FHIR IG Statistics: Measure/CMS826FHIRHHPI

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Narrative

Note: links and images are rebased to the (stated) source

define "Initial Population":
  "Encounter with Age 18 and Older"

define "Initial Population":
  "Encounter with Age 18 and Older"

define "Denominator":
  "Initial Population"

define "Denominator Exclusions":
  "Encounter with Deep Tissue Pressure Injury POA by Indicator or Skin Exam within First 72 Hours"
    union "Encounter with Stage 2, 3, 4 or Unstageable Pressure Injury POA"

define "Numerator":
  "Encounter with New Deep Tissue Pressure Injury"
    union "Encounter with New Stage 2, 3, 4 or Unstageable Pressure Injury"

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

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

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

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

/*
@description: Returns true if any of the given references are to the given resource
@comment: Returns true if the `id` element of the given resource exactly equals the tail of any of the given references.
NOTE: This function assumes resources from the same source server.
*/
define fluent function references(references List<Reference>, resource Resource):
  exists (references R where R.references(resource))

/*
@description: Returns true if the given reference is to the given resource
@comment: Returns true if the `id` element of the given resource exactly equals the tail of the given reference.
NOTE: This function assumes resources from the same source server.
*/
define fluent function references(reference Reference, resource Resource):
  resource.id = Last(Split(reference.reference, '/'))

/*
@description: Returns true if the given reference is to the given resourceId
@comment: Returns true if the `resourceId` parameter exactly equals the tail of the given reference.
NOTE: This function assumes resources from the same source server.
*/
define fluent function references(reference Reference, resourceId String):
  resourceId = Last(Split(reference.reference, '/'))

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

define "Encounter with Age 18 and Older":
  ["Encounter": "Encounter Inpatient"] InpatientEncounter
    where AgeInYearsAt(date from start of InpatientEncounter.period) >= 18
      and InpatientEncounter.period ends during day of "Measurement Period"
      and InpatientEncounter.status = 'finished'

define "Encounter with New Deep Tissue Pressure Injury Not POA by Indicator":
  "Encounter with Age 18 and Older" InpatientHospitalization
    where InpatientHospitalization.isDiagnosisPresentOnAdmission ( "Pressure Injury Deep Tissue Diagnoses", "Not Present On Admission or Documentation Insufficient to Determine" )

define "Clinical SkinExams with Pressure Injury":
  ["ObservationClinicalResult": "Physical findings of Skin"] ClinicalSkinExam
    where ClinicalSkinExam.isIn ( "Pressure Injury Stage 2, 3, 4 or Unstageable" )

define "Simple SkinExams with Pressure Injury":
  ["SimpleObservation": "Physical findings of Skin"] ObsSkinExam
    where ObsSkinExam.isIn ( "Pressure Injury Stage 2, 3, 4 or Unstageable" )

// Skin exams may be either a SimpleObservation or an ObservationClinicalResult
// The following union is used to combine the two types of skin exams



define "SkinExams with Pressure Injury":
  "Clinical SkinExams with Pressure Injury"
    union "Simple SkinExams with Pressure Injury"

define "Encounter with New Deep Tissue Pressure Injury by Skin Exam after First 72 Hours":
  "Encounter with Age 18 and Older" InpatientHospitalization
    let hospitalizationPeriod: InpatientHospitalization.hospitalizationWithObservation ( )
    with "SkinExams with Pressure Injury" SkinExam
      such that SkinExam.effective.toInterval ( ) starts during Interval[start of hospitalizationPeriod + 72 hours, end of hospitalizationPeriod]

define "Encounter with New Deep Tissue Pressure Injury":
  "Encounter with New Deep Tissue Pressure Injury Not POA by Indicator"
    union "Encounter with New Deep Tissue Pressure Injury by Skin Exam after First 72 Hours"

define "Encounter with New Stage 2, 3, 4 or Unstageable Pressure Injury Not POA by Indicator":
  "Encounter with Age 18 and Older" InpatientHospitalization
    where InpatientHospitalization.isDiagnosisPresentOnAdmission ( "Pressure Injury Stage 2, 3, 4, or Unstageable Diagnoses", "Not Present On Admission or Documentation Insufficient to Determine" )

