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FHIR IG Statistics: Measure/CMS646FHIRIntravesicalBacillusCalmetteGuerinForBladderCancer

Packagegov.healthit.ecqi.ecqms
Resource TypeMeasure
IdCMS646FHIRIntravesicalBacillusCalmetteGuerinForBladderCancer
FHIR VersionR4
Sourcehttp://ecqi.healthit.gov/ecqms/https://build.fhir.org/ig/cqframework/ecqm-content-qicore-2025/Measure-CMS646FHIRIntravesicalBacillusCalmetteGuerinForBladderCancer.html
URLhttps://madie.cms.gov/Measure/CMS646FHIRIntravesicalBacillusCalmetteGuerinForBladderCancer
Version1.5.000
Statusactive
Date2025-07-15T13:37:39+00:00
NameCMS646FHIRIntravesicalBacillusCalmetteGuerinForBladderCancer
TitleIntravesical Bacillus-Calmette-Guerin for Non-Muscle Invasive Bladder CancerFHIR
DescriptionPercentage of patients initially diagnosed with non-muscle invasive bladder cancer and who received intravesical Bacillus-Calmette-Guerin (BCG) within 6 months of bladder cancer staging
CopyrightLimited proprietary coding is contained in the measure specifications for convenience. Users of the proprietary code sets should obtain all necessary licenses from the owners of these code sets. Oregon Urology Institute (OUI) and Large Urology Group Practice Association (LUGPA) disclaim all liability for the use or accuracy of third party codes contained in the specifications. CPT(R) contained in the Measure specifications is copyright 2004-2024. American Medical Association. LOINC(R) copyright 2004-2024 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2024 International Health Terminology Standards Development Organisation. ICD-10 copyright 2024 World Health Organization. All Rights Reserved.

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Narrative

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Metadata
Title Intravesical Bacillus-Calmette-Guerin for Non-Muscle Invasive Bladder CancerFHIR
Version 1.5.000
Short Name CMS646FHIR
GUID (Version Independent) urn:uuid:907ead5a-2f8f-468e-b774-309ea8aa6182
GUID (Version Specific) urn:uuid:de3ec699-6af3-4a85-9d3e-a0b487c66927
CMS Identifier 646FHIR
Effective Period 2026-01-01 through 2026-12-31
Steward (Publisher) Oregon Urology
Developer Oregon Urology
Description

Percentage of patients initially diagnosed with non-muscle invasive bladder cancer and who received intravesical Bacillus-Calmette-Guerin (BCG) within 6 months of bladder cancer staging
Copyright

Limited proprietary coding is contained in the measure specifications for convenience. Users of the proprietary code sets should obtain all necessary licenses from the owners of these code sets. Oregon Urology Institute (OUI) and Large Urology Group Practice Association (LUGPA) disclaim all liability for the use or accuracy of third party codes contained in the specifications.

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

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

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

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

Bladder cancer is ranked 10th for new cancer cases in 2020 and is the ninth leading cause of cancer death in the United States. There are 81,400 estimated new cases in 2020 and 17,980 estimated deaths in 2020. In 2016, there were an estimated 699,450 people were living with bladder cancer in the United States. Early detection (discovery of cancer in situ or localized to the primary site) is found in 85% of the patients, and with these there is a five-year survival rate of 95.8% for In Situ and 69.2% for Localized. Bladder cancer is rarely found in patients under age 20, with the median age of diagnosis being 73 (NIH, 2020). National Comprehensive Cancer Network (NCCN) Guidelines for Bladder Cancer (version 6.2021) defines intravesical BCG as Category 1 Treatment for T1, Tis and Ta - high grade, non-muscle invasive bladder cancer. Most public data reflects prophylactic or adjuvant use of intravesical therapy to prevent recurrence or delaying progression to a higher grade or stage. BCG has been shown to be effective as prophylaxis to prevent bladder cancer recurrences following TURBT. The NCCN Bladder Cancer Panel Members recommend BCG as the preferred option over Mitomycin C for adjuvant treatment of high-grade lesions (Ta). BCG is also standard therapy for Primary Tis. Most T1 lesions are high-risk and are similarly treated with adjuvant intravesical therapy, with BCG being a Category 1 recommendation. (NCCN, 2021).
Clinical Recommendation Statement

Intravesical BCG should be administered within 6 months of the initial diagnosis of non-muscle invasive bladder cancer. It may be administered 3-4 weeks after resection, but there needs to be pathological tumor confirmation and must be withheld if there is traumatic catheterization, bacteriuria, persistent gross hematuria, persistent severe local symptoms or systemic symptoms. The normal induction course is 6 weekly instillations of intravesical BCG (AUA Non-Muscle Invasive Bladder Cancer and American Urological Association (AUA) Guideline for the Management of Non-muscle Invasive Bladder Cancer: Stages T1, TIS, and Ta High Risk).
Guidance (Usage) Ta bladder cancer must be high grade Ta only and is supported by the 2016 AUA guidelines and 2018 NCCN guidelines. The BCG dose can be full or partial and can be from any lot or manufacturer. This eCQM is a patient-based measure. Telehealth encounters are not eligible for this measure because the measure requires a clinical action that cannot be conducted via telehealth This FHIR-based measure has been derived from the QDM-based measure: CMS646v5. 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 6.0.0 (https://hl7.org/fhir/us/qicore/STU6/qdm-to-qicore.html).
Measure Group (Rate) (ID: Group_1)
Basis boolean
Scoring Proportion
Type Process
Rate Aggregation None
Improvement Notation Increased score indicates improvement
Initial Population ID: InitialPopulation_1
Description:

All patients initially diagnosed with T1, Tis or high grade Ta non-muscle invasive bladder cancer with bladder cancer staging within 6 months before to 6 months after the start of the measurement period and a qualified encounter in the measurement period

Logic Definition: Initial Population
Denominator ID: Denominator_1
Description:

Equals Initial Population

Logic Definition: Denominator
Denominator Exclusion ID: DenominatorExclusion_1
Description:

Immunosuppressed patients, includes HIV and immunocompromised state, with a diagnosis prior to Bladder Cancer Staging. Immunosuppressive drug therapy starting on or before Bladder Cancer Staging. Active Tuberculosis diagnosis during the Bladder Cancer Staging. Mixed histology urothelial cell carcinoma including micropapillary, plasmacytoid, sarcomatoid, adenocarcinoma and squamous disease prior to Bladder Cancer Staging. Patients who undergo cystectomy, chemotherapy or radiation within 6 months prior to Bladder Cancer Staging.

Logic Definition: Denominator Exclusion
Numerator ID: Numerator_1
Description:

Intravesical Bacillus-Calmette Guerin (BCG) instillation for initial dose or series: BCG is initiated within 6 months of the bladder cancer staging

Logic Definition: Numerator
Denominator Exception ID: DenominatorException_1
Description:

Unavailability of BCG within 6 months after Bladder Cancer Staging

Logic Definition: Denominator Exception
Supplemental Data Guidance For every patient evaluated by this measure also identify payer, race, ethnicity and sex
Supplemental Data Guidance None
Supplemental Data Elements
Supplemental Data Element ID: sde-ethnicity
Usage Code: Supplemental Data
Description: SDE Ethnicity
Logic Definition: SDE Ethnicity
Supplemental Data Element ID: sde-payer
Usage Code: Supplemental Data
Description: SDE Payer
Logic Definition: SDE Payer
Supplemental Data Element ID: sde-race
Usage Code: Supplemental Data
Description: SDE Race
Logic Definition: SDE Race
Supplemental Data Element ID: sde-sex
Usage Code: Supplemental Data
Description: SDE Sex
Logic Definition: SDE Sex
Supplemental Data Element ID: sde-race
Usage Code: Risk Adjustment Factor
Description: SDE Race
Logic Definition: SDE Race
Supplemental Data Element ID: sde-payer
Usage Code: Risk Adjustment Factor
Description: SDE Payer
Logic Definition: SDE Payer
Supplemental Data Element ID: sde-ethnicity
Usage Code: Risk Adjustment Factor
Description: SDE Ethnicity
Logic Definition: SDE Ethnicity
Supplemental Data Element ID: sde-sex
Usage Code: Risk Adjustment Factor
Description: SDE Sex
Logic Definition: SDE Sex
Measure Logic
Primary Library CMS646FHIRIntravesicalBacillusCalmetteGuerinForBladderCancer
Contents Population Criteria
Logic Definitions
Terminology
Dependencies
Data Requirements
Population Criteria
Measure Group (Rate) (ID: Group_1)
Initial Population 
define "Initial Population":
  "Has Most Recent Bladder Cancer Tumor Staging is T1, Tis, Ta HG"
    and "Has Qualifying Encounter"
Initial Population 
define "Initial Population":
  "Has Most Recent Bladder Cancer Tumor Staging is T1, Tis, Ta HG"
    and "Has Qualifying Encounter"
Denominator 
define "Denominator":
  "Initial Population"
Denominator Exclusion 
define "Denominator Exclusion":
  exists "Acute Tuberculosis Diagnosis"
    or exists "Immunosuppressive Drugs"
    or exists "Cystectomy Done"
    or "Has Excluding HIV, Immunocompromised Conditions or Mixed Histology Before Staging"
    or "Has Excluding Chemotherapy or Radiotherapy Procedure Before Staging"
Numerator 
define "Numerator":
  "First BCG Administered" is not null
Denominator Exception 
/*
@commentedOut: exists "BCG Not Available Within 6 Months After Bladder Cancer Staging"
@commentedOutReason: Negation issue related to https://github.com/cqframework/cql-execution/issues/296, which is tied to https://oncprojectracking.healthit.gov/support/browse/BONNIEMAT-1455. Due to this being the only logic in this population added 'false' as a placeholder.
*/


