FHIR IG Statistics: Measure/CMS165FHIRControllingHighBloodPressure

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define "Initial Population":   AgeInYearsAt(date from      end of "Measurement Period"   ) in Interval[18, 85]     and exists "Essential Hypertension Diagnosis"     and exists AdultOutpatientEncounters."Qualifying Encounters"

define "Denominator":   "Initial Population"

define "Denominator Exclusions":   Hospice."Has Hospice Services"     or exists ( "Pregnancy or Renal Diagnosis" )     or exists ( "End Stage Renal Disease Procedures" )     or exists ( "End Stage Renal Disease Encounter" )     or AIFrailLTCF."Is Age 66 to 80 with Advanced Illness and Frailty or Is Age 81 or Older with Frailty"     or AIFrailLTCF."Is Age 66 or Older Living Long Term in a Nursing Home"     or PalliativeCare."Has Palliative Care in the Measurement Period"

define "Numerator":   "Has Systolic Blood Pressure Less Than 140"     and "Has Diastolic Blood Pressure Less Than 90"

define "Qualifying Encounters":   ( ( [Encounter: "Office Visit"]     union [Encounter: "Annual Wellness Visit"]     union [Encounter: "Preventive Care Services Established Office Visit, 18 and Up"]     union [Encounter: "Preventive Care Services Initial Office Visit, 18 and Up"]     union [Encounter: "Home Healthcare Services"]     union [Encounter: "Virtual Encounter"]     union [Encounter: "Telephone Visits"] ).isEncounterPerformed() ) ValidEncounter     where ValidEncounter.period during day of "Measurement Period"

define "Has Hospice Services":   exists ((([Encounter: "Encounter Inpatient"]).isEncounterPerformed()) 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 "Measurement Period"   )     or exists ((([Encounter: "Hospice Encounter"]).isEncounterPerformed()) HospiceEncounter         where HospiceEncounter.period overlaps day of "Measurement Period"     )     or exists ((([ObservationScreeningAssessment: "Hospice care [Minimum Data Set]"]).isAssessmentPerformed()) HospiceAssessment         where HospiceAssessment.value ~ "Yes (qualifier value)"           and HospiceAssessment.effective.toInterval() overlaps day of "Measurement Period"     )     or exists ((([ServiceRequest: "Hospice Care Ambulatory"]).isInterventionOrder()) HospiceOrder         where HospiceOrder.authoredOn during day of "Measurement Period"     )     or exists ((([Procedure: "Hospice Care Ambulatory"]).isInterventionPerformed()) HospicePerformed         where HospicePerformed.performed.toInterval() overlaps day of "Measurement Period"     )     or exists ((([ConditionProblemsHealthConcerns: "Hospice Diagnosis"]         union [ConditionEncounterDiagnosis: "Hospice Diagnosis"]).verified()) HospiceCareDiagnosis         where HospiceCareDiagnosis.prevalenceInterval() overlaps day of "Measurement Period"     )

define "Has Criteria Indicating Frailty":   exists ( (([DeviceRequest: "Frailty Device"]).isDeviceOrderPersonalUseDevices()) FrailtyDeviceOrder       where FrailtyDeviceOrder.authoredOn.toInterval() during day of "Measurement Period"   )     or exists ( (([ObservationScreeningAssessment: "Medical equipment used"]).isAssessmentPerformed()) EquipmentUsed         where EquipmentUsed.value as Concept in "Frailty Device"          and EquipmentUsed.effective.toInterval() ends during day of "Measurement Period"     )     or exists ( (([ConditionProblemsHealthConcerns: "Frailty Diagnosis"]     union [ConditionEncounterDiagnosis: "Frailty Diagnosis"]).verified()) FrailtyDiagnosis         where FrailtyDiagnosis.prevalenceInterval() overlaps day of "Measurement Period"     )     or exists ( (([Encounter: "Frailty Encounter"]).isEncounterPerformed()) FrailtyEncounter         where FrailtyEncounter.period overlaps day of "Measurement Period"     )     or exists ( (([SimpleObservation: "Frailty Symptom"]).isSymptom()) FrailtySymptom         where FrailtySymptom.effective.toInterval() overlaps day of "Measurement Period"     )

define "Has Advanced Illness in Year Before or During Measurement Period": exists ((([ConditionProblemsHealthConcerns: "Advanced Illness"] union [ConditionEncounterDiagnosis: "Advanced Illness"]).verified()) AdvancedIllnessDiagnosis where AdvancedIllnessDiagnosis.prevalenceInterval() starts during day of Interval[start of "Measurement Period" - 1 year, end of "Measurement Period"])

define "Has Dementia Medications in Year Before or During Measurement Period":   exists (( ([MedicationRequest: "Dementia Medications"]).isMedicationActive()) DementiaMedication       where DementiaMedication.medicationRequestPeriod() overlaps day of Interval[start of "Measurement Period" - 1 year,          end of "Measurement Period"]   )

define "Is Age 66 to 80 with Advanced Illness and Frailty or Is Age 81 or Older with Frailty":   ( AgeInYearsAt(date from end of "Measurement Period")in Interval[66, 80]       and "Has Criteria Indicating Frailty"       and ( "Has Advanced Illness in Year Before or During Measurement Period"           or "Has Dementia Medications in Year Before or During Measurement Period"       )   )     or ( AgeInYearsAt(date from end of "Measurement Period")>= 81         and "Has Criteria Indicating Frailty"     )

define "Is Age 66 or Older Living Long Term in a Nursing Home":   AgeInYearsAt(date from       end of "Measurement Period"   )>= 66     and ( ( Last( (([ObservationScreeningAssessment: "Housing status"]).isAssessmentPerformed()) HousingStatus               where HousingStatus.effective.toInterval() ends on or before            day of end of "Measurement Period"           sort by            end of effective.toInterval() asc       )) LastHousingStatus         where LastHousingStatus.value ~ "Lives in nursing home (finding)"     ) is not null

define "Has Palliative Care in the Measurement Period":   exists ((([ObservationScreeningAssessment: "Functional Assessment of Chronic Illness Therapy - Palliative Care Questionnaire (FACIT-Pal)"]).isAssessmentPerformed()) PalliativeAssessment       where PalliativeAssessment.effective.toInterval() overlaps day of "Measurement Period"   )     or exists ((([ConditionProblemsHealthConcerns: "Palliative Care Diagnosis"]     union [ConditionEncounterDiagnosis: "Palliative Care Diagnosis"]).verified()) PalliativeDiagnosis         where PalliativeDiagnosis.prevalenceInterval() overlaps day of "Measurement Period"     )     or exists ((([Encounter: "Palliative Care Encounter"]).isEncounterPerformed()) PalliativeEncounter         where PalliativeEncounter.period overlaps day of "Measurement Period"     )     or exists ((([Procedure: "Palliative Care Intervention"]).isInterventionPerformed()) PalliativeIntervention         where PalliativeIntervention.performed.toInterval() overlaps day of "Measurement Period"     )

define "SDE Sex":   case     when Patient.sex = '248153007' then "Male (finding)"     when Patient.sex = '248152002' then "Female (finding)"     else null   end

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

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

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

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

define "Qualifying Systolic Blood Pressure Reading":   ( ( ( [USCoreBloodPressureProfile] ).isObservationBP ( ) ) BloodPressure       without ( ( [Encounter: "Encounter Inpatient"]           union [Encounter: "Emergency Department Evaluation and Management Visit"]       ).isEncounterPerformed ( ) ) DisqualifyingEncounter         such that BloodPressure.effective.latest ( ) during day of DisqualifyingEncounter.period   )     union ( ( ( [USCoreBloodPressureProfile] ).isObservationBP ( ) ) BloodPressure         where ( not ( ( BloodPressure.encounter.getEncounter ( ) ).class.code in { 'EMER', 'IMP', 'ACUTE', 'NONAC', 'PRENC', 'SS' } ) )           and BloodPressure.effective.latest ( ) during day of "Measurement Period"     )

define "Qualifying Diastolic Blood Pressure Reading":   ( ( ( [USCoreBloodPressureProfile] ).isObservationBP ( ) ) BloodPressure       without ( ( [Encounter: "Encounter Inpatient"]           union [Encounter: "Emergency Department Evaluation and Management Visit"]       ).isEncounterPerformed ( ) ) DisqualifyingEncounter         such that BloodPressure.effective.latest ( ) during day of DisqualifyingEncounter.period   )     union ( ( ( [USCoreBloodPressureProfile] ).isObservationBP ( ) ) BloodPressure         where ( not ( ( BloodPressure.encounter.getEncounter ( ) ).class.code in { 'EMER', 'IMP', 'ACUTE', 'NONAC', 'PRENC', 'SS' } ) )           and BloodPressure.effective.latest ( ) during day of "Measurement Period"     )

define "Blood Pressure Days":   ( "Qualifying Diastolic Blood Pressure Reading" DBPExam       return date from DBPExam.effective.latest ( )   )     intersect ( "Qualifying Systolic Blood Pressure Reading" SBPExam         return date from SBPExam.effective.latest ( )     )

define "Most Recent Blood Pressure Day":   Last("Blood Pressure Days" BPDays       sort asc   )