define "Encounter with New Stage 2, 3, 4 or Unstageable Pressure Injury by Skin Exam after First 24 Hours":
  "Encounter with Age 18 and Older" InpatientHospitalization
    let hospitalizationPeriod: CQMCommon."HospitalizationWithObservation" ( InpatientHospitalization )
    with "SkinExams with Pressure Injury" SkinExam
      such that SkinExam.effective.toInterval ( ) starts during Interval[start of hospitalizationPeriod + 24 hours, end of hospitalizationPeriod]

define "Encounter with New Stage 2, 3, 4 or Unstageable Pressure Injury":
  "Encounter with New Stage 2, 3, 4 or Unstageable Pressure Injury Not POA by Indicator"
    union "Encounter with New Stage 2, 3, 4 or Unstageable Pressure Injury by Skin Exam after First 24 Hours"

define "Numerator":
  "Encounter with New Deep Tissue Pressure Injury"
    union "Encounter with New Stage 2, 3, 4 or Unstageable Pressure Injury"

define "Initial Population":
  "Encounter with Age 18 and Older"

define "Denominator":
  "Initial Population"

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

define "Initial Population":
  "Encounter with Age 18 and Older"

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

define "Encounter with Deep Tissue Pressure Injury POA by Indicator":
  "Encounter with Age 18 and Older" InpatientHospitalization
    where InpatientHospitalization.isDiagnosisPresentOnAdmission ( "Pressure Injury Deep Tissue Diagnoses", "Present on Admission or Clinically Undetermined" )

define "Encounter with Deep Tissue Pressure Injury POA by Skin Exam within First 72 Hours":
  "Encounter with Age 18 and Older" InpatientHospitalization
    let hospitalizationPeriod: InpatientHospitalization.hospitalizationWithObservation ( )
    with "SkinExams with Pressure Injury" SkinExam
      such that SkinExam.effective.toInterval ( ) starts during Interval[start of hospitalizationPeriod, start of hospitalizationPeriod + 72 hours]

define "Encounter with Deep Tissue Pressure Injury POA by Indicator or Skin Exam within First 72 Hours":
  "Encounter with Deep Tissue Pressure Injury POA by Indicator"
    union "Encounter with Deep Tissue Pressure Injury POA by Skin Exam within First 72 Hours"

define "Encounter with Stage 2, 3, 4, or Unstageable Pressure Injury Present on Admission by POA Indicator":
  "Encounter with Age 18 and Older" InpatientHospitalization
    where InpatientHospitalization.isDiagnosisPresentOnAdmission ( "Pressure Injury Stage 2, 3, 4, or Unstageable Diagnoses", "Present on Admission or Clinically Undetermined" )

define "Encounter with Stage 2, 3, 4 or Unstageable Pressure Injury POA by Skin Exam within 24 Hours":
  "Encounter with Age 18 and Older" InpatientHospitalization
    let hospitalizationPeriod: InpatientHospitalization.hospitalizationWithObservation ( )
    with "SkinExams with Pressure Injury" SkinExam
      such that SkinExam.effective.toInterval ( ) starts during Interval[start of hospitalizationPeriod, start of hospitalizationPeriod + 24 hours]

define "Encounter with Stage 2, 3, 4 or Unstageable Pressure Injury POA":
  "Encounter with Stage 2, 3, 4, or Unstageable Pressure Injury Present on Admission by POA Indicator"
    union "Encounter with Stage 2, 3, 4 or Unstageable Pressure Injury POA by Skin Exam within 24 Hours"

define "Denominator Exclusions":
  "Encounter with Deep Tissue Pressure Injury POA by Indicator or Skin Exam within First 72 Hours"
    union "Encounter with Stage 2, 3, 4 or Unstageable Pressure Injury POA"

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

// @description This function, attached to either a SimpleObseration or an ObservationClinicalResult,  is used to determine if the observation is completed and its value is in the given value set
// @example  anObservation.isIn("Pressure Injury Stage 2, 3, 4 or Unstageable")



define fluent function isIn(observation Choice<"SimpleObservation", "ObservationClinicalResult">, vset ValueSet):
  observation.status in { 'final', 'amended', 'corrected' }
    and observation.effective during "Measurement Period"
    and case
      when observation is SimpleObservation then ( observation as SimpleObservation ).value as Concept in vset
      when observation is ObservationClinicalResult then ( observation as ObservationClinicalResult ).value as Concept in vset 
      else null end