define "Denominator Exception":
  false
Logic Definitions
Logic Definition Library Name: SupplementalDataElements 
define "SDE Sex":
  case
    when Patient.sex = '248153007' then "Male (finding)"
    when Patient.sex = '248152002' then "Female (finding)"
    else null
  end
Logic Definition Library Name: SupplementalDataElements 
define "SDE Payer":
  [Coverage: type in "Payer Type"] Payer
    return {
      code: Payer.type,
      period: Payer.period
    }
Logic Definition Library Name: SupplementalDataElements 
define "SDE Ethnicity":
  Patient.ethnicity E
    return Tuple {
      codes: { E.ombCategory } union E.detailed,
      display: E.text
    }
Logic Definition Library Name: SupplementalDataElements 
define "SDE Race":
  Patient.race R
    return Tuple {
      codes: R.ombCategory union R.detailed,
      display: R.text
    }
Logic Definition Library Name: CMS646FHIRIntravesicalBacillusCalmetteGuerinForBladderCancer 
define "SDE Sex":
  SDE."SDE Sex"
Logic Definition Library Name: CMS646FHIRIntravesicalBacillusCalmetteGuerinForBladderCancer 
define "Bladder Cancer Diagnosis":
  ( [ConditionProblemsHealthConcerns: "Bladder Cancer for Urology Care"]
    union [ConditionEncounterDiagnosis: "Bladder Cancer for Urology Care"] ) BladderCancer
    where BladderCancer.prevalenceInterval ( ) starts before day of end of "Measurement Period"
      and BladderCancer.isConfirmedActiveDiagnosis ( )
Logic Definition Library Name: CMS646FHIRIntravesicalBacillusCalmetteGuerinForBladderCancer 
define "First Bladder Cancer Staging Procedure":
  First([Procedure: "Tumor staging (tumor staging)"] BladderCancerStaging
      with "Bladder Cancer Diagnosis" BladderCancer
        such that BladderCancerStaging.performed.toInterval() starts on or before day of start of BladderCancer.prevalenceInterval()
      where BladderCancerStaging.status = 'completed'
      sort by start of performed.toInterval()
  )
Logic Definition Library Name: CMS646FHIRIntravesicalBacillusCalmetteGuerinForBladderCancer 
define "First BCG Administered":
  First([MedicationAdministration: "Bacillus Calmette Guerin for Urology Care"] BCG
      with "First Bladder Cancer Staging Procedure" FirstBladderCancerStaging
        such that BCG.effective.toInterval() starts 6 months or less after day of start of FirstBladderCancerStaging.performed.toInterval()
          and BCG.effective.toInterval() starts during "Measurement Period"
      where BCG.status in { 'in-progress', 'completed' }
      sort by start of effective.toInterval()
  )
Logic Definition Library Name: CMS646FHIRIntravesicalBacillusCalmetteGuerinForBladderCancer 
define "Numerator":
  "First BCG Administered" is not null
Logic Definition Library Name: CMS646FHIRIntravesicalBacillusCalmetteGuerinForBladderCancer 
/*
@commentedOut: exists "BCG Not Available Within 6 Months After Bladder Cancer Staging"
@commentedOutReason: Negation issue related to https://github.com/cqframework/cql-execution/issues/296, which is tied to https://oncprojectracking.healthit.gov/support/browse/BONNIEMAT-1455. Due to this being the only logic in this population added 'false' as a placeholder.
*/


define "Denominator Exception":
  false
Logic Definition Library Name: CMS646FHIRIntravesicalBacillusCalmetteGuerinForBladderCancer 
define "July 1 of Year Prior to the Measurement Period":
  DateTime((year from start of "Measurement Period" - 1), 7, 1, 0, 0, 0, 0, 0)
Logic Definition Library Name: CMS646FHIRIntravesicalBacillusCalmetteGuerinForBladderCancer 
define "June 30 of the Measurement Period":
  DateTime((year from start of "Measurement Period"), 6, 30, 23, 59, 59, 0, 0)
Logic Definition Library Name: CMS646FHIRIntravesicalBacillusCalmetteGuerinForBladderCancer 
define "First Bladder Cancer Staging Procedure during 6 Months Prior to Measurement Period through the First 6 Months of Measurement Period":
  "First Bladder Cancer Staging Procedure" FirstBladderCancerStaging
    where FirstBladderCancerStaging.performed.toInterval ( ) during day of Interval["July 1 of Year Prior to the Measurement Period", "June 30 of the Measurement Period"]
Logic Definition Library Name: CMS646FHIRIntravesicalBacillusCalmetteGuerinForBladderCancer 
/*Ta High Grade only to be included.  Ta low grade is to be excluded from this measure.*/


define "Has Most Recent Bladder Cancer Tumor Staging is T1, Tis, Ta HG":
  exists ( [LaboratoryResultObservation] StagingObservation
      where StagingObservation.getStagingProcedure ( ) is not null
        and ( StagingObservation.value as Concept ~ "American Joint Committee on Cancer cT1 (qualifier value)"
            or StagingObservation.value as Concept ~ "American Joint Committee on Cancer cTis (qualifier value)"
            or StagingObservation.value as Concept ~ "American Joint Committee on Cancer cTa (qualifier value)"
            or StagingObservation.value as Concept ~ "Carcinoma in situ of bladder"
        )
        and StagingObservation.status in { 'final', 'amended', 'corrected' }
  )
Logic Definition Library Name: CMS646FHIRIntravesicalBacillusCalmetteGuerinForBladderCancer 
define "Has Qualifying Encounter":
  exists ( [Encounter: "Office Visit"] ValidEncounter
      where ValidEncounter.period during "Measurement Period"
        and ValidEncounter.class !~ "virtual"
        and ValidEncounter.status = 'finished'
  )
Logic Definition Library Name: CMS646FHIRIntravesicalBacillusCalmetteGuerinForBladderCancer 
define "Initial Population":
  "Has Most Recent Bladder Cancer Tumor Staging is T1, Tis, Ta HG"
    and "Has Qualifying Encounter"
Logic Definition Library Name: CMS646FHIRIntravesicalBacillusCalmetteGuerinForBladderCancer 
define "Denominator":
  "Initial Population"
Logic Definition Library Name: CMS646FHIRIntravesicalBacillusCalmetteGuerinForBladderCancer 
define "SDE Payer":
  SDE."SDE Payer"
Logic Definition Library Name: CMS646FHIRIntravesicalBacillusCalmetteGuerinForBladderCancer 
define "Initial Population":
  "Has Most Recent Bladder Cancer Tumor Staging is T1, Tis, Ta HG"
    and "Has Qualifying Encounter"
Logic Definition Library Name: CMS646FHIRIntravesicalBacillusCalmetteGuerinForBladderCancer 
define "SDE Ethnicity":
  SDE."SDE Ethnicity"
Logic Definition Library Name: CMS646FHIRIntravesicalBacillusCalmetteGuerinForBladderCancer 
define "Acute Tuberculosis Diagnosis":
  ( [ConditionProblemsHealthConcerns: "Tuberculosis for Urology Care"]
    union [ConditionEncounterDiagnosis: "Tuberculosis for Urology Care"] ) ActiveTuberculosis
    with "First Bladder Cancer Staging Procedure" FirstBladderCancerStaging
      such that ActiveTuberculosis.prevalenceInterval ( ) overlaps after day of FirstBladderCancerStaging.performed.toInterval ( )
    where ActiveTuberculosis.isConfirmedActiveDiagnosis ( )
Logic Definition Library Name: CMS646FHIRIntravesicalBacillusCalmetteGuerinForBladderCancer 
define "Immunosuppressive Drugs":
  [MedicationRequest: "Immunosuppressive Drugs for Urology Care"] ImmunosuppressiveDrugs
    let firstMedicationPeriod: First((collapse(ImmunosuppressiveDrugs.dosageInstruction.timing.repeat.bounds DoseTime
          return DoseTime.toInterval()
      )) DrugPeriods
        sort by start of $this
    ),
    //get the very first event
    
    firstMedicationEvent: First((ImmunosuppressiveDrugs.dosageInstruction.timing dosageTiming
        //return first event for the specific dosageTiming
        