define "Lowest Systolic Reading on Most Recent Blood Pressure Day":   First("Qualifying Systolic Blood Pressure Reading" SBPReading       where SBPReading.effective.latest() same day as "Most Recent Blood Pressure Day"       return singleton from(SBPReading.component SBPComponent           where SBPComponent.code ~ "Systolic blood pressure"           return SBPComponent.value as Quantity       )       sort asc   )

define "Has Systolic Blood Pressure Less Than 140":   "Lowest Systolic Reading on Most Recent Blood Pressure Day" < 140 'mm[Hg]'

define "Lowest Diastolic Reading on Most Recent Blood Pressure Day":   First("Qualifying Diastolic Blood Pressure Reading" DBPReading       where DBPReading.effective.latest() same day as "Most Recent Blood Pressure Day"       return singleton from(DBPReading.component DBPComponent           where DBPComponent.code ~ "Diastolic blood pressure"           return DBPComponent.value as Quantity       )       sort asc   )

define "Has Diastolic Blood Pressure Less Than 90":   "Lowest Diastolic Reading on Most Recent Blood Pressure Day" < 90 'mm[Hg]'

define "Numerator":   "Has Systolic Blood Pressure Less Than 140"     and "Has Diastolic Blood Pressure Less Than 90"

define "Essential Hypertension Diagnosis":   ( ( [ConditionProblemsHealthConcerns: "Essential Hypertension"]       union [ConditionEncounterDiagnosis: "Essential Hypertension"]   ).verified ( ) ) Hypertension     where Hypertension.prevalenceInterval ( ) overlaps Interval[start of "Measurement Period", start of "Measurement Period" + 6 months )

define "Initial Population":   AgeInYearsAt(date from      end of "Measurement Period"   ) in Interval[18, 85]     and exists "Essential Hypertension Diagnosis"     and exists AdultOutpatientEncounters."Qualifying Encounters"

define "Denominator":   "Initial Population"

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

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

define "Pregnancy or Renal Diagnosis":   ( ( [ConditionProblemsHealthConcerns: "Pregnancy"]       union [ConditionEncounterDiagnosis: "Pregnancy"]       union [ConditionProblemsHealthConcerns: "End Stage Renal Disease"]       union [ConditionEncounterDiagnosis: "End Stage Renal Disease"]       union [ConditionProblemsHealthConcerns: "Kidney Transplant Recipient"]       union [ConditionEncounterDiagnosis: "Kidney Transplant Recipient"]       union [ConditionProblemsHealthConcerns: "Chronic Kidney Disease, Stage 5"]       union [ConditionEncounterDiagnosis: "Chronic Kidney Disease, Stage 5"]   ).verified ( ) ) PregnancyESRDDiagnosis     where PregnancyESRDDiagnosis.prevalenceInterval ( ) overlaps "Measurement Period"

define "End Stage Renal Disease Procedures":   ( ( [Procedure: "Kidney Transplant"]       union [Procedure: "Dialysis Services"]   ).isProcedurePerformed ( ) ) ESRDProcedure     where ESRDProcedure.performed.toInterval ( ) ends on or before end of "Measurement Period"

define "End Stage Renal Disease Encounter":   ( ( [Encounter: "ESRD Monthly Outpatient Services"] ).isEncounterPerformed ( ) ) ESRDEncounter     where ESRDEncounter.period starts on or before end of "Measurement Period"

define "Denominator Exclusions":   Hospice."Has Hospice Services"     or exists ( "Pregnancy or Renal Diagnosis" )     or exists ( "End Stage Renal Disease Procedures" )     or exists ( "End Stage Renal Disease Encounter" )     or AIFrailLTCF."Is Age 66 to 80 with Advanced Illness and Frailty or Is Age 81 or Older with Frailty"     or AIFrailLTCF."Is Age 66 or Older Living Long Term in a Nursing Home"     or PalliativeCare."Has Palliative Care in the Measurement Period"

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

define fluent function getEncounter(reference Reference):   singleton from ( [Encounter] E       where E.id = reference.reference.getId ( )   )

define function ToString(value uri): value.value

/* @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]

/* @description: Converts the given FHIR [Coding](https://hl7.org/fhir/datatypes.html#Coding) value to a CQL Code. */ define function ToCode(coding FHIR.Coding):     if coding is null then         null     else         System.Code {           code: coding.code.value,           system: coding.system.value,           version: coding.version.value,           display: coding.display.value         }

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

/* @description: 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

//Observation Vital Signs define fluent function isObservationBP(Obs List<USCoreBloodPressureProfile>):   Obs O     where O.status in { 'final', 'amended', 'corrected' }

//Encounter, Performed //General usage unless required otherwise by measure intent (e.g., follow-up encounters) define fluent function isEncounterPerformed(Enc List<Encounter>):   Enc E     where E.status = 'finished'

//This library contains functions used to constrain FHIR resource elements for measures authored by NCQA, based on QICore 6.0.0 resources including IG and authoring patterns. The functions may appear similar to some QICoreCommon functions but differ in that they have constraints that are relevant for measures authored by NCQA.  //Condition //Returns conditions in the given list that either have no verification status or have a verification status of confirmed, unconfirmed, provisional, or differential define fluent function verified(conditions List<Choice<ConditionProblemsHealthConcerns, ConditionEncounterDiagnosis>>):   conditions C     where C.verificationStatus is not null implies       (C.verificationStatus ~ "confirmed"         or C.verificationStatus ~ "unconfirmed"         or C.verificationStatus ~ "provisional"         or C.verificationStatus ~ "differential"       )

//Assessment, Performed define fluent function isAssessmentPerformed(Obs List<ObservationScreeningAssessment>):   Obs O     where O.status in { 'final', 'amended', 'corrected' }

//Intervention, Order define fluent function isInterventionOrder(ServiceRequest List<ServiceRequest>):   ServiceRequest S     where S.status in { 'active', 'completed' }       and S.intent in {'order', 'original-order', 'reflex-order', 'filler-order', 'instance-order'}

//Intervention, Performed define fluent function isInterventionPerformed(Proc List<Procedure>):   Proc P     where P.status ~ 'completed'

//Procedure, Performed define fluent function isProcedurePerformed(Proc List<Procedure>):   Proc P     where P.status ~ 'completed'

//Device, Order - Personal Use Devices define fluent function isDeviceOrderPersonalUseDevices(DeviceRequest List<DeviceRequest>):   DeviceRequest D     where D.status in { 'active', 'completed' }       and D.intent in {'order', 'original-order', 'reflex-order', 'filler-order', 'instance-order'}

//Symptom define fluent function isSymptom(Obs List<SimpleObservation>):   Obs O     where O.status in { 'preliminary', 'final', 'amended', 'corrected' }

//Medication, Active define fluent function isMedicationActive(MedicationRequest List<MedicationRequest>):   MedicationRequest M     where M.status = 'active'       and M.intent in {'order', 'original-order', 'reflex-order', 'filler-order', 'instance-order'}

define fluent function medicationRequestPeriod(Request "MedicationRequest"):   Request R     let       dosage: singleton from R.dosageInstruction,       doseAndRate: singleton from dosage.doseAndRate,       timing: dosage.timing,       frequency: Coalesce(timing.repeat.frequencyMax, timing.repeat.frequency),       period: Quantity(timing.repeat.period, timing.repeat.periodUnit),       doseRange: doseAndRate.dose,       doseQuantity: doseAndRate.dose,       dose: Coalesce(end of doseRange, doseQuantity),       dosesPerDay: Coalesce(ToDaily(frequency, period), Count(timing.repeat.timeOfDay), 1.0),       boundsPeriod: timing.repeat.bounds as Interval<DateTime>,       daysSupply: (convert R.dispenseRequest.expectedSupplyDuration to days).value,       quantity: R.dispenseRequest.quantity,       refills: Coalesce(R.dispenseRequest.numberOfRepeatsAllowed, 0),       startDate:         Coalesce(           date from start of boundsPeriod,           date from R.authoredOn,           date from start of R.dispenseRequest.validityPeriod         ),       totalDaysSupplied: Coalesce(daysSupply, quantity.value / (dose.value * dosesPerDay)) * (1 + refills)     return       if startDate is not null and totalDaysSupplied is not null then         Interval[startDate, startDate + Quantity(totalDaysSupplied - 1, 'day') ]       else if startDate is not null and boundsPeriod."high" is not null then         Interval[startDate, date from end of boundsPeriod]       else         null

/**********************************************************************/ /* Functions in this region are copied from opioid-mme-r4             */ /**********************************************************************/  define function Quantity(value Decimal, unit String):   if value is not null then     System.Quantity { value: value, unit: unit }   else     null

