition
Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-condition-problems-health-concerns
Must Support Elements: code
Code Filter(s):
Path: code
ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.105.12.1152
Data Requirement Type: Condition
Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-condition-encounter-diagnosis
Must Support Elements: code
Code Filter(s):
Path: code
ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.105.12.1152
Data Requirement Type: Patient
Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-patient
Must Support Elements: url
Data Requirement Type: Coverage
Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-coverage
Must Support Elements: type, period
Code Filter(s):
Path: type
ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591
Data Requirement Type: Patient
Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-patient
Must Support Elements: url, extension
Generated using version 0.4.8 of the sample-content-ig Liquid templates

Source

{
  "resourceType": "Measure",
  "id": "CMS159FHIRDepressionRemissionatTwelveMonths",
  "meta": {
    "profile": [
      "http://hl7.org/fhir/uv/crmi/StructureDefinition/crmi-shareablemeasure",
      "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/computable-measure-cqfm",
      "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/publishable-measure-cqfm",
      "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/executable-measure-cqfm",
      "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cql-measure-cqfm",
      "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/elm-measure-cqfm",
      "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/proportion-measure-cqfm"
    ]
  },
  "text": {
    "status": "extensions",
    "div": "<!-- snip (see above) -->"
  },
  "contained": [
    {
      "resourceType": "Library",
      "id": "effective-data-requirements",
      "extension": [
        {
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-directReferenceCode",
          "valueCoding": {
            "system": "http://snomed.info/sct",
            "code": "248153007",
            "display": "Male (finding)"
          }
        },
        {
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-directReferenceCode",
          "valueCoding": {
            "system": "http://snomed.info/sct",
            "code": "248152002",
            "display": "Female (finding)"
          }
        },
        {
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-directReferenceCode",
          "valueCoding": {
            "system": "http://terminology.hl7.org/CodeSystem/condition-clinical",
            "code": "active",
            "display": "Active"
          }
        },
        {
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-directReferenceCode",
          "valueCoding": {
            "system": "http://terminology.hl7.org/CodeSystem/condition-clinical",
            "code": "recurrence",
            "display": "Recurrence"
          }
        },
        {
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-directReferenceCode",
          "valueCoding": {
            "system": "http://terminology.hl7.org/CodeSystem/condition-clinical",
            "code": "relapse",
            "display": "Relapse"
          }
        },
        {
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-directReferenceCode",
          "valueCoding": {
            "system": "http://terminology.hl7.org/CodeSystem/condition-ver-status",
            "code": "confirmed",
            "display": "Confirmed"
          }
        },
        {
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-directReferenceCode",
          "valueCoding": {
            "system": "http://snomed.info/sct",
            "code": "428361000124107",
            "display": "Discharge to home for hospice care (procedure)"
          }
        },
        {
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-directReferenceCode",
          "valueCoding": {
            "system": "http://snomed.info/sct",
            "code": "428371000124100",
            "display": "Discharge to healthcare facility for hospice care (procedure)"
          }
        },
        {
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-directReferenceCode",
          "valueCoding": {
            "system": "http://loinc.org",
            "code": "45755-6",
            "display": "Hospice care [Minimum Data Set]"
          }
        },
        {
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-directReferenceCode",
          "valueCoding": {
            "system": "http://snomed.info/sct",
            "code": "373066001",
            "display": "Yes (qualifier value)"
          }
        },
        {
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-directReferenceCode",
          "valueCoding": {
            "system": "http://loinc.org",
            "code": "71007-9",
            "display": "Functional Assessment of Chronic Illness Therapy - Palliative Care Questionnaire (FACIT-Pal)"
          }
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "SupplementalDataElements"
            },
            {
              "url": "name",
              "valueString": "SDE Sex"
            },
            {
              "url": "statement",
              "valueString": "define \"SDE Sex\":\n  case\n    when Patient.sex = '248153007' then \"Male (finding)\"\n    when Patient.sex = '248152002' then \"Female (finding)\"\n    else null\n  end"
            },
            {
              "url": "displaySequence",
              "valueInteger": 0
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS159FHIRDepressionRemissionatTwelveMonths"
            },
            {
              "url": "name",
              "valueString": "SDE Sex"
            },
            {
              "url": "statement",
              "valueString": "define \"SDE Sex\":\n  SDE.\"SDE Sex\""
            },
            {
              "url": "displaySequence",
              "valueInteger": 1
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS159FHIRDepressionRemissionatTwelveMonths"
            },
            {
              "url": "name",
              "valueString": "Depression Assessments Greater Than 9"
            },
            {
              "url": "statement",
              "valueString": "define \"Depression Assessments Greater Than 9\":\n  [ObservationScreeningAssessment: \"PHQ 9 and PHQ 9M Tools\"] DepressionAssessment\n    where DepressionAssessment.value > 9\n      and DepressionAssessment.status in { 'final', 'amended', 'corrected' }"
            },
            {
              "url": "displaySequence",