        return First(dosageTiming.event dosageTimingEvents
            sort ascending
        )) firstEvents
        sort ascending
    ),
    medicationPeriod: Coalesce(firstMedicationEvent.toInterval(), firstMedicationPeriod)
    with "First Bladder Cancer Staging Procedure" FirstBladderCancerStaging
      such that medicationPeriod starts on or before day of start of FirstBladderCancerStaging.performed.toInterval ( )
    where ImmunosuppressiveDrugs.status in { 'active', 'completed' }
      and ImmunosuppressiveDrugs.intent = 'order'
Logic Definition Library Name: CMS646FHIRIntravesicalBacillusCalmetteGuerinForBladderCancer 
define "Cystectomy Done":
  [Procedure: "Cystectomy for Urology Care"] Cystectomy
    with "First Bladder Cancer Staging Procedure" FirstBladderCancerStaging
      such that Cystectomy.performed.toInterval ( ) 6 months or less before day of start of FirstBladderCancerStaging.performed.toInterval ( )
    where Cystectomy.status = 'completed'
Logic Definition Library Name: CMS646FHIRIntravesicalBacillusCalmetteGuerinForBladderCancer 
define "Has Excluding HIV, Immunocompromised Conditions or Mixed Histology Before Staging":
  exists ( ( ( [ConditionProblemsHealthConcerns: "HIV"]
        union [ConditionEncounterDiagnosis: "HIV"]
    )
      union ( [ConditionProblemsHealthConcerns: "Immunocompromised Conditions"]
          union [ConditionEncounterDiagnosis: "Immunocompromised Conditions"]
      )
      union ( [ConditionProblemsHealthConcerns: "Mixed Histology Urothelial Cell Carcinoma for Urology Care"]
          union [ConditionEncounterDiagnosis: "Mixed Histology Urothelial Cell Carcinoma for Urology Care"]
      ) ) ExclusionDiagnosis
      with "First Bladder Cancer Staging Procedure" FirstBladderCancerStaging
        such that ExclusionDiagnosis.prevalenceInterval ( ) starts on or before day of start of FirstBladderCancerStaging.performed.toInterval ( )
      where ExclusionDiagnosis.isConfirmedActiveDiagnosis ( )
  )
Logic Definition Library Name: CMS646FHIRIntravesicalBacillusCalmetteGuerinForBladderCancer 
define "Has Excluding Chemotherapy or Radiotherapy Procedure Before Staging":
  exists ( ( [MedicationRequest: "Chemotherapy Agents for Advanced Cancer"] ExclusionMed
        let firstMedicationPeriod: First((collapse(ExclusionMed.dosageInstruction.timing.repeat.bounds DoseTime
              return DoseTime.toInterval()
          )) DrugPeriods
            sort by start of $this
        )
        with "First Bladder Cancer Staging Procedure" FirstBladderCancerStaging
          such that firstMedicationPeriod starts 6 months or less before FirstBladderCancerStaging.performed.toInterval ( )
        where ExclusionMed.status in { 'active', 'completed' }
          and ExclusionMed.intent = 'order'
    )
      union ( [Procedure: "Combined radiotherapy (procedure)"] ExclusionProcedure
          with "First Bladder Cancer Staging Procedure" FirstBladderCancerStaging
            such that ExclusionProcedure.performed.toInterval ( ) starts 6 months or less before FirstBladderCancerStaging.performed.toInterval ( )
          where ExclusionProcedure.status = 'completed'
      )
  )
Logic Definition Library Name: CMS646FHIRIntravesicalBacillusCalmetteGuerinForBladderCancer 
define "Denominator Exclusion":
  exists "Acute Tuberculosis Diagnosis"
    or exists "Immunosuppressive Drugs"
    or exists "Cystectomy Done"
    or "Has Excluding HIV, Immunocompromised Conditions or Mixed Histology Before Staging"
    or "Has Excluding Chemotherapy or Radiotherapy Procedure Before Staging"
Logic Definition Library Name: CMS646FHIRIntravesicalBacillusCalmetteGuerinForBladderCancer 
define "SDE Race":
  SDE."SDE Race"
Logic Definition Library Name: CMS646FHIRIntravesicalBacillusCalmetteGuerinForBladderCancer 
define fluent function isConfirmedActiveDiagnosis(Condition Choice<ConditionProblemsHealthConcerns, ConditionEncounterDiagnosis>):
  Condition.isActive ( )
    and Condition.verificationStatus ~ QICoreCommon."confirmed"
Logic Definition Library Name: CMS646FHIRIntravesicalBacillusCalmetteGuerinForBladderCancer 
define fluent function getStagingProcedure(StagingObservation LaboratoryResultObservation):
  StagingObservation.partOf StagingReference
    return "First Bladder Cancer Staging Procedure during 6 Months Prior to Measurement Period through the First 6 Months of Measurement Period" FirstBladderCancerStagingMP
      where FirstBladderCancerStagingMP.id = StagingReference.reference.getId ( )
Logic Definition Library Name: QICoreCommon 
/*
@description: Normalizes a value that is a choice of timing-valued types to an equivalent interval
@comment: Normalizes a choice type of DateTime, Quanitty, Interval<DateTime>, or Interval<Quantity> types
to an equivalent interval. This selection of choice types is a superset of the majority of choice types that are used as possible
representations for timing-valued elements in QICore, allowing this function to be used across any resource.
The input can be provided as a DateTime, Quantity, Interval<DateTime> or Interval<Quantity>.
The intent of this function is to provide a clear and concise mechanism to treat single
elements that have multiple possible representations as intervals so that logic doesn't have to account
for the variability. More complex calculations (such as medication request period or dispense period
calculation) need specific guidance and consideration. That guidance may make use of this function, but
the focus of this function is on single element calculations where the semantics are unambiguous.
If the input is a DateTime, the result a DateTime Interval beginning and ending on that DateTime.
If the input is a Quantity, the quantity is expected to be a calendar-duration interpreted as an Age,
and the result is a DateTime Interval beginning on the Date the patient turned that age and ending immediately before one year later.
If the input is a DateTime Interval, the result is the input.
If the input is a Quantity Interval, the quantities are expected to be calendar-durations interpreted as an Age, and the result
is a DateTime Interval beginning on the date the patient turned the age given as the start of the quantity interval, and ending
immediately before one year later than the date the patient turned the age given as the end of the quantity interval.
If the input is a Timing, an error will be thrown indicating that Timing calculations are not implemented. Any other input will reslt in a null DateTime Interval
*/
define fluent function toInterval(choice Choice<DateTime, Quantity, Interval<DateTime>, Interval<Quantity>, Timing>):
  case
	  when choice is DateTime then
    	Interval[choice as DateTime, choice as DateTime]
		when choice is Interval<DateTime> then
  		choice as Interval<DateTime>
		when choice is Quantity then
		  Interval[Patient.birthDate + (choice as Quantity),
			  Patient.birthDate + (choice as Quantity) + 1 year)
		when choice is Interval<Quantity> then
		  Interval[Patient.birthDate + (choice.low as Quantity),
			  Patient.birthDate + (choice.high as Quantity) + 1 year)
		when choice is Timing then
      Message(null, true, 'NOT_IMPLEMENTED', 'Error', 'Calculation of an interval from a Timing value is not supported') as Interval<DateTime>
		else
			null as Interval<DateTime>
	end
Logic Definition Library Name: QICoreCommon 
/*
@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, '/'))
Logic Definition Library Name: FHIRHelpers 
define function ToString(value uri): value.value
Logic Definition Library Name: FHIRHelpers 
/*
@description: Converts the given [Period](https://hl7.org/fhir/datatypes.html#Period)
value to a CQL DateTime Interval
@comment: If the start value of the given period is unspecified, the starting
boundary of the resulting interval will be open (meaning the start of the interval
is unknown, as opposed to interpreted as the beginning of time).
*/
define function ToInterval(period FHIR.Period):
    if period is null then
        null
    else
        if period."start" is null then
            Interval(period."start".value, period."end".value]
        else
            Interval[period."start".value, period."end".value]
Logic Definition Library Name: FHIRHelpers 
/*
@description: Converts the given FHIR [Coding](https://hl7.org/fhir/datatypes.html#Coding) value to a CQL Code.
*/
define function ToCode(coding FHIR.Coding):
    if coding is null then
        null
    else
        System.Code {
          code: coding.code.value,
          system: coding.system.value,
          version: coding.version.value,
          display: coding.display.value
        }
Terminology
Code System Description: Code system SNOMEDCT
Resource: SNOMED CT (all versions)
Canonical URL: http://snomed.info/sct
Code System Description: Code system SNOMEDCT
Resource: SNOMED CT (all versions)
Canonical URL: http://snomed.info/sct
Code System Description: Code system ConditionVerificationStatusCodes
Resource: ConditionVerificationStatus
Canonical URL: http://terminology.hl7.org/CodeSystem/condition-ver-status
Code System Description: Code system ICD10CM
Resource: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)
Canonical URL: http://hl7.org/fhir/sid/icd-10-cm
Code System Description: Code system ActCode