/*  Goal is to get to number of days  Two broad approaches to the calculation:   1) Based on supply and frequency, calculate the number of expected days the medication will cover/has covered   2) Based on relevant period, determine a covered interval and calculate the length of that interval in days This topic covers several use cases and illustrates how to calculate Cumulative Medication Duration for each type of medication resource using the supply and frequency approach. */  /*   For the first approach, we need to get from frequency to a frequency/day   So we define ToDaily */  /*   Calculates daily frequency given frequency within a period */ define function ToDaily(frequency System.Integer, period System.Quantity):   case period.unit     when 'h' then frequency * (24.0 / period.value)     when 'min' then frequency * (24.0 / period.value) * 60     when 's' then frequency * (24.0 / period.value) * 60 * 60     when 'd' then frequency * (24.0 / period.value) / 24     when 'wk' then frequency * (24.0 / period.value) / (24 * 7)     when 'mo' then frequency * (24.0 / period.value) / (24 * 30) /* assuming 30 days in month */     when 'a' then frequency * (24.0 / period.value) / (24 * 365) /* assuming 365 days in year */     when 'hour' then frequency * (24.0 / period.value)     when 'minute' then frequency * (24.0 / period.value) * 60     when 'second' then frequency * (24.0 / period.value) * 60 * 60     when 'day' then frequency * (24.0 / period.value) / 24     when 'week' then frequency * (24.0 / period.value) / (24 * 7)     when 'month' then frequency * (24.0 / period.value) / (24 * 30) /* assuming 30 days in month */     when 'year' then frequency * (24.0 / period.value) / (24 * 365) /* assuming 365 days in year */     when 'hours' then frequency * (24.0 / period.value)     when 'minutes' then frequency * (24.0 / period.value) * 60     when 'seconds' then frequency * (24.0 / period.value) * 60 * 60     when 'days' then frequency * (24.0 / period.value) / 24     when 'weeks' then frequency * (24.0 / period.value) / (24 * 7)     when 'months' then frequency * (24.0 / period.value) / (24 * 30) /* assuming 30 days in month */     when 'years' then frequency * (24.0 / period.value) / (24 * 365) /* assuming 365 days in year */     else Message(null, true, 'CMDLogic.ToDaily.UnknownUnit', ErrorLevel, 'Unknown unit ' & period.unit)   end