              "valueInteger": 2
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS159FHIRDepressionRemissionatTwelveMonths"
            },
            {
              "url": "name",
              "valueString": "Depression Diagnoses"
            },
            {
              "url": "statement",
              "valueString": "define \"Depression Diagnoses\":\n  ( ( [ConditionProblemsHealthConcerns: \"Major Depression Including Remission\"]\n      union [ConditionEncounterDiagnosis: \"Major Depression Including Remission\"]\n  )\n    union ( [ConditionProblemsHealthConcerns: \"Dysthymia\"]\n        union [ConditionEncounterDiagnosis: \"Dysthymia\"]\n    ) ) Depression\n    where Depression.isConfirmedActiveDiagnosis ( )"
            },
            {
              "url": "displaySequence",
              "valueInteger": 3
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS159FHIRDepressionRemissionatTwelveMonths"
            },
            {
              "url": "name",
              "valueString": "Denominator Identification Period"
            },
            {
              "url": "statement",
              "valueString": "define \"Denominator Identification Period\":\n  Interval[start of \"Measurement Period\" - 14 months, start of \"Measurement Period\" - 2 months )"
            },
            {
              "url": "displaySequence",
              "valueInteger": 4
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS159FHIRDepressionRemissionatTwelveMonths"
            },
            {
              "url": "name",
              "valueString": "Depression Encounter"
            },
            {
              "url": "statement",
              "valueString": "define \"Depression Encounter\":\n  [Encounter: \"Contact or Office Visit\"] ValidEncounter\n    with \"Depression Diagnoses\" Depression\n      such that ValidEncounter.period overlaps Depression.prevalenceInterval ( )\n        and ValidEncounter.period ends during day of \"Denominator Identification Period\"\n        and ValidEncounter.status = 'finished'"
            },
            {
              "url": "displaySequence",
              "valueInteger": 5
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS159FHIRDepressionRemissionatTwelveMonths"
            },
            {
              "url": "name",
              "valueString": "Index Depression Assessment"
            },
            {
              "url": "statement",
              "valueString": "define \"Index Depression Assessment\":\n  First(\"Depression Assessments Greater Than 9\" DepressionAssessment\n      with \"Depression Encounter\" DepressionEncounter\n        such that DepressionAssessment.effective.toInterval() during day of Interval[ToDate((start of DepressionEncounter.period) - 7 days), \n        end of DepressionEncounter.period]\n      sort by start of effective.toInterval()\n  )"
            },
            {
              "url": "displaySequence",
              "valueInteger": 6
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS159FHIRDepressionRemissionatTwelveMonths"
            },
            {
              "url": "name",
              "valueString": "Measure Assessment Period"
            },
            {
              "url": "statement",
              "valueString": "define \"Measure Assessment Period\":\n  \"Index Depression Assessment\" FirstIndexAssessment\n    let YearAfterIndexAssessment: date from start of FirstIndexAssessment.effective.toInterval ( ) + 12 months\n    return Interval[YearAfterIndexAssessment - 60 days, YearAfterIndexAssessment + 60 days]"
            },
            {
              "url": "displaySequence",
              "valueInteger": 7
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS159FHIRDepressionRemissionatTwelveMonths"
            },
            {
              "url": "name",
              "valueString": "Numerator"
            },
            {
              "url": "statement",
              "valueString": "define \"Numerator\":\n  Last([ObservationScreeningAssessment: \"PHQ 9 and PHQ 9M Tools\"] DepressionAssessment\n      where ToDate(start of DepressionAssessment.effective.toInterval()) during day of \"Measure Assessment Period\"\n        and DepressionAssessment.status in { 'final', 'amended', 'corrected' }\n      sort by start of effective.toInterval()\n  ).value < 5"
            },
            {
              "url": "displaySequence",
              "valueInteger": 8
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS159FHIRDepressionRemissionatTwelveMonths"
            },
            {
              "url": "name",
              "valueString": "Initial Population"
            },
            {
              "url": "statement",
              "valueString": "define \"Initial Population\":\n  AgeInYearsAt(start of(\"Index Depression Assessment\".effective.toInterval())) >= 12"
            },
            {
              "url": "displaySequence",
              "valueInteger": 9
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS159FHIRDepressionRemissionatTwelveMonths"
            },
            {
              "url": "name",
              "valueString": "Denominator"
            },
            {
              "url": "statement",
              "valueString": "define \"Denominator\":\n  \"Initial Population\""
            },
            {
              "url": "displaySequence",
              "valueInteger": 10
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "SupplementalDataElements"
            },
            {
              "url": "name",
              "valueString": "SDE Payer"
            },
            {
              "url": "statement",
              "valueString": "define \"SDE Payer\":\n  [Coverage: type in \"Payer Type\"] Payer\n    return {\n      code: Payer.type,\n      period: Payer.period\n    }"
            },
            {
              "url": "displaySequence",
              "valueInteger": 11
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS159FHIRDepressionRemissionatTwelveMonths"
            },
            {
              "url": "name",
              "valueString": "SDE Payer"
            },
            {
              "url": "statement",
              "valueString": "define \"SDE Payer\":\n  SDE.\"SDE Payer\""
            },
            {
              "url": "displaySequence",
              "valueInteger": 12
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS159FHIRDepressionRemissionatTwelveMonths"
            },
            {
              "url": "name",
              "valueString": "Initial Population"
            },
            {
              "url": "statement",