/*
 @description: Returns true if the given diagnosis is present on admission, based on the given poaValueSet
 @comment: See the QICore 6 Authoring Patterns discussion on [Principal Diagnosis and Present on Admission](https://github.com/cqframework/CQL-Formatting-and-Usage-Wiki/wiki/Authoring-Patterns-QICore-v6.0.0#conditions-present-on-admission-and-principal-diagnoses) for more information
 */
 define fluent function isDiagnosisPresentOnAdmission(encounter Encounter, diagnosisValueSet ValueSet, poaValueSet ValueSet):
   exists (
     (encounter.claimDiagnosis()) CD
       where CD.onAdmission in poaValueSet
         and (
           CD.diagnosis in diagnosisValueSet
             or CD.diagnosis.getCondition().code in diagnosisValueSet
         )
   )

/*
@description: Returns the claim diagnosis elements for the given encounter
@comment: See the QICore 6 Authoring Patterns discussion on [Principal Diagnosis and Present on Admission](https://github.com/cqframework/CQL-Formatting-and-Usage-Wiki/wiki/Authoring-Patterns-QICore-v6.0.0#conditions-present-on-admission-and-principal-diagnoses) for more information
*/
define fluent function claimDiagnosis(encounter Encounter):
  encounter E
    let 
      claim: ([Claim] C where C.status = 'active' and C.use = 'claim' and exists (C.item I where I.encounter.references(E))),
      claimItem: (claim.item I where I.encounter.references(E))
    return claim.diagnosis D where D.sequence in claimItem.diagnosisSequence

/*
@description: Returns the Condition resource for the given reference
*/
define fluent function getCondition(reference Reference):
  singleton from (([ConditionEncounterDiagnosis] union [ConditionProblemsHealthConcerns]) C where reference.references(C.id))

/*
@description: Hospitalization with Observation returns the total interval from the start of any immediately prior emergency department visit through the observation visit to the discharge of the given encounter
*/
define fluent function hospitalizationWithObservation(TheEncounter Encounter ):
  TheEncounter Visit
  		let ObsVisit: Last([Encounter: "Observation Services"] LastObs
  				where LastObs.status = 'finished'
            and LastObs.period ends 1 hour or less on or before start of Visit.period
  				sort by end of period
  			),
  			VisitStart: Coalesce(start of ObsVisit.period, start of Visit.period),
  			EDVisit: Last([Encounter: "Emergency Department Visit"] LastED
  				where LastED.status = 'finished'
            and LastED.period ends 1 hour or less on or before VisitStart
  				sort by end of period
  			)
  		return Interval[Coalesce(start of EDVisit.period, VisitStart), end of Visit.period]

/*
@description: Hospitalization with Observation returns the total interval from the start of any immediately prior emergency department visit through the observation visit to the discharge of the given encounter
@deprecated: This function is deprecated. Use the fluent function `hospitalizationWithObservation()` instead.
*/
define function "HospitalizationWithObservation"(TheEncounter Encounter ):
  TheEncounter Visit
  		let ObsVisit: Last([Encounter: "Observation Services"] LastObs
  				where LastObs.status = 'finished'
            and LastObs.period ends 1 hour or less on or before start of Visit.period
  				sort by end of period
  			),
  			VisitStart: Coalesce(start of ObsVisit.period, start of Visit.period),
  			EDVisit: Last([Encounter: "Emergency Department Visit"] LastED
  				where LastED.status = 'finished'
            and LastED.period ends 1 hour or less on or before VisitStart
  				sort by end of period
  			)
  		return Interval[Coalesce(start of EDVisit.period, VisitStart), end of Visit.period]

define function ToString(value uri): value.value

/*
@description: Converts the given [Period](https://hl7.org/fhir/datatypes.html#Period)
value to a CQL DateTime Interval
@comment: If the start value of the given period is unspecified, the starting
boundary of the resulting interval will be open (meaning the start of the interval
is unknown, as opposed to interpreted as the beginning of time).
*/
define function ToInterval(period FHIR.Period):
    if period is null then
        null
    else
        if period."start" is null then
            Interval(period."start".value, period."end".value]
        else
            Interval[period."start".value, period."end".value]