Source

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            {
              "url": "statement",
              "valueString": "define \"SDE Sex\":   case     when Patient.sex = '248153007' then \"Male (finding)\"     when Patient.sex = '248152002' then \"Female (finding)\"     else null   end"
            },
            {
              "url": "displaySequence",
              "valueInteger": 0
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS165FHIRControllingHighBloodPressure"
            },
            {
              "url": "name",
              "valueString": "SDE Sex"
            },
            {
              "url": "statement",
              "valueString": "define \"SDE Sex\":   SDE.\"SDE Sex\""
            },
            {
              "url": "displaySequence",
              "valueInteger": 1
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS165FHIRControllingHighBloodPressure"
            },
            {
              "url": "name",
              "valueString": "Qualifying Systolic Blood Pressure Reading"
            },
            {
              "url": "statement",
              "valueString": "define \"Qualifying Systolic Blood Pressure Reading\":   ( ( ( [USCoreBloodPressureProfile] ).isObservationBP ( ) ) BloodPressure       without ( ( [Encounter: \"Encounter Inpatient\"]           union [Encounter: \"Emergency Department Evaluation and Management Visit\"]       ).isEncounterPerformed ( ) ) DisqualifyingEncounter         such that BloodPressure.effective.latest ( ) during day of DisqualifyingEncounter.period   )     union ( ( ( [USCoreBloodPressureProfile] ).isObservationBP ( ) ) BloodPressure         where ( not ( ( BloodPressure.encounter.getEncounter ( ) ).class.code in { 'EMER', 'IMP', 'ACUTE', 'NONAC', 'PRENC', 'SS' } ) )           and BloodPressure.effective.latest ( ) during day of \"Measurement Period\"     )"
            },
            {
              "url": "displaySequence",
              "valueInteger": 2
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS165FHIRControllingHighBloodPressure"
            },
            {
              "url": "name",
              "valueString": "Qualifying Diastolic Blood Pressure Reading"
            },
            {
              "url": "statement",
              "valueString": "define \"Qualifying Diastolic Blood Pressure Reading\":   ( ( ( [USCoreBloodPressureProfile] ).isObservationBP ( ) ) BloodPressure       without ( ( [Encounter: \"Encounter Inpatient\"]           union [Encounter: \"Emergency Department Evaluation and Management Visit\"]       ).isEncounterPerformed ( ) ) DisqualifyingEncounter         such that BloodPressure.effective.latest ( ) during day of DisqualifyingEncounter.period   )     union ( ( ( [USCoreBloodPressureProfile] ).isObservationBP ( ) ) BloodPressure         where ( not ( ( BloodPressure.encounter.getEncounter ( ) ).class.code in { 'EMER', 'IMP', 'ACUTE', 'NONAC', 'PRENC', 'SS' } ) )           and BloodPressure.effective.latest ( ) during day of \"Measurement Period\"     )"
            },
            {
              "url": "displaySequence",
              "valueInteger": 3
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS165FHIRControllingHighBloodPressure"
            },
            {
              "url": "name",
              "valueString": "Blood Pressure Days"
            },
            {
              "url": "statement",
              "valueString": "define \"Blood Pressure Days\":   ( \"Qualifying Diastolic Blood Pressure Reading\" DBPExam       return date from DBPExam.effective.latest ( )   )     intersect ( \"Qualifying Systolic Blood Pressure Reading\" SBPExam         return date from SBPExam.effective.latest ( )     )"
            },
            {
              "url": "displaySequence",
              "valueInteger": 4
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS165FHIRControllingHighBloodPressure"
            },
            {
              "url": "name",
              "valueString": "Most Recent Blood Pressure Day"
            },
            {
              "url": "statement",
              "valueString": "define \"Most Recent Blood Pressure Day\":   Last(\"Blood Pressure Days\" BPDays       sort asc   )"
            },
            {
              "url": "displaySequence",
              "valueInteger": 5
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS165FHIRControllingHighBloodPressure"
            },
            {
              "url": "name",
              "valueString": "Lowest Systolic Reading on Most Recent Blood Pressure Day"
            },
            {
              "url": "statement",
              "valueString": "define \"Lowest Systolic Reading on Most Recent Blood Pressure Day\":   First(\"Qualifying Systolic Blood Pressure Reading\" SBPReading       where SBPReading.effective.latest() same day as \"Most Recent Blood Pressure Day\"       return singleton from(SBPReading.component SBPComponent           where SBPComponent.code ~ \"Systolic blood pressure\"           return SBPComponent.value as Quantity       )       sort asc   )"
            },
            {
              "url": "displaySequence",
              "valueInteger": 6
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS165FHIRControllingHighBloodPressure"
            },
            {
              "url": "name",
              "valueString": "Has Systolic Blood Pressure Less Than 140"
            },
            {
              "url": "statement",
              "valueString": "define \"Has Systolic Blood Pressure Less Than 140\":   \"Lowest Systolic Reading on Most Recent Blood Pressure Day\" < 140 'mm[Hg]'"
            },
            {
              "url": "displaySequence",
              "valueInteger": 7
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS165FHIRControllingHighBloodPressure"
            },
            {
              "url": "name",
              "valueString": "Lowest Diastolic Reading on Most Recent Blood Pressure Day"
            },
            {
              "url": "statement",
              "valueString": "define \"Lowest Diastolic Reading on Most Recent Blood Pressure Day\":   First(\"Qualifying Diastolic Blood Pressure Reading\" DBPReading       where DBPReading.effective.latest() same day as \"Most Recent Blood Pressure Day\"       return singleton from(DBPReading.component DBPComponent           where DBPComponent.code ~ \"Diastolic blood pressure\"           return DBPComponent.value as Quantity       )       sort asc   )"
            },
            {
              "url": "displaySequence",
              "valueInteger": 8
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS165FHIRControllingHighBloodPressure"
            },
            {
              "url": "name",
              "valueString": "Has Diastolic Blood Pressure Less Than 90"
            },
            {
              "url": "statement",
              "valueString": "define \"Has Diastolic Blood Pressure Less Than 90\":   \"Lowest Diastolic Reading on Most Recent Blood Pressure Day\" < 90 'mm[Hg]'"
            },
            {
              "url": "displaySequence",
              "valueInteger": 9
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS165FHIRControllingHighBloodPressure"
            },
            {
              "url": "name",
              "valueString": "Numerator"
            },
            {
              "url": "statement",
              "valueString": "define \"Numerator\":   \"Has Systolic Blood Pressure Less Than 140\"     and \"Has Diastolic Blood Pressure Less Than 90\""
            },
            {
              "url": "displaySequence",
              "valueInteger": 10
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS165FHIRControllingHighBloodPressure"
            },
            {
              "url": "name",
              "valueString": "Essential Hypertension Diagnosis"
            },
            {
              "url": "statement",
              "valueString": "define \"Essential Hypertension Diagnosis\":   ( ( [ConditionProblemsHealthConcerns: \"Essential Hypertension\"]       union [ConditionEncounterDiagnosis: \"Essential Hypertension\"]   ).verified ( ) ) Hypertension     where Hypertension.prevalenceInterval ( ) overlaps Interval[start of \"Measurement Period\", start of \"Measurement Period\" + 6 months )"
            },
            {
              "url": "displaySequence",
              "valueInteger": 11
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "AdultOutpatientEncounters"
            },
            {
              "url": "name",
              "valueString": "Qualifying Encounters"
            },
            {
              "url": "statement",
              "valueString": "define \"Qualifying Encounters\":   ( ( [Encounter: \"Office Visit\"]     union [Encounter: \"Annual Wellness Visit\"]     union [Encounter: \"Preventive Care Services Established Office Visit, 18 and Up\"]     union [Encounter: \"Preventive Care Services Initial Office Visit, 18 and Up\"]     union [Encounter: \"Home Healthcare Services\"]     union [Encounter: \"Virtual Encounter\"]     union [Encounter: \"Telephone Visits\"] ).isEncounterPerformed() ) ValidEncounter     where ValidEncounter.period during day of \"Measurement Period\""
            },
            {
              "url": "displaySequence",
              "valueInteger": 12
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS165FHIRControllingHighBloodPressure"
            },
            {
              "url": "name",
              "valueString": "Initial Population"
            },
            {
              "url": "statement",
              "valueString": "define \"Initial Population\":   AgeInYearsAt(date from      end of \"Measurement Period\"   ) in Interval[18, 85]     and exists \"Essential Hypertension Diagnosis\"     and exists AdultOutpatientEncounters.\"Qualifying Encounters\""
            },
            {
              "url": "displaySequence",
              "valueInteger": 13
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS165FHIRControllingHighBloodPressure"
            },
            {
              "url": "name",
              "valueString": "Denominator"
            },
            {
              "url": "statement",
              "valueString": "define \"Denominator\":   \"Initial Population\""
            },
            {
              "url": "displaySequence",
              "valueInteger": 14
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "SupplementalDataElements"
            },
            {
              "url": "name",
              "valueString": "SDE Payer"
            },
            {
              "url": "statement",
              "valueString": "define \"SDE Payer\":   [Coverage: type in \"Payer Type\"] Payer     return {       code: Payer.type,       period: Payer.period     }"
            },
            {
              "url": "displaySequence",
              "valueInteger": 15
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS165FHIRControllingHighBloodPressure"
            },
            {
              "url": "name",
              "valueString": "SDE Payer"
            },
            {
              "url": "statement",
              "valueString": "define \"SDE Payer\":   SDE.\"SDE Payer\""
            },
            {
              "url": "displaySequence",
              "valueInteger": 16
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "SupplementalDataElements"
            },
            {
              "url": "name",
              "valueString": "SDE Ethnicity"
            },
            {
              "url": "statement",
              "valueString": "define \"SDE Ethnicity\":   Patient.ethnicity E     return Tuple {       codes: { E.ombCategory } union E.detailed,       display: E.text     }"
            },
            {
              "url": "displaySequence",
              "valueInteger": 17
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS165FHIRControllingHighBloodPressure"
            },
            {
              "url": "name",
              "valueString": "SDE Ethnicity"
            },
            {
              "url": "statement",
              "valueString": "define \"SDE Ethnicity\":   SDE.\"SDE Ethnicity\""
            },
            {
              "url": "displaySequence",
              "valueInteger": 18
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "Hospice"
            },
            {
              "url": "name",
              "valueString": "Has Hospice Services"
            },
            {
              "url": "statement",