              "valueString": "define \"Initial Population\":\n  AgeInYearsAt(start of(\"Index Depression Assessment\".effective.toInterval())) >= 12"
            },
            {
              "url": "displaySequence",
              "valueInteger": 13
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "SupplementalDataElements"
            },
            {
              "url": "name",
              "valueString": "SDE Ethnicity"
            },
            {
              "url": "statement",
              "valueString": "define \"SDE Ethnicity\":\n  Patient.ethnicity E\n    return Tuple {\n      codes: { E.ombCategory } union E.detailed,\n      display: E.text\n    }"
            },
            {
              "url": "displaySequence",
              "valueInteger": 14
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS159FHIRDepressionRemissionatTwelveMonths"
            },
            {
              "url": "name",
              "valueString": "SDE Ethnicity"
            },
            {
              "url": "statement",
              "valueString": "define \"SDE Ethnicity\":\n  SDE.\"SDE Ethnicity\""
            },
            {
              "url": "displaySequence",
              "valueInteger": 15
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS159FHIRDepressionRemissionatTwelveMonths"
            },
            {
              "url": "name",
              "valueString": "Has Hospice Services in the Measure Assessment Period"
            },
            {
              "url": "statement",
              "valueString": "define \"Has Hospice Services in the Measure Assessment Period\":\n  exists ( [Encounter: \"Encounter Inpatient\"] InpatientEncounter\n      where ( InpatientEncounter.hospitalization.dischargeDisposition ~ \"Discharge to home for hospice care (procedure)\"\n          or InpatientEncounter.hospitalization.dischargeDisposition ~ \"Discharge to healthcare facility for hospice care (procedure)\"\n      )\n        and InpatientEncounter.period ends during day of Interval[start of \"Denominator Identification Period\", end of \"Measure Assessment Period\"]\n        and InpatientEncounter.status = 'finished'\n  )\n    or exists ( [Encounter: \"Hospice Encounter\"] HospiceEncounter\n        where HospiceEncounter.period overlaps day of Interval[start of \"Denominator Identification Period\", end of \"Measure Assessment Period\"]\n          and not ( HospiceEncounter.status in { 'cancelled', 'entered-in-error', 'unknown' } )\n    )\n    or exists ( [ObservationScreeningAssessment: \"Hospice care [Minimum Data Set]\"] HospiceAssessment\n        where HospiceAssessment.value ~ \"Yes (qualifier value)\"\n          and HospiceAssessment.effective.toInterval ( ) overlaps day of Interval[start of \"Denominator Identification Period\", end of \"Measure Assessment Period\"]\n          and HospiceAssessment.status in { 'final', 'amended', 'corrected' }\n    )\n    or exists ( [ServiceRequest: \"Hospice Care Ambulatory\"] HospiceOrder\n        where HospiceOrder.authoredOn during day of Interval[start of \"Denominator Identification Period\", end of \"Measure Assessment Period\"]\n          and HospiceOrder.status in { 'active', 'completed' }\n          and HospiceOrder.intent in { 'order', 'original-order', 'reflex-order', 'filler-order', 'instance-order' }\n          and HospiceOrder.doNotPerform is not true\n    )\n    or exists ( [Procedure: \"Hospice Care Ambulatory\"] HospicePerformed\n        where HospicePerformed.performed.toInterval ( ) overlaps day of Interval[start of \"Denominator Identification Period\", end of \"Measure Assessment Period\"]\n          and not ( HospicePerformed.status in { 'not-done', 'entered-in-error', 'unknown' } )\n    )\n    or exists ( ( [ConditionProblemsHealthConcerns: \"Hospice Diagnosis\"]\n        union [ConditionEncounterDiagnosis: \"Hospice Diagnosis\"] ) HospiceCareDiagnosis\n        where HospiceCareDiagnosis.prevalenceInterval ( ) overlaps day of Interval[start of \"Denominator Identification Period\", end of \"Measure Assessment Period\"]\n          and HospiceCareDiagnosis.isConfirmedActiveDiagnosis ( )\n    )"
            },
            {
              "url": "displaySequence",
              "valueInteger": 16
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS159FHIRDepressionRemissionatTwelveMonths"
            },
            {
              "url": "name",
              "valueString": "Has Palliative Care in the Measure Assessment Period"
            },
            {
              "url": "statement",
              "valueString": "define \"Has Palliative Care in the Measure Assessment Period\":\n  exists ( [ObservationScreeningAssessment: \"Functional Assessment of Chronic Illness Therapy - Palliative Care Questionnaire (FACIT-Pal)\"] PalliativeAssessment\n      where PalliativeAssessment.effective.toInterval ( ) overlaps day of Interval[start of \"Denominator Identification Period\", end of \"Measure Assessment Period\"]\n        and PalliativeAssessment.status in { 'final', 'amended', 'corrected' }\n  )\n    or exists ( ( [ConditionProblemsHealthConcerns: \"Palliative Care Diagnosis\"]\n        union [ConditionEncounterDiagnosis: \"Palliative Care Diagnosis\"] ) PalliativeDiagnosis\n        where PalliativeDiagnosis.prevalenceInterval ( ) overlaps day of Interval[start of \"Denominator Identification Period\", end of \"Measure Assessment Period\"]\n          and PalliativeDiagnosis.isConfirmedActiveDiagnosis ( )\n    )\n    or exists ( [Encounter: \"Palliative Care Encounter\"] PalliativeEncounter\n        where PalliativeEncounter.period overlaps day of Interval[start of \"Denominator Identification Period\", end of \"Measure Assessment Period\"]\n          and PalliativeEncounter.status = 'finished'\n    )\n    or exists ( [Procedure: \"Palliative Care Intervention\"] PalliativeIntervention\n        where PalliativeIntervention.performed.toInterval ( ) overlaps day of Interval[start of \"Denominator Identification Period\", end of \"Measure Assessment Period\"]\n          and not ( PalliativeIntervention.status in { 'not-done', 'entered-in-error', 'unknown' } )\n    )"
            },
            {
              "url": "displaySequence",
              "valueInteger": 17
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS159FHIRDepressionRemissionatTwelveMonths"
            },
            {
              "url": "name",
              "valueString": "Patient Expired"
            },
            {
              "url": "statement",
              "valueString": "define \"Patient Expired\":\n  Patient.deceased occurs on or before day of end of \"Measure Assessment Period\""