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

Source

{
  "resourceType": "Measure",
  "id": "CMS826FHIRHHPI",
  "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://loinc.org",
            "code": "8709-8",
            "display": "Physical findings of Skin"
          }
        },
        {
          "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": "CMS826FHIRHHPI"
            },
            {
              "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": "CMS826FHIRHHPI"
            },
            {
              "url": "name",
              "valueString": "Encounter with Age 18 and Older"
            },
            {
              "url": "statement",
              "valueString": "define \"Encounter with Age 18 and Older\":\n  [\"Encounter\": \"Encounter Inpatient\"] InpatientEncounter\n    where AgeInYearsAt(date from start of InpatientEncounter.period) >= 18\n      and InpatientEncounter.period ends during day of \"Measurement Period\"\n      and InpatientEncounter.status = 'finished'"
            },
            {
              "url": "displaySequence",
              "valueInteger": 2
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS826FHIRHHPI"
            },
            {
              "url": "name",
              "valueString": "Encounter with New Deep Tissue Pressure Injury Not POA by Indicator"
            },
            {
              "url": "statement",
              "valueString": "define \"Encounter with New Deep Tissue Pressure Injury Not POA by Indicator\":\n  \"Encounter with Age 18 and Older\" InpatientHospitalization\n    where InpatientHospitalization.isDiagnosisPresentOnAdmission ( \"Pressure Injury Deep Tissue Diagnoses\", \"Not Present On Admission or Documentation Insufficient to Determine\" )"
            },
            {
              "url": "displaySequence",
              "valueInteger": 3
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS826FHIRHHPI"
            },
            {
              "url": "name",
              "valueString": "Clinical SkinExams with Pressure Injury"
            },
            {
              "url": "statement",
              "valueString": "define \"Clinical SkinExams with Pressure Injury\":\n  [\"ObservationClinicalResult\": \"Physical findings of Skin\"] ClinicalSkinExam\n    where ClinicalSkinExam.isIn ( \"Pressure Injury Stage 2, 3, 4 or Unstageable\" )"
            },
            {
              "url": "displaySequence",
              "valueInteger": 4
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS826FHIRHHPI"
            },
            {
              "url": "name",
              "valueString": "Simple SkinExams with Pressure Injury"
            },
            {
              "url": "statement",
              "valueString": "define \"Simple SkinExams with Pressure Injury\":\n  [\"SimpleObservation\": \"Physical findings of Skin\"] ObsSkinExam\n    where ObsSkinExam.isIn ( \"Pressure Injury Stage 2, 3, 4 or Unstageable\" )"
            },
            {
              "url": "displaySequence",
              "valueInteger": 5
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS826FHIRHHPI"
            },
            {
              "url": "name",
              "valueString": "SkinExams with Pressure Injury"
            },
            {
              "url": "statement",
              "valueString": "// Skin exams may be either a SimpleObservation or an ObservationClinicalResult\n// The following union is used to combine the two types of skin exams\n\n\n\ndefine \"SkinExams with Pressure Injury\":\n  \"Clinical SkinExams with Pressure Injury\"\n    union \"Simple SkinExams with Pressure Injury\""
            },
            {
              "url": "displaySequence",
              "valueInteger": 6
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS826FHIRHHPI"
            },
            {
              "url": "name",
              "valueString": "Encounter with New Deep Tissue Pressure Injury by Skin Exam after First 72 Hours"
            },
            {
              "url": "statement",
              "valueString": "define \"Encounter with New Deep Tissue Pressure Injury by Skin Exam after First 72 Hours\":\n  \"Encounter with Age 18 and Older\" InpatientHospitalization\n    let hospitalizationPeriod: InpatientHospitalization.hospitalizationWithObservation ( )\n    with \"SkinExams with Pressure Injury\" SkinExam\n      such that SkinExam.effective.toInterval ( ) starts during Interval[start of hospitalizationPeriod + 72 hours, end of hospitalizationPeriod]"
            },
            {
              "url": "displaySequence",
              "valueInteger": 7
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS826FHIRHHPI"
            },
            {
              "url": "name",
              "valueString": "Encounter with New Deep Tissue Pressure Injury"
            },
            {
              "url": "statement",
              "valueString": "define \"Encounter with New Deep Tissue Pressure Injury\":\n  \"Encounter with New Deep Tissue Pressure Injury Not POA by Indicator\"\n    union \"Encounter with New Deep Tissue Pressure Injury by Skin Exam after First 72 Hours\""