Resource: ActCode
Canonical URL: http://terminology.hl7.org/CodeSystem/v3-ActCode
Value Set Description: Value set Bacillus Calmette Guerin for Urology Care
Resource: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1248.353
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1248.353
Value Set Description: Value set Bladder Cancer for Urology Care
Resource: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1248.354
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1248.354
Value Set Description: Value set Office Visit
Resource: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1001
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1001
Value Set Description: Value set Payer Type
Resource: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591
Value Set Description: Value set Tuberculosis for Urology Care
Resource: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1248.351
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1248.351
Value Set Description: Value set Immunosuppressive Drugs for Urology Care
Resource: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1248.364
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1248.364
Value Set Description: Value set Cystectomy for Urology Care
Resource: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1248.358
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1248.358
Value Set Description: Value set HIV
Resource: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.120.12.1003
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.120.12.1003
Value Set Description: Value set Immunocompromised Conditions
Resource: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1248.363
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1248.363
Value Set Description: Value set Mixed Histology Urothelial Cell Carcinoma for Urology Care
Resource: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1248.365
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1248.365
Value Set Description: Value set Chemotherapy Agents for Advanced Cancer
Resource: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1248.355
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1248.355
Direct Reference Code Display: Male (finding)
Code: 248153007
System: http://snomed.info/sct
Direct Reference Code Display: Female (finding)
Code: 248152002
System: http://snomed.info/sct
Direct Reference Code Display: Tumor staging (tumor staging)
Code: 254292007
System: http://snomed.info/sct
Direct Reference Code Display: Confirmed
Code: confirmed
System: http://terminology.hl7.org/CodeSystem/condition-ver-status
Direct Reference Code Display: American Joint Committee on Cancer cT1 (qualifier value)
Code: 1228889001
System: http://snomed.info/sct
Direct Reference Code Display: American Joint Committee on Cancer cTis (qualifier value)
Code: 1228884006
System: http://snomed.info/sct
Direct Reference Code Display: American Joint Committee on Cancer cTa (qualifier value)
Code: 1228883000
System: http://snomed.info/sct
Direct Reference Code Display: Carcinoma in situ of bladder
Code: D09.0
System: http://hl7.org/fhir/sid/icd-10-cm
Direct Reference Code Display: virtual
Code: VR
System: http://terminology.hl7.org/CodeSystem/v3-ActCode
Direct Reference Code Display: Combined radiotherapy (procedure)
Code: 169331000
System: http://snomed.info/sct
Dependencies
Dependency Description: Library SDE
Resource: Library/SupplementalDataElements|5.1.000
Canonical URL: Library/SupplementalDataElements|5.1.000
Dependency Description: Library FHIRHelpers
Resource: Library/FHIRHelpers|4.4.000
Canonical URL: Library/FHIRHelpers|4.4.000
Dependency Description: Library FHIRHelpers
Resource: Library/FHIRHelpers|4.4.000
Canonical URL: Library/FHIRHelpers|4.4.000
Dependency Description: Library QICoreCommon
Resource: Library/QICoreCommon|4.0.000
Canonical URL: Library/QICoreCommon|4.0.000
Data Requirements
Data Requirement Type: Condition
Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-condition-problems-health-concerns
Must Support Elements: code
Code Filter(s):
Path: code
ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1248.354
Data Requirement Type: Condition
Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-condition-encounter-diagnosis
Must Support Elements: code
Code Filter(s):
Path: code
ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1248.354
Data Requirement Type: Patient
Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-patient
Data Requirement Type: Procedure
Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-procedure
Must Support Elements: code, performed, status, status.value
Code Filter(s):
Path: code
Code(s): SNOMED CT 254292007: Tumor staging (tumor staging)
Data Requirement Type: MedicationAdministration
Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-medicationadministration
Must Support Elements: medication
Code Filter(s):
Path: medication
ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1248.353
Data Requirement Type: MedicationAdministration
Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-medicationadministration
Must Support Elements: medication.reference.value
Data Requirement Type: Observation
Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-observation-lab
Must Support Elements: value, status, status.value
Data Requirement Type: Encounter
Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-encounter
Must Support Elements: type, period, class, status, status.value
Code Filter(s):
Path: type
ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1001
Data Requirement Type: Condition
Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-condition-problems-health-concerns
Must Support Elements: code
Code Filter(s):
Path: code
ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1248.351
Data Requirement Type: Condition
Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-condition-encounter-diagnosis
Must Support Elements: code
Code Filter(s):
Path: code
ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1248.351
Data Requirement Type: MedicationRequest
Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-medicationrequest
Must Support Elements: medication
Code Filter(s):
Path: medication
ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1248.364
Data Requirement Type: Procedure
Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-procedure
Must Support Elements: code, performed, status, status.value
Code Filter(s):
Path: code
ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1248.358
Data Requirement Type: Condition
Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-condition-problems-health-concerns
Must Support Elements: code
Code Filter(s):
Path: code
ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.120.12.1003
Data Requirement Type: Condition
Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-condition-encounter-diagnosis
Must Support Elements: code
Code Filter(s):
Path: code
ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.120.12.1003
Data Requirement Type: Condition
Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-condition-problems-health-concerns
Must Support Elements: code
Code Filter(s):
Path: code
ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1248.363
Data Requirement Type: Condition
Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-condition-encounter-diagnosis
Must Support Elements: code
Code Filter(s):
Path: code
ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1248.363
Data Requirement Type: Condition
Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-condition-problems-health-concerns
Must Support Elements: code
Code Filter(s):
Path: code
ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1248.365
Data Requirement Type: Condition
Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-condition-encounter-diagnosis
Must Support Elements: code
Code Filter(s):
Path: code
ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1248.365
Data Requirement Type: MedicationRequest
Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-medicationrequest
Must Support Elements: medication
Code Filter(s):
Path: medication
ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1248.355
Data Requirement Type: MedicationRequest
Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-medicationrequest
Must Support Elements: medication.reference.value
Data Requirement Type: Medication
Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-medication
Must Support Elements: id.value, code
Data Requirement Type: Procedure
Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-procedure
Must Support Elements: code, performed, status, status.value
Code Filter(s):
Path: code
Code(s): SNOMED CT 169331000: Combined radiotherapy (procedure)
Data Requirement Type: Patient
Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-patient
Must Support Elements: url
Data Requirement Type: Coverage
Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-coverage
Must Support Elements: type, period
Code Filter(s):
Path: type
ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591
Data Requirement Type: Patient
Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-patient
Must Support Elements: url, extension
Generated using version 0.4.8 of the sample-content-ig Liquid templates