            },
            {
              "url": "displaySequence",
              "valueInteger": 18
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS159FHIRDepressionRemissionatTwelveMonths"
            },
            {
              "url": "name",
              "valueString": "Has Mental Health Disorder Diagnoses"
            },
            {
              "url": "statement",
              "valueString": "define \"Has Mental Health Disorder Diagnoses\":\n  exists ( ( ( [ConditionProblemsHealthConcerns: \"Bipolar Disorder\"]\n        union [ConditionEncounterDiagnosis: \"Bipolar Disorder\"]\n    )\n      union ( [ConditionProblemsHealthConcerns: \"Personality Disorder Emotionally Labile\"]\n          union [ConditionEncounterDiagnosis: \"Personality Disorder Emotionally Labile\"]\n      )\n      union ( [ConditionProblemsHealthConcerns: \"Schizophrenia or Psychotic Disorder\"]\n          union [ConditionEncounterDiagnosis: \"Schizophrenia or Psychotic Disorder\"]\n      )\n      union ( [ConditionProblemsHealthConcerns: \"Pervasive Developmental Disorder\"]\n          union [ConditionEncounterDiagnosis: \"Pervasive Developmental Disorder\"]\n      ) ) MentalHealthDisorderDiagnoses\n      where ToDate(start of MentalHealthDisorderDiagnoses.prevalenceInterval()) on or before day of end of \"Measure Assessment Period\"\n        and MentalHealthDisorderDiagnoses.isConfirmedActiveDiagnosis ( )\n  )"
            },
            {
              "url": "displaySequence",
              "valueInteger": 19
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS159FHIRDepressionRemissionatTwelveMonths"
            },
            {
              "url": "name",
              "valueString": "Denominator Exclusions"
            },
            {
              "url": "statement",
              "valueString": "define \"Denominator Exclusions\":\n  \"Has Hospice Services in the Measure Assessment Period\"\n    or \"Has Palliative Care in the Measure Assessment Period\"\n    or \"Patient Expired\"\n    or \"Has Mental Health Disorder Diagnoses\""
            },
            {
              "url": "displaySequence",
              "valueInteger": 20
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "SupplementalDataElements"
            },
            {
              "url": "name",
              "valueString": "SDE Race"
            },
            {
              "url": "statement",
              "valueString": "define \"SDE Race\":\n  Patient.race R\n    return Tuple {\n      codes: R.ombCategory union R.detailed,\n      display: R.text\n    }"
            },
            {
              "url": "displaySequence",
              "valueInteger": 21
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS159FHIRDepressionRemissionatTwelveMonths"
            },
            {
              "url": "name",
              "valueString": "SDE Race"
            },
            {
              "url": "statement",
              "valueString": "define \"SDE Race\":\n  SDE.\"SDE Race\""
            },
            {
              "url": "displaySequence",
              "valueInteger": 22
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "FHIRHelpers"
            },
            {
              "url": "name",
              "valueString": "ToString"
            },
            {
              "url": "statement",
              "valueString": "define function ToString(value uri): value.value"
            },
            {
              "url": "displaySequence",
              "valueInteger": 23
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS159FHIRDepressionRemissionatTwelveMonths"
            },
            {
              "url": "name",
              "valueString": "isConfirmedActiveDiagnosis"
            },
            {
              "url": "statement",
              "valueString": "define fluent function isConfirmedActiveDiagnosis(condition ConditionProblemsHealthConcerns):\n  condition.isActive ( )\n    and condition.verificationStatus ~ QICoreCommon.\"confirmed\""
            },
            {
              "url": "displaySequence",
              "valueInteger": 24
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "QICoreCommon"
            },
            {
              "url": "name",
              "valueString": "isActive"
            },
            {
              "url": "statement",
              "valueString": "/* Candidates for FHIRCommon */\n\n/*\n@description: Returns true if the given condition has a clinical status of active, recurrence, or relapse\n*/\ndefine fluent function isActive(condition Choice<\"ConditionEncounterDiagnosis\", \"ConditionProblemsHealthConcerns\">):\n  condition.clinicalStatus ~ \"active\"\n    or condition.clinicalStatus ~ \"recurrence\"\n    or condition.clinicalStatus ~ \"relapse\""
            },
            {
              "url": "displaySequence",
              "valueInteger": 25
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "FHIRHelpers"
            },
            {
              "url": "name",
              "valueString": "ToInterval"
            },
            {
              "url": "statement",
              "valueString": "/*\n@description: Converts the given [Period](https://hl7.org/fhir/datatypes.html#Period)\nvalue to a CQL DateTime Interval\n@comment: If the start value of the given period is unspecified, the starting\nboundary of the resulting interval will be open (meaning the start of the interval\nis unknown, as opposed to interpreted as the beginning of time).\n*/\ndefine function ToInterval(period FHIR.Period):\n    if period is null then\n        null\n    else\n        if period.\"start\" is null then\n            Interval(period.\"start\".value, period.\"end\".value]\n        else\n            Interval[period.\"start\".value, period.\"end\".value]"
            },
            {
              "url": "displaySequence",
              "valueInteger": 26
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "FHIRHelpers"
            },
            {
              "url": "name",
              "valueString": "ToCode"
            },
            {
              "url": "statement",
              "valueString": "/*\n@description: Converts the given FHIR [Coding](https://hl7.org/fhir/datatypes.html#Coding) value to a CQL Code.\n*/\ndefine function ToCode(coding FHIR.Coding):\n    if coding is null then\n        null\n    else\n        System.Code {\n          code: coding.code.value,\n          system: coding.system.value,\n          version: coding.version.value,\n          display: coding.display.value\n        }"
            },