            },
            {
              "url": "displaySequence",
              "valueInteger": 8
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS826FHIRHHPI"
            },
            {
              "url": "name",
              "valueString": "Encounter with New Stage 2, 3, 4 or Unstageable Pressure Injury Not POA by Indicator"
            },
            {
              "url": "statement",
              "valueString": "define \"Encounter with New Stage 2, 3, 4 or Unstageable Pressure Injury Not POA by Indicator\":\n  \"Encounter with Age 18 and Older\" InpatientHospitalization\n    where InpatientHospitalization.isDiagnosisPresentOnAdmission ( \"Pressure Injury Stage 2, 3, 4, or Unstageable Diagnoses\", \"Not Present On Admission or Documentation Insufficient to Determine\" )"
            },
            {
              "url": "displaySequence",
              "valueInteger": 9
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS826FHIRHHPI"
            },
            {
              "url": "name",
              "valueString": "Encounter with New Stage 2, 3, 4 or Unstageable Pressure Injury by Skin Exam after First 24 Hours"
            },
            {
              "url": "statement",
              "valueString": "define \"Encounter with New Stage 2, 3, 4 or Unstageable Pressure Injury by Skin Exam after First 24 Hours\":\n  \"Encounter with Age 18 and Older\" InpatientHospitalization\n    let hospitalizationPeriod: CQMCommon.\"HospitalizationWithObservation\" ( InpatientHospitalization )\n    with \"SkinExams with Pressure Injury\" SkinExam\n      such that SkinExam.effective.toInterval ( ) starts during Interval[start of hospitalizationPeriod + 24 hours, end of hospitalizationPeriod]"
            },
            {
              "url": "displaySequence",
              "valueInteger": 10
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS826FHIRHHPI"
            },
            {
              "url": "name",
              "valueString": "Encounter with New Stage 2, 3, 4 or Unstageable Pressure Injury"
            },
            {
              "url": "statement",
              "valueString": "define \"Encounter with New Stage 2, 3, 4 or Unstageable Pressure Injury\":\n  \"Encounter with New Stage 2, 3, 4 or Unstageable Pressure Injury Not POA by Indicator\"\n    union \"Encounter with New Stage 2, 3, 4 or Unstageable Pressure Injury by Skin Exam after First 24 Hours\""
            },
            {
              "url": "displaySequence",
              "valueInteger": 11
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS826FHIRHHPI"
            },
            {
              "url": "name",
              "valueString": "Numerator"
            },
            {
              "url": "statement",
              "valueString": "define \"Numerator\":\n  \"Encounter with New Deep Tissue Pressure Injury\"\n    union \"Encounter with New Stage 2, 3, 4 or Unstageable Pressure Injury\""
            },
            {
              "url": "displaySequence",
              "valueInteger": 12
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS826FHIRHHPI"
            },
            {
              "url": "name",
              "valueString": "Initial Population"
            },
            {
              "url": "statement",
              "valueString": "define \"Initial Population\":\n  \"Encounter with Age 18 and Older\""
            },
            {
              "url": "displaySequence",
              "valueInteger": 13
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS826FHIRHHPI"
            },
            {
              "url": "name",
              "valueString": "Denominator"
            },
            {
              "url": "statement",
              "valueString": "define \"Denominator\":\n  \"Initial Population\""
            },
            {
              "url": "displaySequence",
              "valueInteger": 14
            }
          ],
          "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": 15
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS826FHIRHHPI"
            },
            {
              "url": "name",
              "valueString": "SDE Payer"
            },
            {
              "url": "statement",
              "valueString": "define \"SDE Payer\":\n  SDE.\"SDE Payer\""
            },
            {
              "url": "displaySequence",
              "valueInteger": 16
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS826FHIRHHPI"
            },
            {
              "url": "name",
              "valueString": "Initial Population"
            },
            {
              "url": "statement",
              "valueString": "define \"Initial Population\":\n  \"Encounter with Age 18 and Older\""
            },
            {
              "url": "displaySequence",
              "valueInteger": 17
            }
          ],
          "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": 18
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS826FHIRHHPI"
            },
            {
              "url": "name",