              "valueString": "define \"Has Hospice Services\":   exists ((([Encounter: \"Encounter Inpatient\"]).isEncounterPerformed()) 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 \"Measurement Period\"   )     or exists ((([Encounter: \"Hospice Encounter\"]).isEncounterPerformed()) HospiceEncounter         where HospiceEncounter.period overlaps day of \"Measurement Period\"     )     or exists ((([ObservationScreeningAssessment: \"Hospice care [Minimum Data Set]\"]).isAssessmentPerformed()) HospiceAssessment         where HospiceAssessment.value ~ \"Yes (qualifier value)\"           and HospiceAssessment.effective.toInterval() overlaps day of \"Measurement Period\"     )     or exists ((([ServiceRequest: \"Hospice Care Ambulatory\"]).isInterventionOrder()) HospiceOrder         where HospiceOrder.authoredOn during day of \"Measurement Period\"     )     or exists ((([Procedure: \"Hospice Care Ambulatory\"]).isInterventionPerformed()) HospicePerformed         where HospicePerformed.performed.toInterval() overlaps day of \"Measurement Period\"     )     or exists ((([ConditionProblemsHealthConcerns: \"Hospice Diagnosis\"]         union [ConditionEncounterDiagnosis: \"Hospice Diagnosis\"]).verified()) HospiceCareDiagnosis         where HospiceCareDiagnosis.prevalenceInterval() overlaps day of \"Measurement Period\"     )"
            },
            {
              "url": "displaySequence",
              "valueInteger": 19
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS165FHIRControllingHighBloodPressure"
            },
            {
              "url": "name",
              "valueString": "Pregnancy or Renal Diagnosis"
            },
            {
              "url": "statement",
              "valueString": "define \"Pregnancy or Renal Diagnosis\":   ( ( [ConditionProblemsHealthConcerns: \"Pregnancy\"]       union [ConditionEncounterDiagnosis: \"Pregnancy\"]       union [ConditionProblemsHealthConcerns: \"End Stage Renal Disease\"]       union [ConditionEncounterDiagnosis: \"End Stage Renal Disease\"]       union [ConditionProblemsHealthConcerns: \"Kidney Transplant Recipient\"]       union [ConditionEncounterDiagnosis: \"Kidney Transplant Recipient\"]       union [ConditionProblemsHealthConcerns: \"Chronic Kidney Disease, Stage 5\"]       union [ConditionEncounterDiagnosis: \"Chronic Kidney Disease, Stage 5\"]   ).verified ( ) ) PregnancyESRDDiagnosis     where PregnancyESRDDiagnosis.prevalenceInterval ( ) overlaps \"Measurement Period\""
            },
            {
              "url": "displaySequence",
              "valueInteger": 20
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS165FHIRControllingHighBloodPressure"
            },
            {
              "url": "name",
              "valueString": "End Stage Renal Disease Procedures"
            },
            {
              "url": "statement",
              "valueString": "define \"End Stage Renal Disease Procedures\":   ( ( [Procedure: \"Kidney Transplant\"]       union [Procedure: \"Dialysis Services\"]   ).isProcedurePerformed ( ) ) ESRDProcedure     where ESRDProcedure.performed.toInterval ( ) ends on or before end of \"Measurement Period\""
            },
            {
              "url": "displaySequence",
              "valueInteger": 21
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS165FHIRControllingHighBloodPressure"
            },
            {
              "url": "name",
              "valueString": "End Stage Renal Disease Encounter"
            },
            {
              "url": "statement",
              "valueString": "define \"End Stage Renal Disease Encounter\":   ( ( [Encounter: \"ESRD Monthly Outpatient Services\"] ).isEncounterPerformed ( ) ) ESRDEncounter     where ESRDEncounter.period starts on or before end of \"Measurement Period\""
            },
            {
              "url": "displaySequence",
              "valueInteger": 22
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "AdvancedIllnessandFrailty"
            },
            {
              "url": "name",
              "valueString": "Has Criteria Indicating Frailty"
            },
            {
              "url": "statement",
              "valueString": "define \"Has Criteria Indicating Frailty\":   exists ( (([DeviceRequest: \"Frailty Device\"]).isDeviceOrderPersonalUseDevices()) FrailtyDeviceOrder       where FrailtyDeviceOrder.authoredOn.toInterval() during day of \"Measurement Period\"   )     or exists ( (([ObservationScreeningAssessment: \"Medical equipment used\"]).isAssessmentPerformed()) EquipmentUsed         where EquipmentUsed.value as Concept in \"Frailty Device\"          and EquipmentUsed.effective.toInterval() ends during day of \"Measurement Period\"     )     or exists ( (([ConditionProblemsHealthConcerns: \"Frailty Diagnosis\"]     union [ConditionEncounterDiagnosis: \"Frailty Diagnosis\"]).verified()) FrailtyDiagnosis         where FrailtyDiagnosis.prevalenceInterval() overlaps day of \"Measurement Period\"     )     or exists ( (([Encounter: \"Frailty Encounter\"]).isEncounterPerformed()) FrailtyEncounter         where FrailtyEncounter.period overlaps day of \"Measurement Period\"     )     or exists ( (([SimpleObservation: \"Frailty Symptom\"]).isSymptom()) FrailtySymptom         where FrailtySymptom.effective.toInterval() overlaps day of \"Measurement Period\"     )"
            },
            {
              "url": "displaySequence",
              "valueInteger": 23
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "AdvancedIllnessandFrailty"
            },
            {
              "url": "name",
              "valueString": "Has Advanced Illness in Year Before or During Measurement Period"
            },
            {
              "url": "statement",
              "valueString": "define \"Has Advanced Illness in Year Before or During Measurement Period\": exists ((([ConditionProblemsHealthConcerns: \"Advanced Illness\"] union [ConditionEncounterDiagnosis: \"Advanced Illness\"]).verified()) AdvancedIllnessDiagnosis where AdvancedIllnessDiagnosis.prevalenceInterval() starts during day of Interval[start of \"Measurement Period\" - 1 year, end of \"Measurement Period\"])"
            },
            {
              "url": "displaySequence",
              "valueInteger": 24
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "AdvancedIllnessandFrailty"
            },
            {
              "url": "name",
              "valueString": "Has Dementia Medications in Year Before or During Measurement Period"
            },
            {
              "url": "statement",
              "valueString": "define \"Has Dementia Medications in Year Before or During Measurement Period\":   exists (( ([MedicationRequest: \"Dementia Medications\"]).isMedicationActive()) DementiaMedication       where DementiaMedication.medicationRequestPeriod() overlaps day of Interval[start of \"Measurement Period\" - 1 year,          end of \"Measurement Period\"]   )"
            },
            {
              "url": "displaySequence",
              "valueInteger": 25
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "AdvancedIllnessandFrailty"
            },
            {
              "url": "name",
              "valueString": "Is Age 66 to 80 with Advanced Illness and Frailty or Is Age 81 or Older with Frailty"
            },
            {
              "url": "statement",
              "valueString": "define \"Is Age 66 to 80 with Advanced Illness and Frailty or Is Age 81 or Older with Frailty\":   ( AgeInYearsAt(date from end of \"Measurement Period\")in Interval[66, 80]       and \"Has Criteria Indicating Frailty\"       and ( \"Has Advanced Illness in Year Before or During Measurement Period\"           or \"Has Dementia Medications in Year Before or During Measurement Period\"       )   )     or ( AgeInYearsAt(date from end of \"Measurement Period\")>= 81         and \"Has Criteria Indicating Frailty\"     )"
            },
            {
              "url": "displaySequence",
              "valueInteger": 26
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "AdvancedIllnessandFrailty"
            },
            {
              "url": "name",
              "valueString": "Is Age 66 or Older Living Long Term in a Nursing Home"
            },
            {
              "url": "statement",
              "valueString": "define \"Is Age 66 or Older Living Long Term in a Nursing Home\":   AgeInYearsAt(date from       end of \"Measurement Period\"   )>= 66     and ( ( Last( (([ObservationScreeningAssessment: \"Housing status\"]).isAssessmentPerformed()) HousingStatus               where HousingStatus.effective.toInterval() ends on or before            day of end of \"Measurement Period\"           sort by            end of effective.toInterval() asc       )) LastHousingStatus         where LastHousingStatus.value ~ \"Lives in nursing home (finding)\"     ) is not null"
            },
            {
              "url": "displaySequence",
              "valueInteger": 27
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "PalliativeCare"
            },
            {
              "url": "name",
              "valueString": "Has Palliative Care in the Measurement Period"
            },
            {
              "url": "statement",
              "valueString": "define \"Has Palliative Care in the Measurement Period\":   exists ((([ObservationScreeningAssessment: \"Functional Assessment of Chronic Illness Therapy - Palliative Care Questionnaire (FACIT-Pal)\"]).isAssessmentPerformed()) PalliativeAssessment       where PalliativeAssessment.effective.toInterval() overlaps day of \"Measurement Period\"   )     or exists ((([ConditionProblemsHealthConcerns: \"Palliative Care Diagnosis\"]     union [ConditionEncounterDiagnosis: \"Palliative Care Diagnosis\"]).verified()) PalliativeDiagnosis         where PalliativeDiagnosis.prevalenceInterval() overlaps day of \"Measurement Period\"     )     or exists ((([Encounter: \"Palliative Care Encounter\"]).isEncounterPerformed()) PalliativeEncounter         where PalliativeEncounter.period overlaps day of \"Measurement Period\"     )     or exists ((([Procedure: \"Palliative Care Intervention\"]).isInterventionPerformed()) PalliativeIntervention         where PalliativeIntervention.performed.toInterval() overlaps day of \"Measurement Period\"     )"
            },
            {
              "url": "displaySequence",
              "valueInteger": 28
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS165FHIRControllingHighBloodPressure"
            },
            {
              "url": "name",
              "valueString": "Denominator Exclusions"
            },
            {
              "url": "statement",
              "valueString": "define \"Denominator Exclusions\":   Hospice.\"Has Hospice Services\"     or exists ( \"Pregnancy or Renal Diagnosis\" )     or exists ( \"End Stage Renal Disease Procedures\" )     or exists ( \"End Stage Renal Disease Encounter\" )     or AIFrailLTCF.\"Is Age 66 to 80 with Advanced Illness and Frailty or Is Age 81 or Older with Frailty\"     or AIFrailLTCF.\"Is Age 66 or Older Living Long Term in a Nursing Home\"     or PalliativeCare.\"Has Palliative Care in the Measurement Period\""
            },
            {
              "url": "displaySequence",
              "valueInteger": 29
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "SupplementalDataElements"
            },
            {
              "url": "name",
              "valueString": "SDE Race"
            },
            {
              "url": "statement",
              "valueString": "define \"SDE Race\":   Patient.race R     return Tuple {       codes: R.ombCategory union R.detailed,       display: R.text     }"
            },
            {
              "url": "displaySequence",
              "valueInteger": 30
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS165FHIRControllingHighBloodPressure"
            },
            {
              "url": "name",
              "valueString": "SDE Race"
            },
            {
              "url": "statement",
              "valueString": "define \"SDE Race\":   SDE.\"SDE Race\""
            },
            {
              "url": "displaySequence",
              "valueInteger": 31
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "FHIRHelpers"
            },
            {
              "url": "name",
              "valueString": "ToString"
            },
            {
              "url": "statement",
              "valueString": "define function ToString(value uri): value.value"
            },
            {
              "url": "displaySequence",
              "valueInteger": 32
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "Status"
            },
            {
              "url": "name",
              "valueString": "isObservationBP"
            },
            {
              "url": "statement",
              "valueString": "//Observation Vital Signs define fluent function isObservationBP(Obs List<USCoreBloodPressureProfile>):   Obs O     where O.status in { 'final', 'amended', 'corrected' }"
            },
            {
              "url": "displaySequence",
              "valueInteger": 33
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "Status"
            },
            {
              "url": "name",
              "valueString": "isEncounterPerformed"
            },
            {
              "url": "statement",
              "valueString": "//Encounter, Performed //General usage unless required otherwise by measure intent (e.g., follow-up encounters) define fluent function isEncounterPerformed(Enc List<Encounter>):   Enc E     where E.status = 'finished'"