Source

{
  "resourceType": "Measure",
  "id": "CMS646FHIRIntravesicalBacillusCalmetteGuerinForBladderCancer",
  "meta": {
    "profile": [
      "http://hl7.org/fhir/uv/crmi/StructureDefinition/crmi-shareablemeasure",
      "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/computable-measure-cqfm",
      "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/publishable-measure-cqfm",
      "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/executable-measure-cqfm",
      "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cql-measure-cqfm",
      "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/elm-measure-cqfm",
      "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/proportion-measure-cqfm"
    ]
  },
  "text": {
    "status": "extensions",
    "div": "<!-- snip (see above) -->"
  },
  "contained": [
    {
      "resourceType": "Library",
      "id": "effective-data-requirements",
      "extension": [
        {
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-directReferenceCode",
          "valueCoding": {
            "system": "http://snomed.info/sct",
            "code": "248153007",
            "display": "Male (finding)"
          }
        },
        {
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-directReferenceCode",
          "valueCoding": {
            "system": "http://snomed.info/sct",
            "code": "248152002",
            "display": "Female (finding)"
          }
        },
        {
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-directReferenceCode",
          "valueCoding": {
            "system": "http://snomed.info/sct",
            "code": "254292007",
            "display": "Tumor staging (tumor staging)"
          }
        },
        {
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-directReferenceCode",
          "valueCoding": {
            "system": "http://terminology.hl7.org/CodeSystem/condition-ver-status",
            "code": "confirmed",
            "display": "Confirmed"
          }
        },
        {
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-directReferenceCode",
          "valueCoding": {
            "system": "http://snomed.info/sct",
            "code": "1228889001",
            "display": "American Joint Committee on Cancer cT1 (qualifier value)"
          }
        },
        {
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-directReferenceCode",
          "valueCoding": {
            "system": "http://snomed.info/sct",
            "code": "1228884006",
            "display": "American Joint Committee on Cancer cTis (qualifier value)"
          }
        },
        {
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-directReferenceCode",
          "valueCoding": {
            "system": "http://snomed.info/sct",
            "code": "1228883000",
            "display": "American Joint Committee on Cancer cTa (qualifier value)"
          }
        },
        {
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-directReferenceCode",
          "valueCoding": {
            "system": "http://hl7.org/fhir/sid/icd-10-cm",
            "code": "D09.0",
            "display": "Carcinoma in situ of bladder"
          }
        },
        {
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-directReferenceCode",
          "valueCoding": {
            "system": "http://terminology.hl7.org/CodeSystem/v3-ActCode",
            "code": "VR",
            "display": "virtual"
          }
        },
        {
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-directReferenceCode",
          "valueCoding": {
            "system": "http://snomed.info/sct",
            "code": "169331000",
            "display": "Combined radiotherapy (procedure)"
          }
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "SupplementalDataElements"
            },
            {
              "url": "name",
              "valueString": "SDE Sex"
            },
            {
              "url": "statement",
              "valueString": "define \"SDE Sex\":\n  case\n    when Patient.sex = '248153007' then \"Male (finding)\"\n    when Patient.sex = '248152002' then \"Female (finding)\"\n    else null\n  end"
            },
            {
              "url": "displaySequence",
              "valueInteger": 0
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS646FHIRIntravesicalBacillusCalmetteGuerinForBladderCancer"
            },
            {
              "url": "name",
              "valueString": "SDE Sex"
            },
            {
              "url": "statement",
              "valueString": "define \"SDE Sex\":\n  SDE.\"SDE Sex\""
            },
            {
              "url": "displaySequence",
              "valueInteger": 1
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS646FHIRIntravesicalBacillusCalmetteGuerinForBladderCancer"
            },
            {
              "url": "name",
              "valueString": "Bladder Cancer Diagnosis"
            },
            {
              "url": "statement",
              "valueString": "define \"Bladder Cancer Diagnosis\":\n  ( [ConditionProblemsHealthConcerns: \"Bladder Cancer for Urology Care\"]\n    union [ConditionEncounterDiagnosis: \"Bladder Cancer for Urology Care\"] ) BladderCancer\n    where BladderCancer.prevalenceInterval ( ) starts before day of end of \"Measurement Period\"\n      and BladderCancer.isConfirmedActiveDiagnosis ( )"
            },
            {
              "url": "displaySequence",
              "valueInteger": 2
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS646FHIRIntravesicalBacillusCalmetteGuerinForBladderCancer"
            },
            {
              "url": "name",
              "valueString": "First Bladder Cancer Staging Procedure"
            },
            {
              "url": "statement",
              "valueString": "define \"First Bladder Cancer Staging Procedure\":\n  First([Procedure: \"Tumor staging (tumor staging)\"] BladderCancerStaging\n      with \"Bladder Cancer Diagnosis\" BladderCancer\n        such that BladderCancerStaging.performed.toInterval() starts on or before day of start of BladderCancer.prevalenceInterval()\n      where BladderCancerStaging.status = 'completed'\n      sort by start of performed.toInterval()\n  )"
            },
            {
              "url": "displaySequence",
              "valueInteger": 3
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS646FHIRIntravesicalBacillusCalmetteGuerinForBladderCancer"
            },
            {
              "url": "name",
              "valueString": "First BCG Administered"
            },
            {
              "url": "statement",
              "valueString": "define \"First BCG Administered\":\n  First([MedicationAdministration: \"Bacillus Calmette Guerin for Urology Care\"] BCG\n      with \"First Bladder Cancer Staging Procedure\" FirstBladderCancerStaging\n        such that BCG.effective.toInterval() starts 6 months or less after day of start of FirstBladderCancerStaging.performed.toInterval()\n          and BCG.effective.toInterval() starts during \"Measurement Period\"\n      where BCG.status in { 'in-progress', 'completed' }\n      sort by start of effective.toInterval()\n  )"
            },
            {
              "url": "displaySequence",
              "valueInteger": 4
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS646FHIRIntravesicalBacillusCalmetteGuerinForBladderCancer"
            },
            {
              "url": "name",
              "valueString": "Numerator"
            },
            {
              "url": "statement",
              "valueString": "define \"Numerator\":\n  \"First BCG Administered\" is not null"
            },
            {
              "url": "displaySequence",
              "valueInteger": 5
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS646FHIRIntravesicalBacillusCalmetteGuerinForBladderCancer"
            },
            {
              "url": "name",
              "valueString": "Denominator Exception"
            },
            {
              "url": "statement",
              "valueString": "/*\n@commentedOut: exists \"BCG Not Available Within 6 Months After Bladder Cancer Staging\"\n@commentedOutReason: Negation issue related to https://github.com/cqframework/cql-execution/issues/296, which is tied to https://oncprojectracking.healthit.gov/support/browse/BONNIEMAT-1455. Due to this being the only logic in this population added 'false' as a placeholder.\n*/\n\n\ndefine \"Denominator Exception\":\n  false"
            },
            {
              "url": "displaySequence",
              "valueInteger": 6
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS646FHIRIntravesicalBacillusCalmetteGuerinForBladderCancer"
            },
            {
              "url": "name",
              "valueString": "July 1 of Year Prior to the Measurement Period"
            },
            {
              "url": "statement",
              "valueString": "define \"July 1 of Year Prior to the Measurement Period\":\n  DateTime((year from start of \"Measurement Period\" - 1), 7, 1, 0, 0, 0, 0, 0)"
            },
            {
              "url": "displaySequence",
              "valueInteger": 7
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS646FHIRIntravesicalBacillusCalmetteGuerinForBladderCancer"
            },
            {
              "url": "name",
              "valueString": "June 30 of the Measurement Period"
            },
            {
              "url": "statement",
              "valueString": "define \"June 30 of the Measurement Period\":\n  DateTime((year from start of \"Measurement Period\"), 6, 30, 23, 59, 59, 0, 0)"
            },
            {
              "url": "displaySequence",
              "valueInteger": 8
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS646FHIRIntravesicalBacillusCalmetteGuerinForBladderCancer"
            },
            {
              "url": "name",
              "valueString": "First Bladder Cancer Staging Procedure during 6 Months Prior to Measurement Period through the First 6 Months of Measurement Period"
            },
            {
              "url": "statement",
              "valueString": "define \"First Bladder Cancer Staging Procedure during 6 Months Prior to Measurement Period through the First 6 Months of Measurement Period\":\n  \"First Bladder Cancer Staging Procedure\" FirstBladderCancerStaging\n    where FirstBladderCancerStaging.performed.toInterval ( ) during day of Interval[\"July 1 of Year Prior to the Measurement Period\", \"June 30 of the Measurement Period\"]"
            },
            {
              "url": "displaySequence",
              "valueInteger": 9
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS646FHIRIntravesicalBacillusCalmetteGuerinForBladderCancer"
            },
            {
              "url": "name",
              "valueString": "Has Most Recent Bladder Cancer Tumor Staging is T1, Tis, Ta HG"
            },
            {
              "url": "statement",
              "valueString": "/*Ta High Grade only to be included.  Ta low grade is to be excluded from this measure.*/\n\n\ndefine \"Has Most Recent Bladder Cancer Tumor Staging is T1, Tis, Ta HG\":\n  exists ( [LaboratoryResultObservation] StagingObservation\n      where StagingObservation.getStagingProcedure ( ) is not null\n        and ( StagingObservation.value as Concept ~ \"American Joint Committee on Cancer cT1 (qualifier value)\"\n            or StagingObservation.value as Concept ~ \"American Joint Committee on Cancer cTis (qualifier value)\"\n            or StagingObservation.value as Concept ~ \"American Joint Committee on Cancer cTa (qualifier value)\"\n            or StagingObservation.value as Concept ~ \"Carcinoma in situ of bladder\"\n        )\n        and StagingObservation.status in { 'final', 'amended', 'corrected' }\n  )"
            },
            {
              "url": "displaySequence",
              "valueInteger": 10
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS646FHIRIntravesicalBacillusCalmetteGuerinForBladderCancer"
            },
            {