              "valueString": "SDE Ethnicity"
            },
            {
              "url": "statement",
              "valueString": "define \"SDE Ethnicity\":\n  SDE.\"SDE Ethnicity\""
            },
            {
              "url": "displaySequence",
              "valueInteger": 19
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS826FHIRHHPI"
            },
            {
              "url": "name",
              "valueString": "Encounter with Deep Tissue Pressure Injury POA by Indicator"
            },
            {
              "url": "statement",
              "valueString": "define \"Encounter with Deep Tissue Pressure Injury POA by Indicator\":\n  \"Encounter with Age 18 and Older\" InpatientHospitalization\n    where InpatientHospitalization.isDiagnosisPresentOnAdmission ( \"Pressure Injury Deep Tissue Diagnoses\", \"Present on Admission or Clinically Undetermined\" )"
            },
            {
              "url": "displaySequence",
              "valueInteger": 20
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS826FHIRHHPI"
            },
            {
              "url": "name",
              "valueString": "Encounter with Deep Tissue Pressure Injury POA by Skin Exam within First 72 Hours"
            },
            {
              "url": "statement",
              "valueString": "define \"Encounter with Deep Tissue Pressure Injury POA by Skin Exam within First 72 Hours\":\n  \"Encounter with Age 18 and Older\" InpatientHospitalization\n    let hospitalizationPeriod: InpatientHospitalization.hospitalizationWithObservation ( )\n    with \"SkinExams with Pressure Injury\" SkinExam\n      such that SkinExam.effective.toInterval ( ) starts during Interval[start of hospitalizationPeriod, start of hospitalizationPeriod + 72 hours]"
            },
            {
              "url": "displaySequence",
              "valueInteger": 21
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS826FHIRHHPI"
            },
            {
              "url": "name",
              "valueString": "Encounter with Deep Tissue Pressure Injury POA by Indicator or Skin Exam within First 72 Hours"
            },
            {
              "url": "statement",
              "valueString": "define \"Encounter with Deep Tissue Pressure Injury POA by Indicator or Skin Exam within First 72 Hours\":\n  \"Encounter with Deep Tissue Pressure Injury POA by Indicator\"\n    union \"Encounter with Deep Tissue Pressure Injury POA by Skin Exam within First 72 Hours\""
            },
            {
              "url": "displaySequence",
              "valueInteger": 22
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS826FHIRHHPI"
            },
            {
              "url": "name",
              "valueString": "Encounter with Stage 2, 3, 4, or Unstageable Pressure Injury Present on Admission by POA Indicator"
            },
            {
              "url": "statement",
              "valueString": "define \"Encounter with Stage 2, 3, 4, or Unstageable Pressure Injury Present on Admission by POA Indicator\":\n  \"Encounter with Age 18 and Older\" InpatientHospitalization\n    where InpatientHospitalization.isDiagnosisPresentOnAdmission ( \"Pressure Injury Stage 2, 3, 4, or Unstageable Diagnoses\", \"Present on Admission or Clinically Undetermined\" )"
            },
            {
              "url": "displaySequence",
              "valueInteger": 23
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS826FHIRHHPI"
            },
            {
              "url": "name",
              "valueString": "Encounter with Stage 2, 3, 4 or Unstageable Pressure Injury POA by Skin Exam within 24 Hours"
            },
            {
              "url": "statement",
              "valueString": "define \"Encounter with Stage 2, 3, 4 or Unstageable Pressure Injury POA by Skin Exam within 24 Hours\":\n  \"Encounter with Age 18 and Older\" InpatientHospitalization\n    let hospitalizationPeriod: InpatientHospitalization.hospitalizationWithObservation ( )\n    with \"SkinExams with Pressure Injury\" SkinExam\n      such that SkinExam.effective.toInterval ( ) starts during Interval[start of hospitalizationPeriod, start of hospitalizationPeriod + 24 hours]"
            },
            {
              "url": "displaySequence",
              "valueInteger": 24
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS826FHIRHHPI"
            },
            {
              "url": "name",
              "valueString": "Encounter with Stage 2, 3, 4 or Unstageable Pressure Injury POA"
            },
            {
              "url": "statement",
              "valueString": "define \"Encounter with Stage 2, 3, 4 or Unstageable Pressure Injury POA\":\n  \"Encounter with Stage 2, 3, 4, or Unstageable Pressure Injury Present on Admission by POA Indicator\"\n    union \"Encounter with Stage 2, 3, 4 or Unstageable Pressure Injury POA by Skin Exam within 24 Hours\""
            },
            {
              "url": "displaySequence",
              "valueInteger": 25
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS826FHIRHHPI"
            },
            {
              "url": "name",