            },
            {
              "url": "displaySequence",
              "valueInteger": 34
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "FHIRHelpers"
            },
            {
              "url": "name",
              "valueString": "ToInterval"
            },
            {
              "url": "statement",
              "valueString": "/* @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]"
            },
            {
              "url": "displaySequence",
              "valueInteger": 35
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS165FHIRControllingHighBloodPressure"
            },
            {
              "url": "name",
              "valueString": "getEncounter"
            },
            {
              "url": "statement",
              "valueString": "define fluent function getEncounter(reference Reference):   singleton from ( [Encounter] E       where E.id = reference.reference.getId ( )   )"
            },
            {
              "url": "displaySequence",
              "valueInteger": 36
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "QICoreCommon"
            },
            {
              "url": "name",
              "valueString": "getId"
            },
            {
              "url": "statement",
              "valueString": "/* @description: Returns the tail of the given uri (i.e. everything after the last slash in the URI). @comment: This function can be used to determine the logical id of a given resource. It can be used in a single-server environment to trace references. However, this function does not attempt to resolve or distinguish the base of the given url, and so cannot be used safely in multi-server environments. */ define fluent function getId(uri String):   Last(Split(uri, '/'))"
            },
            {
              "url": "displaySequence",
              "valueInteger": 37
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "Status"
            },
            {
              "url": "name",
              "valueString": "verified"
            },
            {
              "url": "statement",
              "valueString": "//This library contains functions used to constrain FHIR resource elements for measures authored by NCQA, based on QICore 6.0.0 resources including IG and authoring patterns. The functions may appear similar to some QICoreCommon functions but differ in that they have constraints that are relevant for measures authored by NCQA.  //Condition //Returns conditions in the given list that either have no verification status or have a verification status of confirmed, unconfirmed, provisional, or differential define fluent function verified(conditions List<Choice<ConditionProblemsHealthConcerns, ConditionEncounterDiagnosis>>):   conditions C     where C.verificationStatus is not null implies       (C.verificationStatus ~ \"confirmed\"         or C.verificationStatus ~ \"unconfirmed\"         or C.verificationStatus ~ \"provisional\"         or C.verificationStatus ~ \"differential\"       )"
            },
            {
              "url": "displaySequence",
              "valueInteger": 38
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "FHIRHelpers"
            },
            {
              "url": "name",
              "valueString": "ToCode"
            },
            {
              "url": "statement",
              "valueString": "/* @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         }"
            },
            {
              "url": "displaySequence",
              "valueInteger": 39
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "Status"
            },
            {
              "url": "name",
              "valueString": "isAssessmentPerformed"
            },
            {
              "url": "statement",
              "valueString": "//Assessment, Performed define fluent function isAssessmentPerformed(Obs List<ObservationScreeningAssessment>):   Obs O     where O.status in { 'final', 'amended', 'corrected' }"
            },
            {
              "url": "displaySequence",
              "valueInteger": 40
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "Status"
            },
            {
              "url": "name",
              "valueString": "isInterventionOrder"
            },
            {
              "url": "statement",
              "valueString": "//Intervention, Order define fluent function isInterventionOrder(ServiceRequest List<ServiceRequest>):   ServiceRequest S     where S.status in { 'active', 'completed' }       and S.intent in {'order', 'original-order', 'reflex-order', 'filler-order', 'instance-order'}"
            },
            {
              "url": "displaySequence",
              "valueInteger": 41
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "Status"
            },
            {
              "url": "name",
              "valueString": "isInterventionPerformed"
            },
            {
              "url": "statement",
              "valueString": "//Intervention, Performed define fluent function isInterventionPerformed(Proc List<Procedure>):   Proc P     where P.status ~ 'completed'"
            },
            {
              "url": "displaySequence",
              "valueInteger": 42
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "QICoreCommon"
            },
            {
              "url": "name",
              "valueString": "toInterval"
            },
            {
              "url": "statement",
              "valueString": "/* @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"
            },
            {
              "url": "displaySequence",
              "valueInteger": 43
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "Status"
            },
            {
              "url": "name",
              "valueString": "isProcedurePerformed"
            },
            {
              "url": "statement",
              "valueString": "//Procedure, Performed define fluent function isProcedurePerformed(Proc List<Procedure>):   Proc P     where P.status ~ 'completed'"
            },
            {
              "url": "displaySequence",
              "valueInteger": 44
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "Status"
            },
            {
              "url": "name",
              "valueString": "isDeviceOrderPersonalUseDevices"
            },
            {
              "url": "statement",
              "valueString": "//Device, Order - Personal Use Devices define fluent function isDeviceOrderPersonalUseDevices(DeviceRequest List<DeviceRequest>):   DeviceRequest D     where D.status in { 'active', 'completed' }       and D.intent in {'order', 'original-order', 'reflex-order', 'filler-order', 'instance-order'}"
            },
            {
              "url": "displaySequence",
              "valueInteger": 45
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "Status"
            },
            {
              "url": "name",
              "valueString": "isSymptom"
            },
            {
              "url": "statement",
              "valueString": "//Symptom define fluent function isSymptom(Obs List<SimpleObservation>):   Obs O     where O.status in { 'preliminary', 'final', 'amended', 'corrected' }"
            },
            {
              "url": "displaySequence",
              "valueInteger": 46
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "Status"
            },
            {
              "url": "name",
              "valueString": "isMedicationActive"
            },
            {
              "url": "statement",
              "valueString": "//Medication, Active define fluent function isMedicationActive(MedicationRequest List<MedicationRequest>):   MedicationRequest M     where M.status = 'active'       and M.intent in {'order', 'original-order', 'reflex-order', 'filler-order', 'instance-order'}"
            },
            {
              "url": "displaySequence",
              "valueInteger": 47
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CumulativeMedicationDuration"
            },
            {
              "url": "name",
              "valueString": "medicationRequestPeriod"
            },
            {
              "url": "statement",
              "valueString": "define fluent function medicationRequestPeriod(Request \"MedicationRequest\"):   Request R     let       dosage: singleton from R.dosageInstruction,       doseAndRate: singleton from dosage.doseAndRate,       timing: dosage.timing,       frequency: Coalesce(timing.repeat.frequencyMax, timing.repeat.frequency),       period: Quantity(timing.repeat.period, timing.repeat.periodUnit),       doseRange: doseAndRate.dose,       doseQuantity: doseAndRate.dose,       dose: Coalesce(end of doseRange, doseQuantity),       dosesPerDay: Coalesce(ToDaily(frequency, period), Count(timing.repeat.timeOfDay), 1.0),       boundsPeriod: timing.repeat.bounds as Interval<DateTime>,       daysSupply: (convert R.dispenseRequest.expectedSupplyDuration to days).value,       quantity: R.dispenseRequest.quantity,       refills: Coalesce(R.dispenseRequest.numberOfRepeatsAllowed, 0),       startDate:         Coalesce(           date from start of boundsPeriod,           date from R.authoredOn,           date from start of R.dispenseRequest.validityPeriod         ),       totalDaysSupplied: Coalesce(daysSupply, quantity.value / (dose.value * dosesPerDay)) * (1 + refills)     return       if startDate is not null and totalDaysSupplied is not null then         Interval[startDate, startDate + Quantity(totalDaysSupplied - 1, 'day') ]       else if startDate is not null and boundsPeriod.\"high\" is not null then         Interval[startDate, date from end of boundsPeriod]       else         null"
            },
            {
              "url": "displaySequence",
              "valueInteger": 48
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CumulativeMedicationDuration"
            },
            {
              "url": "name",
              "valueString": "Quantity"
            },
            {
              "url": "statement",
              "valueString": "/**********************************************************************/ /* Functions in this region are copied from opioid-mme-r4             */ /**********************************************************************/  define function Quantity(value Decimal, unit String):   if value is not null then     System.Quantity { value: value, unit: unit }   else     null"
            },
            {
              "url": "displaySequence",
              "valueInteger": 49
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CumulativeMedicationDuration"
            },
            {
              "url": "name",
              "valueString": "ToDaily"
            },
            {
              "url": "statement",
              "valueString": "/*  Goal is to get to number of days  Two broad approaches to the calculation:   1) Based on supply and frequency, calculate the number of expected days the medication will cover/has covered   2) Based on relevant period, determine a covered interval and calculate the length of that interval in days This topic covers several use cases and illustrates how to calculate Cumulative Medication Duration for each type of medication resource using the supply and frequency approach. */  /*   For the first approach, we need to get from frequency to a frequency/day   So we define ToDaily */  /*   Calculates daily frequency given frequency within a period */ define function ToDaily(frequency System.Integer, period System.Quantity):   case period.unit     when 'h' then frequency * (24.0 / period.value)     when 'min' then frequency * (24.0 / period.value) * 60     when 's' then frequency * (24.0 / period.value) * 60 * 60     when 'd' then frequency * (24.0 / period.value) / 24     when 'wk' then frequency * (24.0 / period.value) / (24 * 7)     when 'mo' then frequency * (24.0 / period.value) / (24 * 30) /* assuming 30 days in month */     when 'a' then frequency * (24.0 / period.value) / (24 * 365) /* assuming 365 days in year */     when 'hour' then frequency * (24.0 / period.value)     when 'minute' then frequency * (24.0 / period.value) * 60     when 'second' then frequency * (24.0 / period.value) * 60 * 60     when 'day' then frequency * (24.0 / period.value) / 24     when 'week' then frequency * (24.0 / period.value) / (24 * 7)     when 'month' then frequency * (24.0 / period.value) / (24 * 30) /* assuming 30 days in month */     when 'year' then frequency * (24.0 / period.value) / (24 * 365) /* assuming 365 days in year */     when 'hours' then frequency * (24.0 / period.value)     when 'minutes' then frequency * (24.0 / period.value) * 60     when 'seconds' then frequency * (24.0 / period.value) * 60 * 60     when 'days' then frequency * (24.0 / period.value) / 24     when 'weeks' then frequency * (24.0 / period.value) / (24 * 7)     when 'months' then frequency * (24.0 / period.value) / (24 * 30) /* assuming 30 days in month */     when 'years' then frequency * (24.0 / period.value) / (24 * 365) /* assuming 365 days in year */     else Message(null, true, 'CMDLogic.ToDaily.UnknownUnit', ErrorLevel, 'Unknown unit ' & period.unit)   end"