              "url": "name",
              "valueString": "Has Qualifying Encounter"
            },
            {
              "url": "statement",
              "valueString": "define \"Has Qualifying Encounter\":\n  exists ( [Encounter: \"Office Visit\"] ValidEncounter\n      where ValidEncounter.period during \"Measurement Period\"\n        and ValidEncounter.class !~ \"virtual\"\n        and ValidEncounter.status = 'finished'\n  )"
            },
            {
              "url": "displaySequence",
              "valueInteger": 11
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS646FHIRIntravesicalBacillusCalmetteGuerinForBladderCancer"
            },
            {
              "url": "name",
              "valueString": "Initial Population"
            },
            {
              "url": "statement",
              "valueString": "define \"Initial Population\":\n  \"Has Most Recent Bladder Cancer Tumor Staging is T1, Tis, Ta HG\"\n    and \"Has Qualifying Encounter\""
            },
            {
              "url": "displaySequence",
              "valueInteger": 12
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS646FHIRIntravesicalBacillusCalmetteGuerinForBladderCancer"
            },
            {
              "url": "name",
              "valueString": "Denominator"
            },
            {
              "url": "statement",
              "valueString": "define \"Denominator\":\n  \"Initial Population\""
            },
            {
              "url": "displaySequence",
              "valueInteger": 13
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "SupplementalDataElements"
            },
            {
              "url": "name",
              "valueString": "SDE Payer"
            },
            {
              "url": "statement",
              "valueString": "define \"SDE Payer\":\n  [Coverage: type in \"Payer Type\"] Payer\n    return {\n      code: Payer.type,\n      period: Payer.period\n    }"
            },
            {
              "url": "displaySequence",
              "valueInteger": 14
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS646FHIRIntravesicalBacillusCalmetteGuerinForBladderCancer"
            },
            {
              "url": "name",
              "valueString": "SDE Payer"
            },
            {
              "url": "statement",
              "valueString": "define \"SDE Payer\":\n  SDE.\"SDE Payer\""
            },
            {
              "url": "displaySequence",
              "valueInteger": 15
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS646FHIRIntravesicalBacillusCalmetteGuerinForBladderCancer"
            },
            {
              "url": "name",
              "valueString": "Initial Population"
            },
            {
              "url": "statement",
              "valueString": "define \"Initial Population\":\n  \"Has Most Recent Bladder Cancer Tumor Staging is T1, Tis, Ta HG\"\n    and \"Has Qualifying Encounter\""
            },
            {
              "url": "displaySequence",
              "valueInteger": 16
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "SupplementalDataElements"
            },
            {
              "url": "name",
              "valueString": "SDE Ethnicity"
            },
            {
              "url": "statement",
              "valueString": "define \"SDE Ethnicity\":\n  Patient.ethnicity E\n    return Tuple {\n      codes: { E.ombCategory } union E.detailed,\n      display: E.text\n    }"
            },
            {
              "url": "displaySequence",
              "valueInteger": 17
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS646FHIRIntravesicalBacillusCalmetteGuerinForBladderCancer"
            },
            {
              "url": "name",
              "valueString": "SDE Ethnicity"
            },
            {
              "url": "statement",
              "valueString": "define \"SDE Ethnicity\":\n  SDE.\"SDE Ethnicity\""
            },
            {
              "url": "displaySequence",
              "valueInteger": 18
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS646FHIRIntravesicalBacillusCalmetteGuerinForBladderCancer"
            },
            {
              "url": "name",
              "valueString": "Acute Tuberculosis Diagnosis"
            },
            {
              "url": "statement",
              "valueString": "define \"Acute Tuberculosis Diagnosis\":\n  ( [ConditionProblemsHealthConcerns: \"Tuberculosis for Urology Care\"]\n    union [ConditionEncounterDiagnosis: \"Tuberculosis for Urology Care\"] ) ActiveTuberculosis\n    with \"First Bladder Cancer Staging Procedure\" FirstBladderCancerStaging\n      such that ActiveTuberculosis.prevalenceInterval ( ) overlaps after day of FirstBladderCancerStaging.performed.toInterval ( )\n    where ActiveTuberculosis.isConfirmedActiveDiagnosis ( )"
            },
            {
              "url": "displaySequence",
              "valueInteger": 19
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS646FHIRIntravesicalBacillusCalmetteGuerinForBladderCancer"
            },
            {
              "url": "name",
              "valueString": "Immunosuppressive Drugs"
            },
            {
              "url": "statement",
              "valueString": "define \"Immunosuppressive Drugs\":\n  [MedicationRequest: \"Immunosuppressive Drugs for Urology Care\"] ImmunosuppressiveDrugs\n    let firstMedicationPeriod: First((collapse(ImmunosuppressiveDrugs.dosageInstruction.timing.repeat.bounds DoseTime\n          return DoseTime.toInterval()\n      )) DrugPeriods\n        sort by start of $this\n    ),\n    //get the very first event\n    \n    firstMedicationEvent: First((ImmunosuppressiveDrugs.dosageInstruction.timing dosageTiming\n        //return first event for the specific dosageTiming\n        \n        return First(dosageTiming.event dosageTimingEvents\n            sort ascending\n        )) firstEvents\n        sort ascending\n    ),\n    medicationPeriod: Coalesce(firstMedicationEvent.toInterval(), firstMedicationPeriod)\n    with \"First Bladder Cancer Staging Procedure\" FirstBladderCancerStaging\n      such that medicationPeriod starts on or before day of start of FirstBladderCancerStaging.performed.toInterval ( )\n    where ImmunosuppressiveDrugs.status in { 'active', 'completed' }\n      and ImmunosuppressiveDrugs.intent = 'order'"
            },
            {
              "url": "displaySequence",
              "valueInteger": 20
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS646FHIRIntravesicalBacillusCalmetteGuerinForBladderCancer"
            },
            {
              "url": "name",
              "valueString": "Cystectomy Done"
            },
            {
              "url": "statement",
              "valueString": "define \"Cystectomy Done\":\n  [Procedure: \"Cystectomy for Urology Care\"] Cystectomy\n    with \"First Bladder Cancer Staging Procedure\" FirstBladderCancerStaging\n      such that Cystectomy.performed.toInterval ( ) 6 months or less before day of start of FirstBladderCancerStaging.performed.toInterval ( )\n    where Cystectomy.status = 'completed'"
            },
            {
              "url": "displaySequence",
              "valueInteger": 21
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS646FHIRIntravesicalBacillusCalmetteGuerinForBladderCancer"
            },
            {
              "url": "name",
              "valueString": "Has Excluding HIV, Immunocompromised Conditions or Mixed Histology Before Staging"
            },
            {
              "url": "statement",
              "valueString": "define \"Has Excluding HIV, Immunocompromised Conditions or Mixed Histology Before Staging\":\n  exists ( ( ( [ConditionProblemsHealthConcerns: \"HIV\"]\n        union [ConditionEncounterDiagnosis: \"HIV\"]\n    )\n      union ( [ConditionProblemsHealthConcerns: \"Immunocompromised Conditions\"]\n          union [ConditionEncounterDiagnosis: \"Immunocompromised Conditions\"]\n      )\n      union ( [ConditionProblemsHealthConcerns: \"Mixed Histology Urothelial Cell Carcinoma for Urology Care\"]\n          union [ConditionEncounterDiagnosis: \"Mixed Histology Urothelial Cell Carcinoma for Urology Care\"]\n      ) ) ExclusionDiagnosis\n      with \"First Bladder Cancer Staging Procedure\" FirstBladderCancerStaging\n        such that ExclusionDiagnosis.prevalenceInterval ( ) starts on or before day of start of FirstBladderCancerStaging.performed.toInterval ( )\n      where ExclusionDiagnosis.isConfirmedActiveDiagnosis ( )\n  )"
            },
            {
              "url": "displaySequence",
              "valueInteger": 22
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS646FHIRIntravesicalBacillusCalmetteGuerinForBladderCancer"
            },
            {
              "url": "name",
              "valueString": "Has Excluding Chemotherapy or Radiotherapy Procedure Before Staging"
            },
            {
              "url": "statement",
              "valueString": "define \"Has Excluding Chemotherapy or Radiotherapy Procedure Before Staging\":\n  exists ( ( [MedicationRequest: \"Chemotherapy Agents for Advanced Cancer\"] ExclusionMed\n        let firstMedicationPeriod: First((collapse(ExclusionMed.dosageInstruction.timing.repeat.bounds DoseTime\n              return DoseTime.toInterval()\n          )) DrugPeriods\n            sort by start of $this\n        )\n        with \"First Bladder Cancer Staging Procedure\" FirstBladderCancerStaging\n          such that firstMedicationPeriod starts 6 months or less before FirstBladderCancerStaging.performed.toInterval ( )\n        where ExclusionMed.status in { 'active', 'completed' }\n          and ExclusionMed.intent = 'order'\n    )\n      union ( [Procedure: \"Combined radiotherapy (procedure)\"] ExclusionProcedure\n          with \"First Bladder Cancer Staging Procedure\" FirstBladderCancerStaging\n            such that ExclusionProcedure.performed.toInterval ( ) starts 6 months or less before FirstBladderCancerStaging.performed.toInterval ( )\n          where ExclusionProcedure.status = 'completed'\n      )\n  )"
            },
            {
              "url": "displaySequence",
              "valueInteger": 23
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS646FHIRIntravesicalBacillusCalmetteGuerinForBladderCancer"
            },
            {
              "url": "name",
              "valueString": "Denominator Exclusion"
            },
            {
              "url": "statement",
              "valueString": "define \"Denominator Exclusion\":\n  exists \"Acute Tuberculosis Diagnosis\"\n    or exists \"Immunosuppressive Drugs\"\n    or exists \"Cystectomy Done\"\n    or \"Has Excluding HIV, Immunocompromised Conditions or Mixed Histology Before Staging\"\n    or \"Has Excluding Chemotherapy or Radiotherapy Procedure Before Staging\""
            },
            {
              "url": "displaySequence",
              "valueInteger": 24
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "SupplementalDataElements"
            },
            {
              "url": "name",
              "valueString": "SDE Race"
            },
            {
              "url": "statement",
              "valueString": "define \"SDE Race\":\n  Patient.race R\n    return Tuple {\n      codes: R.ombCategory union R.detailed,\n      display: R.text\n    }"
            },
            {
              "url": "displaySequence",
              "valueInteger": 25
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS646FHIRIntravesicalBacillusCalmetteGuerinForBladderCancer"
            },
            {
              "url": "name",
              "valueString": "SDE Race"
            },
            {
              "url": "statement",
              "valueString": "define \"SDE Race\":\n  SDE.\"SDE Race\""
            },
            {
              "url": "displaySequence",
              "valueInteger": 26
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "FHIRHelpers"
            },
            {
              "url": "name",