              "valueString": "Denominator Exclusions"
            },
            {
              "url": "statement",
              "valueString": "define \"Denominator Exclusions\":\n  \"Encounter with Deep Tissue Pressure Injury POA by Indicator or Skin Exam within First 72 Hours\"\n    union \"Encounter with Stage 2, 3, 4 or Unstageable Pressure Injury POA\""
            },
            {
              "url": "displaySequence",
              "valueInteger": 26
            }
          ],
          "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": 27
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS826FHIRHHPI"
            },
            {
              "url": "name",
              "valueString": "SDE Race"
            },
            {
              "url": "statement",
              "valueString": "define \"SDE Race\":\n  SDE.\"SDE Race\""
            },
            {
              "url": "displaySequence",
              "valueInteger": 28
            }
          ],
          "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": 29
            }
          ],
          "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": 30
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CQMCommon"
            },
            {
              "url": "name",
              "valueString": "isDiagnosisPresentOnAdmission"
            },
            {
              "url": "statement",
              "valueString": "/*\n @description: Returns true if the given diagnosis is present on admission, based on the given poaValueSet\n @comment: See the QICore 6 Authoring Patterns discussion on [Principal Diagnosis and Present on Admission](https://github.com/cqframework/CQL-Formatting-and-Usage-Wiki/wiki/Authoring-Patterns-QICore-v6.0.0#conditions-present-on-admission-and-principal-diagnoses) for more information\n */\n define fluent function isDiagnosisPresentOnAdmission(encounter Encounter, diagnosisValueSet ValueSet, poaValueSet ValueSet):\n   exists (\n     (encounter.claimDiagnosis()) CD\n       where CD.onAdmission in poaValueSet\n         and (\n           CD.diagnosis in diagnosisValueSet\n             or CD.diagnosis.getCondition().code in diagnosisValueSet\n         )\n   )"
            },
            {
              "url": "displaySequence",
              "valueInteger": 31
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CQMCommon"
            },
            {
              "url": "name",
              "valueString": "claimDiagnosis"
            },
            {
              "url": "statement",
              "valueString": "/*\n@description: Returns the claim diagnosis elements for the given encounter\n@comment: See the QICore 6 Authoring Patterns discussion on [Principal Diagnosis and Present on Admission](https://github.com/cqframework/CQL-Formatting-and-Usage-Wiki/wiki/Authoring-Patterns-QICore-v6.0.0#conditions-present-on-admission-and-principal-diagnoses) for more information\n*/\ndefine fluent function claimDiagnosis(encounter Encounter):\n  encounter E\n    let \n      claim: ([Claim] C where C.status = 'active' and C.use = 'claim' and exists (C.item I where I.encounter.references(E))),\n      claimItem: (claim.item I where I.encounter.references(E))\n    return claim.diagnosis D where D.sequence in claimItem.diagnosisSequence"
            },
            {
              "url": "displaySequence",
              "valueInteger": 32
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "QICoreCommon"
            },
            {
              "url": "name",
              "valueString": "references"
            },
            {
              "url": "statement",
              "valueString": "/*\n@description: Returns true if any of the given references are to the given resource\n@comment: Returns true if the `id` element of the given resource exactly equals the tail of any of the given references.\nNOTE: This function assumes resources from the same source server.\n*/\ndefine fluent function references(references List<Reference>, resource Resource):\n  exists (references R where R.references(resource))"
            },
            {
              "url": "displaySequence",
              "valueInteger": 33
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "QICoreCommon"
            },
            {
              "url": "name",
              "valueString": "references"
            },
            {
              "url": "statement",
              "valueString": "/*\n@description: Returns true if the given reference is to the given resource\n@comment: Returns true if the `id` element of the given resource exactly equals the tail of the given reference.\nNOTE: This function assumes resources from the same source server.\n*/\ndefine fluent function references(reference Reference, resource Resource):\n  resource.id = Last(Split(reference.reference, '/'))"
            },
            {
              "url": "displaySequence",
              "valueInteger": 34
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CQMCommon"
            },
            {
              "url": "name",
              "valueString": "getCondition"
            },