            {
              "url": "displaySequence",
              "valueInteger": 27
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "QICoreCommon"
            },
            {
              "url": "name",
              "valueString": "toInterval"
            },
            {
              "url": "statement",
              "valueString": "/*\n@description: Normalizes a value that is a choice of timing-valued types to an equivalent interval\n@comment: Normalizes a choice type of DateTime, Quanitty, Interval<DateTime>, or Interval<Quantity> types\nto an equivalent interval. This selection of choice types is a superset of the majority of choice types that are used as possible\nrepresentations for timing-valued elements in QICore, allowing this function to be used across any resource.\nThe input can be provided as a DateTime, Quantity, Interval<DateTime> or Interval<Quantity>.\nThe intent of this function is to provide a clear and concise mechanism to treat single\nelements that have multiple possible representations as intervals so that logic doesn't have to account\nfor the variability. More complex calculations (such as medication request period or dispense period\ncalculation) need specific guidance and consideration. That guidance may make use of this function, but\nthe focus of this function is on single element calculations where the semantics are unambiguous.\nIf the input is a DateTime, the result a DateTime Interval beginning and ending on that DateTime.\nIf the input is a Quantity, the quantity is expected to be a calendar-duration interpreted as an Age,\nand the result is a DateTime Interval beginning on the Date the patient turned that age and ending immediately before one year later.\nIf the input is a DateTime Interval, the result is the input.\nIf the input is a Quantity Interval, the quantities are expected to be calendar-durations interpreted as an Age, and the result\nis a DateTime Interval beginning on the date the patient turned the age given as the start of the quantity interval, and ending\nimmediately before one year later than the date the patient turned the age given as the end of the quantity interval.\nIf the input is a Timing, an error will be thrown indicating that Timing calculations are not implemented. Any other input will reslt in a null DateTime Interval\n*/\ndefine fluent function toInterval(choice Choice<DateTime, Quantity, Interval<DateTime>, Interval<Quantity>, Timing>):\n  case\n\t  when choice is DateTime then\n    \tInterval[choice as DateTime, choice as DateTime]\n\t\twhen choice is Interval<DateTime> then\n  \t\tchoice as Interval<DateTime>\n\t\twhen choice is Quantity then\n\t\t  Interval[Patient.birthDate + (choice as Quantity),\n\t\t\t  Patient.birthDate + (choice as Quantity) + 1 year)\n\t\twhen choice is Interval<Quantity> then\n\t\t  Interval[Patient.birthDate + (choice.low as Quantity),\n\t\t\t  Patient.birthDate + (choice.high as Quantity) + 1 year)\n\t\twhen choice is Timing then\n      Message(null, true, 'NOT_IMPLEMENTED', 'Error', 'Calculation of an interval from a Timing value is not supported') as Interval<DateTime>\n\t\telse\n\t\t\tnull as Interval<DateTime>\n\tend"
            },
            {
              "url": "displaySequence",
              "valueInteger": 28
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        }
      ],
      "name": "EffectiveDataRequirements",
      "status": "active",
      "type": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/library-type",
            "code": "module-definition"
          }
        ]
      },
      "relatedArtifact": [
        {
          "type": "depends-on",
          "display": "Library SDE",
          "resource": "Library/SupplementalDataElements|5.1.000"
        },
        {
          "type": "depends-on",
          "display": "Library FHIRHelpers",
          "resource": "Library/FHIRHelpers|4.4.000"
        },
        {
          "type": "depends-on",
          "display": "Library FHIRHelpers",
          "resource": "Library/FHIRHelpers|4.4.000"
        },
        {
          "type": "depends-on",
          "display": "Library QICoreCommon",
          "resource": "Library/QICoreCommon|4.0.000"
        },
        {
          "type": "depends-on",
          "display": "Library FHIRHelpers",
          "resource": "Library/FHIRHelpers|4.4.000"
        },
        {
          "type": "depends-on",
          "display": "Code system SNOMEDCT",
          "resource": "http://snomed.info/sct"
        },
        {
          "type": "depends-on",
          "display": "Code system ConditionClinicalStatusCodes",
          "resource": "http://terminology.hl7.org/CodeSystem/condition-clinical"
        },
        {
          "type": "depends-on",
          "display": "Code system ConditionVerificationStatusCodes",
          "resource": "http://terminology.hl7.org/CodeSystem/condition-ver-status"
        },
        {
          "type": "depends-on",
          "display": "Code system SNOMEDCT",
          "resource": "http://snomed.info/sct"
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        {
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      "valueReference": {
        "reference": "#effective-data-requirements"
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  ],
  "url": "https://madie.cms.gov/Measure/CMS159FHIRDepressionRemissionatTwelveMonths",
  "identifier": [
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      "type": {
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          {
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            "code": "short-name",
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      "system": "https://madie.cms.gov/measure/shortName",
      "value": "CMS159FHIR"
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      "system": "urn:ietf:rfc:3986",
      "value": "urn:uuid:bdf0219b-209a-4b64-8542-03bc3769157b"
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      "value": "0710e",
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        "display": "CMS Consensus Based Entity"
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            "display": "Publisher"
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      "system": "https://madie.cms.gov/measure/cmsId",
      "value": "159FHIR",
      "assigner": {
        "display": "CMS"
      }
    }
  ],
  "version": "0.3.000",
  "name": "CMS159FHIRDepressionRemissionatTwelveMonths",
  "title": "Depression Remission at Twelve MonthsFHIR",
  "status": "active",
  "experimental": false,
  "date": "2025-07-15T13:37:41+00:00",