              "valueString": "ToString"
            },
            {
              "url": "statement",
              "valueString": "define function ToString(value uri): value.value"
            },
            {
              "url": "displaySequence",
              "valueInteger": 27
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS646FHIRIntravesicalBacillusCalmetteGuerinForBladderCancer"
            },
            {
              "url": "name",
              "valueString": "isConfirmedActiveDiagnosis"
            },
            {
              "url": "statement",
              "valueString": "define fluent function isConfirmedActiveDiagnosis(Condition Choice<ConditionProblemsHealthConcerns, ConditionEncounterDiagnosis>):\n  Condition.isActive ( )\n    and Condition.verificationStatus ~ QICoreCommon.\"confirmed\""
            },
            {
              "url": "displaySequence",
              "valueInteger": 28
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "QICoreCommon"
            },
            {
              "url": "name",
              "valueString": "toInterval"
            },
            {
              "url": "statement",
              "valueString": "/*\n@description: Normalizes a value that is a choice of timing-valued types to an equivalent interval\n@comment: Normalizes a choice type of DateTime, Quanitty, Interval<DateTime>, or Interval<Quantity> types\nto an equivalent interval. This selection of choice types is a superset of the majority of choice types that are used as possible\nrepresentations for timing-valued elements in QICore, allowing this function to be used across any resource.\nThe input can be provided as a DateTime, Quantity, Interval<DateTime> or Interval<Quantity>.\nThe intent of this function is to provide a clear and concise mechanism to treat single\nelements that have multiple possible representations as intervals so that logic doesn't have to account\nfor the variability. More complex calculations (such as medication request period or dispense period\ncalculation) need specific guidance and consideration. That guidance may make use of this function, but\nthe focus of this function is on single element calculations where the semantics are unambiguous.\nIf the input is a DateTime, the result a DateTime Interval beginning and ending on that DateTime.\nIf the input is a Quantity, the quantity is expected to be a calendar-duration interpreted as an Age,\nand the result is a DateTime Interval beginning on the Date the patient turned that age and ending immediately before one year later.\nIf the input is a DateTime Interval, the result is the input.\nIf the input is a Quantity Interval, the quantities are expected to be calendar-durations interpreted as an Age, and the result\nis a DateTime Interval beginning on the date the patient turned the age given as the start of the quantity interval, and ending\nimmediately before one year later than the date the patient turned the age given as the end of the quantity interval.\nIf the input is a Timing, an error will be thrown indicating that Timing calculations are not implemented. Any other input will reslt in a null DateTime Interval\n*/\ndefine fluent function toInterval(choice Choice<DateTime, Quantity, Interval<DateTime>, Interval<Quantity>, Timing>):\n  case\n\t  when choice is DateTime then\n    \tInterval[choice as DateTime, choice as DateTime]\n\t\twhen choice is Interval<DateTime> then\n  \t\tchoice as Interval<DateTime>\n\t\twhen choice is Quantity then\n\t\t  Interval[Patient.birthDate + (choice as Quantity),\n\t\t\t  Patient.birthDate + (choice as Quantity) + 1 year)\n\t\twhen choice is Interval<Quantity> then\n\t\t  Interval[Patient.birthDate + (choice.low as Quantity),\n\t\t\t  Patient.birthDate + (choice.high as Quantity) + 1 year)\n\t\twhen choice is Timing then\n      Message(null, true, 'NOT_IMPLEMENTED', 'Error', 'Calculation of an interval from a Timing value is not supported') as Interval<DateTime>\n\t\telse\n\t\t\tnull as Interval<DateTime>\n\tend"
            },
            {
              "url": "displaySequence",
              "valueInteger": 29
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS646FHIRIntravesicalBacillusCalmetteGuerinForBladderCancer"
            },
            {
              "url": "name",
              "valueString": "getStagingProcedure"
            },
            {
              "url": "statement",
              "valueString": "define fluent function getStagingProcedure(StagingObservation LaboratoryResultObservation):\n  StagingObservation.partOf StagingReference\n    return \"First Bladder Cancer Staging Procedure during 6 Months Prior to Measurement Period through the First 6 Months of Measurement Period\" FirstBladderCancerStagingMP\n      where FirstBladderCancerStagingMP.id = StagingReference.reference.getId ( )"
            },
            {
              "url": "displaySequence",
              "valueInteger": 30
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "QICoreCommon"
            },
            {
              "url": "name",
              "valueString": "getId"
            },
            {
              "url": "statement",
              "valueString": "/*\n@description: Returns the tail of the given uri (i.e. everything after the last slash in the URI).\n@comment: This function can be used to determine the logical id of a given resource. It can be used in\na single-server environment to trace references. However, this function does not attempt to resolve\nor distinguish the base of the given url, and so cannot be used safely in multi-server environments.\n*/\ndefine fluent function getId(uri String):\n  Last(Split(uri, '/'))"
            },
            {
              "url": "displaySequence",
              "valueInteger": 31
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "FHIRHelpers"
            },
            {
              "url": "name",
              "valueString": "ToInterval"
            },
            {
              "url": "statement",
              "valueString": "/*\n@description: Converts the given [Period](https://hl7.org/fhir/datatypes.html#Period)\nvalue to a CQL DateTime Interval\n@comment: If the start value of the given period is unspecified, the starting\nboundary of the resulting interval will be open (meaning the start of the interval\nis unknown, as opposed to interpreted as the beginning of time).\n*/\ndefine function ToInterval(period FHIR.Period):\n    if period is null then\n        null\n    else\n        if period.\"start\" is null then\n            Interval(period.\"start\".value, period.\"end\".value]\n        else\n            Interval[period.\"start\".value, period.\"end\".value]"
            },
            {
              "url": "displaySequence",
              "valueInteger": 32
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "FHIRHelpers"
            },
            {
              "url": "name",
              "valueString": "ToCode"
            },
            {
              "url": "statement",
              "valueString": "/*\n@description: Converts the given FHIR [Coding](https://hl7.org/fhir/datatypes.html#Coding) value to a CQL Code.\n*/\ndefine function ToCode(coding FHIR.Coding):\n    if coding is null then\n        null\n    else\n        System.Code {\n          code: coding.code.value,\n          system: coding.system.value,\n          version: coding.version.value,\n          display: coding.display.value\n        }"
            },
            {
              "url": "displaySequence",
              "valueInteger": 33
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        }
      ],
      "name": "EffectiveDataRequirements",
      "status": "active",
      "type": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/library-type",
            "code": "module-definition"
          }
        ]
      },
      "relatedArtifact": [
        {
          "type": "depends-on",
          "display": "Library SDE",
          "resource": "Library/SupplementalDataElements|5.1.000"
        },
        {
          "type": "depends-on",
          "display": "Library FHIRHelpers",
          "resource": "Library/FHIRHelpers|4.4.000"
        },
        {
          "type": "depends-on",
          "display": "Library FHIRHelpers",
          "resource": "Library/FHIRHelpers|4.4.000"
        },
        {
          "type": "depends-on",
          "display": "Library QICoreCommon",
          "resource": "Library/QICoreCommon|4.0.000"
        },
        {
          "type": "depends-on",
          "display": "Code system SNOMEDCT",
          "resource": "http://snomed.info/sct"
        },
        {
          "type": "depends-on",
          "display": "Code system SNOMEDCT",
          "resource": "http://snomed.info/sct"
        },
        {
          "type": "depends-on",
          "display": "Code system ConditionVerificationStatusCodes",
          "resource": "http://terminology.hl7.org/CodeSystem/condition-ver-status"
        },
        {
          "type": "depends-on",
          "display": "Code system ICD10CM",
          "resource": "http://hl7.org/fhir/sid/icd-10-cm"
        },
        {
          "type": "depends-on",
          "display": "Code system ActCode",
          "resource": "http://terminology.hl7.org/CodeSystem/v3-ActCode"
        },
        {
          "type": "depends-on",
          "display": "Value set Bacillus Calmette Guerin for Urology Care",
          "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1248.353"
        },
        {
          "type": "depends-on",
          "display": "Value set Bladder Cancer for Urology Care",
          "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1248.354"
        },
        {
          "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 Payer Type",
          "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591"
        },
        {
          "type": "depends-on",
          "display": "Value set Tuberculosis for Urology Care",
          "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1248.351"
        },
        {
          "type": "depends-on",
          "display": "Value set Immunosuppressive Drugs for Urology Care",
          "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1248.364"
        },
        {
          "type": "depends-on",
          "display": "Value set Cystectomy for Urology Care",
          "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1248.358"
        },
        {
          "type": "depends-on",
          "display": "Value set HIV",
          "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.120.12.1003"
        },
        {
          "type": "depends-on",
          "display": "Value set Immunocompromised Conditions",
          "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1248.363"
        },
        {
          "type": "depends-on",
          "display": "Value set Mixed Histology Urothelial Cell Carcinoma for Urology Care",
          "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1248.365"
        },
        {
          "type": "depends-on",
          "display": "Value set Chemotherapy Agents for Advanced Cancer",
          "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1248.355"
        }
      ],
      "parameter": [
        {
          "name": "Measurement Period",
          "use": "in",
          "min": 0,
          "max": "1",
          "type": "Period"
        },
        {
          "name": "SDE Sex",
          "use": "out",
          "min": 0,
          "max": "1",
          "type": "Coding"
        },
        {
          "name": "Numerator",
          "use": "out",
          "min": 0,
          "max": "1",
          "type": "boolean"
        },
        {
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      "id": "supplementalDataGuidance",
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          "url": "guidance",
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      "valueCanonical": "#effective-data-requirements"
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      "valueReference": {
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  ],