            },
            {
              "url": "displaySequence",
              "valueInteger": 50
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-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": "https://madie.cms.gov/Library/SupplementalDataElements|5.1.000"
        },
        {
          "type": "depends-on",
          "display": "Library FHIRHelpers",
          "resource": "https://madie.cms.gov/Library/FHIRHelpers|4.4.000"
        },
        {
          "type": "depends-on",
          "display": "Library Status",
          "resource": "https://madie.cms.gov/Library/Status|1.15.000"
        },
        {
          "type": "depends-on",
          "display": "Library QICoreCommon",
          "resource": "https://madie.cms.gov/Library/QICoreCommon|4.0.000"
        },
        {
          "type": "depends-on",
          "display": "Library AdultOutpatientEncounters",
          "resource": "https://madie.cms.gov/Library/AdultOutpatientEncounters|4.19.000"
        },
        {
          "type": "depends-on",
          "display": "Library Hospice",
          "resource": "https://madie.cms.gov/Library/Hospice|6.18.000"
        },
        {
          "type": "depends-on",
          "display": "Library AIFrailLTCF",
          "resource": "https://madie.cms.gov/Library/AdvancedIllnessandFrailty|1.27.000"
        },
        {
          "type": "depends-on",
          "display": "Library CMD",
          "resource": "https://madie.cms.gov/Library/CumulativeMedicationDuration|6.0.000"
        },
        {
          "type": "depends-on",
          "display": "Library PalliativeCare",
          "resource": "https://madie.cms.gov/Library/PalliativeCare|1.18.000"
        },
        {
          "type": "depends-on",
          "display": "Code system SNOMEDCT",
          "resource": "http://snomed.info/sct"
        },
        {
          "type": "depends-on",
          "display": "Code system LOINC",
          "resource": "http://loinc.org"
        },
        {
          "type": "depends-on",
          "display": "Code system ConditionVerificationStatusCodes",
          "resource": "http://terminology.hl7.org/CodeSystem/condition-ver-status"
        },
        {
          "type": "depends-on",
          "display": "Value set Encounter Inpatient",
          "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.666.5.307"
        },
        {
          "type": "depends-on",
          "display": "Value set Emergency Department Evaluation and Management Visit",
          "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1010"
        },
        {
          "type": "depends-on",
          "display": "Value set Essential Hypertension",
          "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.104.12.1011"
        },
        {
          "type": "depends-on",
          "display": "Value set Office Visit",
          "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1001"
        },
        {
          "type": "depends-on",
          "display": "Value set Annual Wellness Visit",
          "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.526.3.1240"
        },
        {
          "type": "depends-on",
          "display": "Value set Preventive Care Services Established Office Visit, 18 and Up",
          "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1025"
        },
        {
          "type": "depends-on",
          "display": "Value set Preventive Care Services Initial Office Visit, 18 and Up",
          "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1023"
        },
        {
          "type": "depends-on",
          "display": "Value set Home Healthcare Services",
          "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1016"
        },
        {
          "type": "depends-on",
          "display": "Value set Virtual Encounter",
          "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1089"
        },
        {
          "type": "depends-on",
          "display": "Value set Telephone Visits",
          "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1080"
        },
        {
          "type": "depends-on",
          "display": "Value set Payer Type",
          "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591"
        },
        {
          "type": "depends-on",
          "display": "Value set Hospice Encounter",
          "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.1003"
        },
        {
          "type": "depends-on",
          "display": "Value set Hospice Care Ambulatory",
          "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.526.3.1584"
        },
        {
          "type": "depends-on",
          "display": "Value set Hospice Diagnosis",
          "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.1165"
        },
        {
          "type": "depends-on",
          "display": "Value set Pregnancy",
          "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.526.3.378"
        },
        {
          "type": "depends-on",
          "display": "Value set End Stage Renal Disease",
          "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.526.3.353"
        },
        {
          "type": "depends-on",
          "display": "Value set Kidney Transplant Recipient",
          "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.109.12.1029"
        },
        {
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  "url": "https://madie.cms.gov/Measure/CMS165FHIRControllingHighBloodPressure",
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  "name": "CMS165FHIRControllingHighBloodPressure",
  "title": "Controlling High Blood PressureFHIR",
  "status": "active",
  "experimental": false,
  "date": "2025-06-27T20:07:00+00:00",
  "publisher": "National Committee for Quality Assurance",
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  "description": "Percentage of patients 18-85 years of age who had a diagnosis of essential hypertension starting before and continuing into, or starting during the first six months of the measurement period, and whose most recent blood pressure was adequately controlled (<140/90 mmHg) during the measurement period",
  "usage": "In reference to the numerator element, only blood pressure readings performed by a clinician or an automated blood pressure monitor or device are acceptable for numerator compliance with this measure. This includes blood pressures taken in person by a clinician and blood pressures measured remotely by electronic monitoring devices capable of transmitting the blood pressure data to the clinician. Blood pressure readings taken by an automated blood pressure monitor or device and conveyed by the patient to the clinician are also acceptable. It is the clinician’s responsibility and discretion to confirm the automated blood pressure monitor or device used to obtain the blood pressure is considered acceptable and reliable and whether the blood pressure reading is considered accurate before documenting it in the patient’s medical record.  Do not include BP readings taken during an acute inpatient stay or an emergency department (ED) visit.  If no blood pressure is recorded during the measurement period, the patient's blood pressure is assumed \"not controlled\".  If there are multiple blood pressure readings on the same day, use the lowest systolic and the lowest diastolic reading as the most recent blood pressure reading. Ranges and thresholds do not meet criteria for this measure. A distinct numeric result for both the systolic and diastolic BP reading is required for numerator compliance.  This eCQM is a patient-based measure.  This FHIR-based measure has been derived from the QDM-based measure: CMS165v14.  Please refer to the HL7 QI-Core Implementation Guide (https://hl7.org/fhir/us/qicore/STU6/) for more information on QI-Core and mapping recommendations from QDM to QI-Core STU 6. (https://hl7.org/fhir/us/qicore/STU6/qdm-to-qicore.html).",
  "copyright": "This Physician Performance Measure (Measure) and related data specifications are owned and were developed by the National Committee for Quality Assurance (NCQA). NCQA is not responsible for any use of the Measure. NCQA makes no representations, warranties or endorsements about the quality of any product, test or protocol identified as numerator compliant or otherwise identified as meeting the requirements of the measure or specification. NCQA makes no representations, warranties, or endorsement about the quality of any organization or physician that uses or reports performance measures and NCQA has no liability to anyone who relies on such measures or specifications. NCQA holds a copyright in the Measure. The Measure may be used for internal, noncommercial purposes (e.g., use by healthcare providers in connection with their practices) without obtaining approval from NCQA. All other uses, including a commercial use (including but not limited to vendors using or embedding the measures and specifications into any product or service to calculate measure results for customers for any purpose), must be approved by NCQA and are subject to a license at the discretion of NCQA. (C) 2012-2025 National Committee for Quality Assurance. 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. NCQA disclaims all liability for use or accuracy of any third-party codes contained in the specifications.  CPT(R) codes, descriptions and other data are copyright 2025. American Medical Association. All rights reserved. CPT is a trademark of the American Medical Association. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. Applicable FARS/DFARS restrictions apply to government use.  Some measure specifications contain coding from LOINC(R) (https://loinc.org). The LOINC table, LOINC codes, LOINC panels and form file, LOINC linguistic variants file, LOINC/RSNA Radiology Playbook, and LOINC/IEEE Medical Device Code Mapping Table are copyright 2004-2025 Regenstrief Institute, Inc. and the Logical Observation Identifiers Names and Codes (LOINC) Committee, and are available at no cost under the license at https://loinc.org/kb/license/.  This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2024 International Health Terminology Standards Development Organisation.   ICD-10 copyright 2025 World Health Organization. All Rights Reserved.  Some measures use RxNorm, a standardized nomenclature and coding for clinical drugs and drug delivery devices, which is made publicly available courtesy of the U.S. National Library of Medicine (NLM), National Institutes of Health, Department of Health and Human Services. NLM is not responsible for the measures and does not endorse or recommend this or any other product.  “HL7” is the registered trademark of Health Level Seven International.",
  "effectivePeriod": {
    "start": "2026-01-01",
    "end": "2026-12-31"
  },
  "author": [
    {
      "name": "National Committee for Quality Assurance",
      "telecom": [
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          "system": "url",
          "value": "https://www.ncqa.org/"
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  "relatedArtifact": [
    {
      "type": "citation",
      "citation": "CITATION - American Diabetes Association. (2022). 10. Cardiovascular disease and risk management: Standards of medical care in diabetes—2022. Diabetes Care 2022, 44(Suppl. 1), S144-S175. https://doi.org/10.2337/dc22-S010 "
    },
    {
      "type": "citation",
      "citation": "CITATION - Centers for Disease Control and Prevention, National Center for Health Statistics. (2022). About Multiple Cause of Death, 1999–2020. CDC WONDER Online Database website. Atlanta, GA: Centers for Disease Control and Prevention. Available from http://www.cdc.gov/nchs/data_access/Vitalstatsonline.htm#Mortality_Multiple "
    },
    {
      "type": "citation",
      "citation": "CITATION - Centers for Disease Control and Prevention. (2021). Team-based care for high blood pressure. Retrieved from https://www.cdc.gov/policy/polaris/healthtopics/highbloodpressure/tbctool.html "
    },
    {
      "type": "citation",
      "citation": "CITATION - Centers for Disease Control and Prevention. (2023). Facts about hypertension. Retrieved from https://www.cdc.gov/bloodpressure/facts.htm "
    },
    {
      "type": "citation",
      "citation": "Citation - Coles, S., Fisher, L., Lin, K. W., Lyon, C., Vosooney, A. A., & Bird, M. D. (2022). Blood Pressure Targets in Adults With Hypertension: A Clinical Practice Guideline From the AAFP. American family physician, 106(6). Retrieved from https://www.aafp.org/pubs/afp/issues/2022/1200/practice-guidelines-aafp-hypertension-full-guideline.html "
    },
    {
      "type": "citation",
      "citation": "CITATION - James, P.A., Oparil, S., Carter, B.L., et al. (2014). 2014 Evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014;311(5):507-520. doi: 10.1001/jama.2013.284427 "