  "publisher": "MN Community Measurement",
  "contact": [
    {
      "telecom": [
        {
          "system": "url",
          "value": "www.mncm.org"
        }
      ]
    }
  ],
  "description": "The percentage of adolescent patients 12 to 17 years of age and adult patients 18 years of age or older with major depression or dysthymia who reached remission 12 months (+/- 60 days) after an index event",
  "usage": "When an index assessment is conducted with PHQ-9M, the follow-up assessment can use either a PHQ-9M or PHQ-9.\n\nThis eCQM is a patient-based measure.\n\nThis FHIR-based measure has been derived from the QDM-based measure: CMS159v13 \n\nPlease 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-Core 4.1.1 (https://hl7.org/fhir/us/qicore/STU4.1.1/qdm-to-qicore.html). \n\nNote: There are issues related to Stratification in QMIG STU 3 that were addressed in QMIG STU 4. MADiE needs updated to use the technical correction introduced in QMIG STU 4. Refer to https://oncprojectracking.healthit.gov/support/browse/BONNIEMAT-1489. Furthermore, there are issues related to human readable generation of stratification. Refer to https://github.com/cqframework/sample-content-ig/issues/70. Until such time that these issues can be addressed within the tooling, stratification logic has been commented out in this measure.",
  "copyright": "Copyright MN Community Measurement, 2025. All rights reserved.\n\nLimited 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. MN Community Measurement disclaims all liability for the use or accuracy of any third-party codes contained in the specifications.\n\nCPT(R) contained in the Measure specifications is copyright 2004-2024 American Medical Association. LOINC(R) copyright 2004-2024 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2024 International Health Terminology Standards Development Organisation. ICD-10 copyright 2024 World Health Organization. All Rights Reserved.",
  "effectivePeriod": {
    "start": "2026-01-01",
    "end": "2026-12-31"
  },
  "author": [
    {
      "name": "MN Community Measurement",
      "telecom": [
        {
          "system": "url",
          "value": "www.mncm.org"
        }
      ]
    }
  ],
  "library": [
    "https://madie.cms.gov/Library/CMS159FHIRDepressionRemissionatTwelveMonths"
  ],
  "disclaimer": "The performance measure is not a clinical guideline and does not establish a standard of medical care, and has not been tested for all potential applications.\n\nTHE MEASURES AND SPECIFICATIONS ARE PROVIDED “AS IS” WITHOUT WARRANTY OF ANY KIND.\n\nDue to technical limitations, registered trademarks are indicated by (R) or [R] and unregistered trademarks are indicated by (TM) or [TM].",
  "rationale": "Adults:\nDepression is a common and treatable mental disorder. During 2013-2016, 8.1% of American adults aged 20 and over had depression in a given 2-week period. Women (10.4%) were almost twice as likely as men (5.5%) to have had depression. The prevalence of depression among adults decreased as family income levels increased. About 80% of adults with depression reported at least some difficulty with work, home, or social activities because of their depression symptoms (Brody et al., 2018).\n\nDepression is a risk factor for development of chronic illnesses such as diabetes and coronary heart disease and adversely affects the course, complications and management of chronic medical illness. Both maladaptive health risk behaviors and psychobiological factors associated with depression may explain depression's negative effect on outcomes of chronic illness (Katon, 2011).\n\nAdolescents and Adults:\nThe Centers for Disease Control and Prevention states that during 2009-2012 an estimated 7.6% of the U.S. population aged 12 and over had depression, including 3% of Americans with severe depressive symptoms. Almost 43% of persons with severe depressive symptoms reported serious difficulties in work, home and social activities, yet only 35% reported having contact with a mental health professional in the past year (Pratt & Brody, 2014).\nDepression is associated with higher mortality rates in all age groups. Depression is also a leading cause of medical disability, and depressed people lose 5.6 hours of productive work every week when they are depressed, 50% of which is due to absenteeism and short-term disability (Stewart et al., 2003).\n\nAdolescents:\nIn 2014, an estimated 2.8 million adolescents aged 12 to 17 in the United States had at least one major depressive episode (MDE) in the past year (Center for Behavioral Health Statistics and Quality, 2015). The 2013 Youth Risk Behavior Survey of students in grades 9 to 12 indicated that during the past 12 months 39.1% (F) and 20.8% (M) indicated feeling sad or hopeless almost every day for at least 2 weeks, planned suicide attempt 16.9% (F) and 10.3% (M), with attempted suicide 10.6% (F) and 5.4% (M) (Kann et al., 2014). Adolescent-onset depression is associated with chronic depression in adulthood. Many mental health conditions (anxiety, bipolar, depression, eating disorders, and substance abuse) are evident by age 14. The 12-month prevalence of MDEs increased from 8.7% in 2005 to 11.3% in 2014 in adolescents and from 8.8% to 9.6% in young adults (both P < .001). The increase was larger and statistically significant only in the age range of 12 to 20 years. The trends remained significant after adjustment for substance use disorders and sociodemographic factors (Mojtabai et al., 2016). Mental health care contacts overall did not change over time; however, the use of specialty mental health providers increased in adolescents and young adults, and the use of prescription medications and inpatient hospitalizations increased in adolescents (Mojtabai et al., 2016).",