  "url": "https://madie.cms.gov/Measure/CMS646FHIRIntravesicalBacillusCalmetteGuerinForBladderCancer",
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      "system": "https://madie.cms.gov/measure/shortName",
      "value": "CMS646FHIR"
    },
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            "display": "Publisher"
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      "system": "https://madie.cms.gov/measure/cmsId",
      "value": "646FHIR",
      "assigner": {
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      }
    }
  ],
  "version": "1.5.000",
  "name": "CMS646FHIRIntravesicalBacillusCalmetteGuerinForBladderCancer",
  "title": "Intravesical Bacillus-Calmette-Guerin for Non-Muscle Invasive Bladder CancerFHIR",
  "status": "active",
  "experimental": false,
  "date": "2025-07-15T13:37:39+00:00",
  "publisher": "Oregon Urology",
  "contact": [
    {
      "telecom": [
        {
          "system": "url",
          "value": "www.oregonurology.com"
        }
      ]
    }
  ],
  "description": "Percentage of patients initially diagnosed with non-muscle invasive bladder cancer and who received intravesical Bacillus-Calmette-Guerin (BCG) within 6 months of bladder cancer staging",
  "usage": "Ta bladder cancer must be high grade Ta only and is supported by the 2016 AUA guidelines and 2018 NCCN guidelines.\n\nThe BCG dose can be full or partial and can be from any lot or manufacturer.\n\nThis eCQM is a patient-based measure.\n\nTelehealth encounters are not eligible for this measure because the measure requires a clinical action that cannot be conducted via telehealth\n\nThis FHIR-based measure has been derived from the QDM-based measure: CMS646v5.\n \nPlease 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 6.0.0 (https://hl7.org/fhir/us/qicore/STU6/qdm-to-qicore.html).",
  "copyright": "Limited proprietary coding is contained in the measure specifications for convenience. Users of the proprietary code sets should obtain all necessary licenses from the owners of these code sets. Oregon Urology Institute (OUI) and Large Urology Group Practice Association (LUGPA) disclaim all liability for the use or accuracy of third party codes contained in the specifications.\n\nCPT(R) contained in the Measure specifications is copyright 2004-2024. American Medical Association. LOINC(R) copyright 2004-2024 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2024 International Health Terminology Standards Development Organisation. ICD-10 copyright 2024 World Health Organization. All Rights Reserved.",
  "effectivePeriod": {
    "start": "2026-01-01",
    "end": "2026-12-31"
  },
  "author": [
    {
      "name": "Oregon Urology",
      "telecom": [
        {
          "system": "url",
          "value": "www.oregonurology.com"
        }
      ]
    }
  ],
  "library": [
    "https://madie.cms.gov/Library/CMS646FHIRIntravesicalBacillusCalmetteGuerinForBladderCancer"
  ],
  "disclaimer": "The performance measure is not a clinical guideline and does not establish a standard of medical care, and has not been tested for all potential applications.\n\nTHE MEASURES AND SPECIFICATIONS ARE PROVIDED \"AS IS\" WITHOUT WARRANTY OF ANY KIND.\n\nDue to technical limitations, registered trademarks are indicated by (R) or [R] and unregistered trademarks are indicated by TM or [TM].",
  "rationale": "Bladder cancer is ranked 10th for new cancer cases in 2020 and is the ninth leading cause of cancer death in the United States. There are 81,400 estimated new cases in 2020 and 17,980 estimated deaths in 2020. In 2016, there were an estimated 699,450 people were living with bladder cancer in the United States. Early detection (discovery of cancer in situ or localized to the primary site) is found in 85% of the patients, and with these there is a five-year survival rate of 95.8% for In Situ and 69.2% for Localized. Bladder cancer is rarely found in patients under age 20, with the median age of diagnosis being 73 (NIH, 2020).\nNational Comprehensive Cancer Network (NCCN) Guidelines for Bladder Cancer (version 6.2021) defines intravesical BCG as Category 1 Treatment for T1, Tis and Ta - high grade, non-muscle invasive bladder cancer. Most public data reflects prophylactic or adjuvant use of intravesical therapy to prevent recurrence or delaying progression to a higher grade or stage. BCG has been shown to be effective as prophylaxis to prevent bladder cancer recurrences following TURBT. The NCCN Bladder Cancer Panel Members recommend BCG as the preferred option over Mitomycin C for adjuvant treatment of high-grade lesions (Ta). BCG is also standard therapy for Primary Tis. Most T1 lesions are high-risk and are similarly treated with adjuvant intravesical therapy, with BCG being a Category 1 recommendation. (NCCN, 2021).",
  "clinicalRecommendationStatement": "Intravesical BCG should be administered within 6 months of the initial diagnosis of non-muscle invasive bladder cancer. It may be administered 3-4 weeks after resection, but there needs to be pathological tumor confirmation and must be withheld if there is traumatic catheterization, bacteriuria, persistent gross hematuria, persistent severe local symptoms or systemic symptoms. The normal induction course is 6 weekly instillations of intravesical BCG (AUA Non-Muscle Invasive Bladder Cancer and American Urological Association (AUA) Guideline for the Management of Non-muscle Invasive Bladder Cancer: Stages T1, TIS, and Ta High Risk).",
  "definition": [
    "Bacillus Calmette-Guerin (BCG)  - A live attenuated strain of Mycobacterium bovis, first indicated as a tuberculosis vaccine, has had widespread use in intravesical immunotherapy since the 1970's.\n",
    "Histology - urothelial carcinoma\n",
    "Intravescial - Within the urinary bladder\n",
    "Primary Tumor (T) stage - T1 - The tumor invades subepithelial connective tissue (high grade or low grade)\n",
    "Primary Tumor (T) stage - Ta - Noninvasive and high grade\n",
    "Primary Tumor (T) stage - Tis - Carcinoma in situ: \"flat tumor\"\n",
    "Tumor location - urinary bladder\n"
  ],
  "guidance": "Ta bladder cancer must be high grade Ta only and is supported by the 2016 AUA guidelines and 2018 NCCN guidelines.\n\nThe BCG dose can be full or partial and can be from any lot or manufacturer.\n\nThis eCQM is a patient-based measure.\n\nTelehealth encounters are not eligible for this measure because the measure requires a clinical action that cannot be conducted via telehealth\n\nThis FHIR-based measure has been derived from the QDM-based measure: CMS646v5.\n \nPlease 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 6.0.0 (https://hl7.org/fhir/us/qicore/STU6/qdm-to-qicore.html).",
  "group": [
    {
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                "code": "proportion",
                "display": "Proportion"
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          }
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        {
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-populationBasis",
          "valueCode": "boolean"
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          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-rateAggregation",
          "valueCode": "None"
        },
        {
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-improvementNotation",
          "valueCodeableConcept": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/measure-improvement-notation",
                "code": "increase",
                "display": "Increased score indicates improvement"
              }
            ]
          }
        }
      ],
      "population": [
        {
          "id": "InitialPopulation_1",
          "code": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/measure-population",
                "code": "initial-population",
                "display": "Initial Population"
              }
            ]
          },
          "description": "All patients initially diagnosed with T1, Tis or high grade Ta non-muscle invasive bladder cancer with bladder cancer staging within 6 months before to 6 months after the start of the measurement period and a qualified encounter in the measurement period",
          "criteria": {
            "language": "text/cql-identifier",
            "expression": "Initial Population"
          }
        },
        {
          "id": "Denominator_1",
          "code": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/measure-population",
                "code": "denominator",
                "display": "Denominator"
              }
            ]
          },
          "description": "Equals Initial Population",
          "criteria": {
            "language": "text/cql-identifier",
            "expression": "Denominator"
          }
        },
        {
          "id": "DenominatorExclusion_1",
          "code": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/measure-population",
                "code": "denominator-exclusion",
                "display": "Denominator Exclusion"
              }
            ]
          },
          "description": "Immunosuppressed patients, includes HIV and immunocompromised state, with a diagnosis prior to Bladder Cancer Staging.\n\nImmunosuppressive drug therapy starting on or before Bladder Cancer Staging.\n\nActive Tuberculosis diagnosis during the Bladder Cancer Staging.\n\nMixed histology urothelial cell carcinoma including micropapillary, plasmacytoid, sarcomatoid, adenocarcinoma and squamous disease prior to Bladder Cancer Staging.\n\nPatients who undergo cystectomy, chemotherapy or radiation within 6 months prior to Bladder Cancer Staging.",
          "criteria": {
            "language": "text/cql-identifier",
            "expression": "Denominator Exclusion"
          }
        },
        {
          "id": "Numerator_1",
          "code": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/measure-population",
                "code": "numerator",
                "display": "Numerator"
              }
            ]
          },
          "description": "Intravesical Bacillus-Calmette Guerin (BCG) instillation for initial dose or series:\nBCG is initiated within 6 months of the bladder cancer staging",
          "criteria": {
            "language": "text/cql-identifier",
            "expression": "Numerator"
          }
        },
        {
          "id": "DenominatorException_1",
          "code": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/measure-population",
                "code": "denominator-exception",
                "display": "Denominator Exception"
              }
            ]
          },
          "description": "Unavailability of BCG within 6 months after Bladder Cancer Staging",
          "criteria": {
            "language": "text/cql-identifier",
            "expression": "Denominator Exception"
          }
        }
      ]
    }
  ],
  "supplementalData": [
    {
      "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"
      }
    },
    {
      "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-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-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": "risk-adjustment-factor"
            }
          ]
        }
      ],
      "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": "risk-adjustment-factor"
            }
          ]
        }
      ],
      "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": "risk-adjustment-factor"
            }
          ]
        }
      ],
      "description": "SDE Ethnicity",
      "criteria": {
        "language": "text/cql-identifier",
        "expression": "SDE Ethnicity"
      }
    },
    {
      "id": "sde-sex",
      "usage": [
        {
          "coding": [
            {
              "system": "http://terminology.hl7.org/CodeSystem/measure-data-usage",
              "code": "risk-adjustment-factor"
            }
          ]
        }
      ],
      "description": "SDE Sex",
      "criteria": {
        "language": "text/cql-identifier",
        "expression": "SDE Sex"
      }
    }
  ]
}