    },
    {
      "type": "citation",
      "citation": "Citation - Kirkland, E. B., Heincelman, M., Bishu, K. G., Schumann, S. O., Schreiner, A., Axon, R. N.,...Moran, W. P. (2018). Trends in Healthcare Expenditures Among US Adults With Hypertension: National Estimates, 2003–2014. Journal of the American Heart Association, 7(11), e008731. https://doi.org/10.1161/JAHA.118.008731 "
    },
    {
      "type": "citation",
      "citation": "CITATION - Moran, A. E., Odden, M. C., Thanataveerat, A., et al. (2015). Cost-effectiveness of hypertension therapy according to 2014 guidelines. [published correction appears in N Engl J. Med. 2015;372:1677]. New England Journal of Medicine. 2015;372, 447-455. doi: 10.1056/NEJMsa1406751. [published correction appears on page 1677] "
    },
    {
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      "citation": "CITATION - Patel, S. A., Winkel, M., Ali, M. K., et al. (2015). Cardiovascular mortality associated with 5 leading risk factors: National and state preventable fractions estimated from survey data. Annals of Internal Medicine, 163(4), 245-253. doi: 10.7326/M14-1753 "
    },
    {
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      "citation": "CITATION - Qaseem, A., Wilt, T. J., Rich, R., et al. (2017). Pharmacologic treatment of hypertension in adults aged 60 years or older to higher versus lower blood pressure targets: A clinical practice guideline from the American College of Physicians and the American Academy of Family Physicians. Annals of Internal Medicine, 166(6), 430-437. Retrieved from https://annals.org/aim/fullarticle/2598413/pharmacologic-treatment-hypertension-adults-aged-60-years-older-higher-versus "
    },
    {
      "type": "citation",
      "citation": "CITATION - SPRINT Research Group, Wright, J. T., Jr., Williamson, J. D., et al. (2015). A randomized trial of intensive versus standard blood-pressure control. New England Journal of Medicine, 373(22), 2103–2116. "
    },
    {
      "type": "citation",
      "citation": "Citation - Tsao, C. W., Aday, A. W., Almarzooq, Z. I., Alonso, A., Beaton, A. Z., Bittencourt, M. S.,...Kissela, B. M. (2022). Heart Disease and Stroke Statistics—2022 Update: A Report From the American Heart Association. Circulation, 145(8), e153–e639. https://doi.org/10.1161/CIR.0000000000001052 "
    },
    {
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      "citation": "CITATION - U.S. Preventive Services Task Force. Screening for hypertension in adults: U.S. Preventive Services Task Force reaffirmation recommendation statement. JAMA, 325(16), 1650. Retrieved from https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/hypertension-in-adults-screening "
    },
    {
      "type": "citation",
      "citation": "CITATION - Virani, S.S., Alonso, A., Aparicio, H.J., et al.; on behalf of the American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee. (2021). Heart disease and stroke statistics—2021 update: a report from the American Heart Association. Circulation. 2021;143:e254–e743. doi: 10.1161/CIR.0000000000000950 "
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    }
  ],
  "library": [
    "https://madie.cms.gov/Library/CMS165FHIRControllingHighBloodPressure"
  ],
  "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 MEASURE 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": "High blood pressure (HBP), also known as hypertension, is when the pressure in blood vessels is higher than normal (Centers for Disease Control and Prevention [CDC], 2023). The causes of hypertension are multiple and multifaceted and can be based on genetic predisposition, environmental risk factors, being overweight and obese, sodium intake, potassium intake, physical activity, and alcohol use. High blood pressure is common; according to the American Heart Association, between 2013-2016, approximately 121.5 million US adults >= 20 years of age had HBP and the prevalence of hypertension among US adults 65 and older was 77.0 percent (Virani et al., 2021). In an analysis of adults with hypertension in National Health and Nutrition Examination Survey (NHANES), the estimated age-adjusted proportion with controlled blood pressure (BP) increased from 31.8 percent in 1999 to 53.8 percent in 2014. However, that proportion declined to 43.7 percent in 2017 to 2018 (Tsao et al., 2022).  HBP increases risks of heart disease and stroke which are two of the leading causes of death in the US (CDC, 2023). A person who has HBP is four times more likely to die from a stroke and three times more likely to die from heart disease (CDC, 2021). The National Center for Health Statistics reported that in 2020 there were over 670,000 deaths with HBP as a primary or contributing cause (CDC, 2022). Between 2009 and 2019 the number of deaths due to HBP rose by 65.3 percent (Tsao et al., 2022). Managing and treating HBP would reduce cardiovascular disease mortality for males and females by 30.4 percent and 38.0 percent, respectively (Patel et al., 2015). Age-adjusted death rates attributable to HBP in 2019 were more than twice as high in non-Hispanic Black males (56.7 percent) when compared to rates for non-Hispanic White males (25.7 percent) (Tsao et al., 2022).  HBP costs the U.S. approximately 131 billion dollars each year, averaged over 12 years from 2003 to 2014 (Kirkland et al., 2018). A study on cost-effectiveness on treating hypertension found that controlling HBP in patients with cardiovascular disease and systolic blood pressures (SBP) of >= 160 mmHg could be effective and cost-saving (Moran et al., 2015).  Many studies have shown that controlling high blood pressure reduces cardiovascular events and mortality. The Systolic Blood Pressure Intervention Trial (SPRINT) investigated the impact of obtaining a SBP goal of <120 mmHg compared to a SBP goal of <140 mmHg among patients 50 and older with established cardiovascular disease and found that the patients with the former goal had reduced cardiovascular events and mortality (SPRINT Research Group et al., 2015).   Controlling HBP will significantly reduce the risks of cardiovascular disease mortality and lead to better health outcomes like reduction of heart attacks, stroke, and kidney disease (James et al., 2014). Thus, the relationship between the measure (control of hypertension) and the long-term clinical outcomes listed is well established.",
  "clinicalRecommendationStatement": "U.S. Preventive Services Task Force (USPSTF) (2021):  - The USPSTF recommends screening for hypertension in adults 18 years or older with office blood pressure measurement (OBPM). The USPSTF recommends obtaining blood pressure measurements outside of the clinical setting for diagnostic confirmation before starting treatment. This is a grade A recommendation.    American College of Cardiology/American Heart Association (2017):  - For adults with confirmed hypertension and known cardiovascular disease (CVD) or 10-year atherosclerotic cardiovascular disease (ASCVD) event risk of 10 percent or higher, a blood pressure target of less than 130/80 mmHg is recommended (Level of evidence: B-R (for systolic blood pressures), Level of evidence: C-EO (for diastolic blood pressure))   - For adults with confirmed hypertension, without additional markers of increased CVD risk, a blood pressure target of less than 130/80 mmHg may be reasonable (Note: clinical trial evidence is strongest for a target blood pressure of 140/90 mmHg in this population. However, observational studies suggest that these individuals often have a high lifetime risk and would benefit from blood pressure control earlier in life) (Level of evidence: B-NR (for systolic blood pressure), Level of evidence: C-EO (for diastolic blood pressure)).  American Academy of Family Physicians (2022):     - Treat adults who have hypertension to a standard blood pressure target (less than 140/90 mm Hg) to reduce the risk of all-cause and cardiovascular mortality (strong recommendation; high-quality evidence). Treating to a lower blood pressure target (less than 135/85 mm Hg) does not provide additional benefit at preventing mortality; however, a lower blood pressure target could be considered based on patient preferences and values. (Grade: strong recommendation, Quality of evidence: high)  - Consider treating adults who have hypertension to a lower blood pressure target (less than 135/85 mm Hg) to reduce risk of myocardial infarction (weak recommendation; moderate-quality evidence). Although treatment to a standard blood pressure target (less than 140/90 mm Hg) reduced the risk of myocardial infarction, there was a small additional benefit observed with a lower blood pressure target. There was no observed additional benefit in preventing stroke with the lower blood pressure target. (Grade: weak recommendation, Quality of evidence: low)  American Diabetes Association (2022):   - For individuals with diabetes and hypertension at higher cardiovascular risk (existing atherosclerotic cardiovascular disease or 10-year atherosclerotic cardiovascular disease risk >=15 percent), a blood pressure target of <130/80 mmHg may be appropriate, if it can be safely attained (Level of evidence: B)  - For individuals with diabetes and hypertension at lower risk for cardiovascular disease (10-year atherosclerotic cardiovascular disease risk <15 percent), treat to a blood pressure target of <140/90 mmHg (Level of evidence: A)",
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            ]
          },
          "description": "Exclude patients who are in hospice care for any part of the measurement period.  Patients with evidence of end stage renal disease (ESRD), dialysis or renal transplant before or during the measurement period. Also exclude patients with a diagnosis of pregnancy during the measurement period.  Exclude patients 66-80 by the end of the measurement period with an indication of frailty for any part of the measurement period who also meet any of the following advanced illness criteria: - Advanced illness diagnosis during the measurement period or the year prior - OR taking dementia medications during the measurement period or the year prior  Exclude patients 81 and older by the end of the measurement period with an indication of frailty for any part of the measurement period.  Exclude patients 66 and older by the end of the measurement period who are living long term in a nursing home any time on or before the end of the measurement period.   Exclude patients receiving palliative care for any part of the measurement period.",
          "criteria": {
            "language": "text/cql-identifier",
            "expression": "Denominator Exclusions"
          }
        },
        {
          "id": "Numerator_1",
          "code": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/measure-population",
                "code": "numerator",
                "display": "Numerator"
              }
            ]
          },
          "description": "Patients whose most recent blood pressure is adequately controlled (systolic blood pressure < 140 mmHg and diastolic blood pressure < 90 mmHg) during the measurement period",
          "criteria": {
            "language": "text/cql-identifier",
            "expression": "Numerator"
          }
        }
      ]
    }
  ],
  "supplementalData": [
    {
      "id": "sde-sex",
      "usage": [
        {
          "coding": [
            {
              "system": "http://terminology.hl7.org/CodeSystem/measure-data-usage",
              "code": "supplemental-data"
            }
          ]
        }
      ],
      "description": "SDE Sex",
      "criteria": {
        "language": "text/cql-identifier",
        "expression": "SDE Sex"
      }
    },
    {
      "id": "sde-race",
      "usage": [
        {
          "coding": [
            {
              "system": "http://terminology.hl7.org/CodeSystem/measure-data-usage",
              "code": "supplemental-data"
            }
          ]
        }
      ],
      "description": "SDE Race",
      "criteria": {
        "language": "text/cql-identifier",
        "expression": "SDE Race"
      }
    },
    {
      "id": "sde-payer",
      "usage": [
        {
          "coding": [
            {
              "system": "http://terminology.hl7.org/CodeSystem/measure-data-usage",
              "code": "supplemental-data"
            }
          ]
        }
      ],
      "description": "SDE Payer",
      "criteria": {
        "language": "text/cql-identifier",
        "expression": "SDE Payer"
      }
    },
    {
      "id": "sde-ethnicity",
      "usage": [
        {
          "coding": [
            {
              "system": "http://terminology.hl7.org/CodeSystem/measure-data-usage",
              "code": "supplemental-data"
            }
          ]
        }
      ],
      "description": "SDE Ethnicity",
      "criteria": {
        "language": "text/cql-identifier",
        "expression": "SDE Ethnicity"
      }
    }
  ]
}