  "clinicalRecommendationStatement": "Adults:\n\nRecommendations and algorithm notations supporting depression outcomes and duration of treatment according to Institute for Clinical Systems Improvement Health Care Guideline (Trangle et al., 2016):\n\nRecommendation: Clinicians should establish and maintain follow-up with patients. Appropriate, reliable follow-up is highly correlated with improved response and remission scores. It is also correlated with the improved safety and efficacy of medications and helps prevent relapse (Trangle et al., 2016).\n\nProactive follow-up contacts (in person, telephone) based on the collaborative care model have been shown to significantly lower depression severity (Unutzer et al., 2002). In the available clinical effectiveness trials conducted in real clinical practice settings, even the addition of a care manager leads to modest remission rates (Trivedi et al., 2006; Unutzer et al., 2002). Interventions are critical to educating the patient regarding the importance of preventing relapse, safety and efficacy of medications, and management of potential side effects. Establish and maintain initial follow-up contact intervals (office, phone, other) (Hunkeler et al., 2000; Simon et al., 2000).\n\nThe Patient Health Questionnaire-9 (PHQ-9) is an effective monitoring and management tool, and should be used routinely for subsequent visits to monitor treatment outcomes and severity. It can also help the clinician decide if/how to modify the treatment plan (Duffy et al., 2008; Lowe et al., 2004). Using a measurement-based approach to depression care, PHQ-9 results and side effect evaluation should be combined with treatment algorithms to drive patients toward remission. A five-point drop in PHQ-9 score is considered the minimal clinically significant difference (Trivedi, 2009).\n\nThe goals of treatment should be to achieve remission, reduce relapse and recurrence, and return to previous level of occupational and psychosocial function.\n\nIf using a PHQ-9 tool, remission translates to PHQ-9 score of less than 5 (Kroenke, et al., 2001). Results from the  Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study showed that remission rates lowered with more treatment steps, but the overall cumulative rate was 67% (Rush et al., 2006).\n\nResponse and remission take time. In the STAR*D study, longer times than expected were needed to reach response or remission. In fact, one-third of those who ultimately responded did so after six weeks. Of those who achieved remission by Quick Inventory of Depressive Symptomatology, 50% did so only at or after six weeks of treatment (Trivedi et al., 2006). If the primary care clinician is seeing some improvement, continue working with that patient to augment or increase dosage to reach remission. This can take up to three months.\n\nThis measure assesses achievement of remission, which is a desired outcome of effective depression treatment and monitoring.\n\nAdult Depression in Primary Care - Guideline Aims (Trangle et al., 2016): \n- Increase the percentage of patients with major depression or persistent depressive disorder who have improvement in outcomes from treatment for major depression or persistent depressive disorder.\n- Increase the percentage of patients with major depression or persistent depressive disorder who have follow-up to assess for outcomes from treatment.\n- Improve communication between the primary care physician and the mental health care clinician (if patient is co-managed).\n\nAdolescents:\n\nRecommendations supporting depression outcomes and duration of treatment according to American Academy of Child and Adolescent Psychiatry guideline (Birmaher et al., 2007): \n- Treatment of depressive disorders should always include an acute and continuation phase; some children may also require maintenance treatment. The main goal of the acute phase is to achieve response and ultimately full symptomatic remission (definitions below).\n- Each phase of treatment should include psychoeducation, supportive management, and family and school involvement.\n- Education, support, and case management appear to be sufficient treatment for the management of depressed children and adolescents with an uncomplicated or brief depression or with mild psychosocial impairment.\n- For children and adolescents who do not respond to supportive psychotherapy or who have more complicated depressions, a trial with specific types of psychotherapy and/or antidepressants is indicated.\n\n\nRecommendations supporting depression outcomes and duration of treatment according to Guidelines for Adolescent Depression in Primary Care (Zuckerbrot et al., 2018 (Part I), Zuckerbrot et al., 2018 (Part II)): \n- Mild depression: consider a period of active support and monitoring before starting other evidence-based treatment\n- Moderate or severe major clinical depression or complicating factors:\n  -- consultation with mental health specialist with agreed upon roles\n  -- evidence based treatment (cognitive behavioral therapy or interpersonal psychotherapy and/or antidepressant selective serotonin reuptake inhibitors)  \n- Monitor for adverse effects during antidepressant therapy\n  -- clinical worsening, suicidality, unusual changes in behavior\n- Systematic and regular tracking of goals and outcomes\n  -- improvement in functioning status and resolution of depressive symptoms\nRegardless of the length of treatment, all patients should be monitored on a monthly basis for 6 to 12 months after the full resolution of symptoms.",
  "definition": [
    "Denominator Identification Period - The period in which eligible patients can have an index event. The denominator identification period occurs prior to the measurement period and is defined as 14 months to two months prior to the start of the measurement period. For patients with an index event, there needs to be enough time following index for the patients to have the opportunity to reach remission twelve months +/- 60 days after the index event date. \n",
    "Index Event Date - The date in which the first instance of elevated PHQ-9 or PHQ-9M greater than nine and diagnosis of depression or dysthymia occurs during the denominator identification measurement period. Patients may be assessed using PHQ-9 or PHQ-9M on the same date or up to 7 days prior to the encounter (index event). \n",
    "Measure Assessment Period - The index event date marks the start of the measurement assessment period for each patient which is 14 months (12 months +/- 60 days) in length to allow for a follow-up PHQ-9 or PHQ-9M between 10 and 14 months following the index event. This assessment period is fixed and does not start over with a higher PHQ-9 or PHQ-9M that may occur after the index event date.\n",
    "Remission  - A PHQ-9 or PHQ-9M score of less than five.\n"
  ],
  "guidance": "When an index assessment is conducted with PHQ-9M, the follow-up assessment can use either a PHQ-9M or PHQ-9.\n\nThis eCQM is a patient-based measure.\n\nThis FHIR-based measure has been derived from the QDM-based measure: CMS159v13 \n\nPlease 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-Core 4.1.1 (https://hl7.org/fhir/us/qicore/STU4.1.1/qdm-to-qicore.html). \n\nNote: There are issues related to Stratification in QMIG STU 3 that were addressed in QMIG STU 4. MADiE needs updated to use the technical correction introduced in QMIG STU 4. Refer to https://oncprojectracking.healthit.gov/support/browse/BONNIEMAT-1489. Furthermore, there are issues related to human readable generation of stratification. Refer to https://github.com/cqframework/sample-content-ig/issues/70. Until such time that these issues can be addressed within the tooling, stratification logic has been commented out in this measure.",
  "group": [
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          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-rateAggregation",
          "valueCode": "None"
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      "population": [
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              {
                "system": "http://terminology.hl7.org/CodeSystem/measure-population",
                "code": "initial-population",
                "display": "Initial Population"
              }
            ]
          },
          "description": "Adolescent patients 12 to 17 years of age and adult patients 18 years of age and older with a diagnosis of major depression or dysthymia and an initial PHQ-9 or PHQ-9M score greater than nine during the index event. Patients may be assessed using PHQ-9 or PHQ-9M on the same date or up to 7 days prior to the encounter (index event)",
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          "description": "Equals Initial Population",
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                "display": "Denominator Exclusion"
              }
            ]
          },
          "description": "- Patients who died any time prior to the end of the measure assessment period\n- Patients who received hospice or palliative care services between the start of the denominator period and the end of the measurement assessment period\n- Patients with a diagnosis of bipolar disorder any time prior to the end of the measure assessment period\n- Patients with a diagnosis of personality disorder emotionally labile any time prior to the end of the measure assessment period\n- Patients with a diagnosis of schizophrenia or psychotic disorder any time prior to the end of the measure assessment period\n- Patients with a diagnosis of pervasive developmental disorder (e.g., autism spectrum disorder) any time prior to the end of the measure assessment period",
          "criteria": {
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            "expression": "Denominator Exclusions"
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        },
        {
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              {
                "system": "http://terminology.hl7.org/CodeSystem/measure-population",
                "code": "numerator",
                "display": "Numerator"
              }
            ]
          },
          "description": "Adolescent patients 12 to 17 years of age and adult patients 18 years of age and older who achieved remission at twelve months as demonstrated by the most recent twelve month (+/- 60 days) PHQ-9 or PHQ-9M score of less than five",
          "criteria": {
            "language": "text/cql-identifier",
            "expression": "Numerator"
          }
        }
      ]
    }
  ],
  "supplementalData": [
    {
      "id": "sde-ethnicity",
      "usage": [
        {
          "coding": [
            {
              "system": "http://terminology.hl7.org/CodeSystem/measure-data-usage",
              "code": "supplemental-data"
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          ]
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      ],
      "description": "SDE Ethnicity",
      "criteria": {
        "language": "text/cql-identifier",
        "expression": "SDE Ethnicity"
      }
    },
    {
      "id": "sde-payer",
      "usage": [
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            {
              "system": "http://terminology.hl7.org/CodeSystem/measure-data-usage",
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      "description": "SDE Payer",
      "criteria": {
        "language": "text/cql-identifier",
        "expression": "SDE Payer"
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    },
    {
      "id": "sde-race",
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      ],
      "description": "SDE Race",
      "criteria": {
        "language": "text/cql-identifier",
        "expression": "SDE Race"
      }
    },
    {
      "id": "sde-sex",
      "usage": [
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            {
              "system": "http://terminology.hl7.org/CodeSystem/measure-data-usage",
              "code": "supplemental-data"
            }
          ]
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      ],
      "description": "SDE Sex",
      "criteria": {
        "language": "text/cql-identifier",
        "expression": "SDE Sex"
      }
    },
    {
      "id": "sde-ethnicity",
      "usage": [
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          "coding": [
            {
              "system": "http://terminology.hl7.org/CodeSystem/measure-data-usage",
              "code": "risk-adjustment-factor"
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          ]
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      ],
      "description": "SDE Ethnicity",
      "criteria": {
        "language": "text/cql-identifier",
        "expression": "SDE Ethnicity"
      }
    },
    {
      "id": "sde-payer",
      "usage": [
        {
          "coding": [
            {
              "system": "http://terminology.hl7.org/CodeSystem/measure-data-usage",
              "code": "risk-adjustment-factor"
            }
          ]
        }
      ],
      "description": "SDE Payer",
      "criteria": {
        "language": "text/cql-identifier",
        "expression": "SDE Payer"
      }
    },
    {
      "id": "sde-race",
      "usage": [
        {
          "coding": [
            {
              "system": "http://terminology.hl7.org/CodeSystem/measure-data-usage",
              "code": "risk-adjustment-factor"
            }
          ]
        }
      ],
      "description": "SDE Race",
      "criteria": {
        "language": "text/cql-identifier",
        "expression": "SDE Race"
      }
    },
    {
      "id": "sde-sex",
      "usage": [
        {
          "coding": [
            {
              "system": "http://terminology.hl7.org/CodeSystem/measure-data-usage",
              "code": "risk-adjustment-factor"
            }
          ]
        }
      ],
      "description": "SDE Sex",
      "criteria": {
        "language": "text/cql-identifier",
        "expression": "SDE Sex"
      }
    }
  ]
}