            {
              "url": "statement",
              "valueString": "/*\n@description: Returns the Condition resource for the given reference\n*/\ndefine fluent function getCondition(reference Reference):\n  singleton from (([ConditionEncounterDiagnosis] union [ConditionProblemsHealthConcerns]) C where reference.references(C.id))"
            },
            {
              "url": "displaySequence",
              "valueInteger": 35
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "QICoreCommon"
            },
            {
              "url": "name",
              "valueString": "references"
            },
            {
              "url": "statement",
              "valueString": "/*\n@description: Returns true if the given reference is to the given resourceId\n@comment: Returns true if the `resourceId` parameter exactly equals the tail of the given reference.\nNOTE: This function assumes resources from the same source server.\n*/\ndefine fluent function references(reference Reference, resourceId String):\n  resourceId = Last(Split(reference.reference, '/'))"
            },
            {
              "url": "displaySequence",
              "valueInteger": 36
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CQMCommon"
            },
            {
              "url": "name",
              "valueString": "hospitalizationWithObservation"
            },
            {
              "url": "statement",
              "valueString": "/*\n@description: Hospitalization with Observation returns the total interval from the start of any immediately prior emergency department visit through the observation visit to the discharge of the given encounter\n*/\ndefine fluent function hospitalizationWithObservation(TheEncounter Encounter ):\n  TheEncounter Visit\n  \t\tlet ObsVisit: Last([Encounter: \"Observation Services\"] LastObs\n  \t\t\t\twhere LastObs.status = 'finished'\n            and LastObs.period ends 1 hour or less on or before start of Visit.period\n  \t\t\t\tsort by end of period\n  \t\t\t),\n  \t\t\tVisitStart: Coalesce(start of ObsVisit.period, start of Visit.period),\n  \t\t\tEDVisit: Last([Encounter: \"Emergency Department Visit\"] LastED\n  \t\t\t\twhere LastED.status = 'finished'\n            and LastED.period ends 1 hour or less on or before VisitStart\n  \t\t\t\tsort by end of period\n  \t\t\t)\n  \t\treturn Interval[Coalesce(start of EDVisit.period, VisitStart), end of Visit.period]"
            },
            {
              "url": "displaySequence",
              "valueInteger": 37
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS826FHIRHHPI"
            },
            {
              "url": "name",
              "valueString": "isIn"
            },
            {
              "url": "statement",
              "valueString": "// @description This function, attached to either a SimpleObseration or an ObservationClinicalResult,  is used to determine if the observation is completed and its value is in the given value set\n// @example  anObservation.isIn(\"Pressure Injury Stage 2, 3, 4 or Unstageable\")\n\n\n\ndefine fluent function isIn(observation Choice<\"SimpleObservation\", \"ObservationClinicalResult\">, vset ValueSet):\n  observation.status in { 'final', 'amended', 'corrected' }\n    and observation.effective during \"Measurement Period\"\n    and case\n      when observation is SimpleObservation then ( observation as SimpleObservation ).value as Concept in vset\n      when observation is ObservationClinicalResult then ( observation as ObservationClinicalResult ).value as Concept in vset \n      else null end"
            },
            {
              "url": "displaySequence",
              "valueInteger": 38
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CQMCommon"
            },
            {
              "url": "name",
              "valueString": "HospitalizationWithObservation"
            },
            {
              "url": "statement",
              "valueString": "/*\n@description: Hospitalization with Observation returns the total interval from the start of any immediately prior emergency department visit through the observation visit to the discharge of the given encounter\n@deprecated: This function is deprecated. Use the fluent function `hospitalizationWithObservation()` instead.\n*/\ndefine function \"HospitalizationWithObservation\"(TheEncounter Encounter ):\n  TheEncounter Visit\n  \t\tlet ObsVisit: Last([Encounter: \"Observation Services\"] LastObs\n  \t\t\t\twhere LastObs.status = 'finished'\n            and LastObs.period ends 1 hour or less on or before start of Visit.period\n  \t\t\t\tsort by end of period\n  \t\t\t),\n  \t\t\tVisitStart: Coalesce(start of ObsVisit.period, start of Visit.period),\n  \t\t\tEDVisit: Last([Encounter: \"Emergency Department Visit\"] LastED\n  \t\t\t\twhere LastED.status = 'finished'\n            and LastED.period ends 1 hour or less on or before VisitStart\n  \t\t\t\tsort by end of period\n  \t\t\t)\n  \t\treturn Interval[Coalesce(start of EDVisit.period, VisitStart), end of Visit.period]"
            },
            {
              "url": "displaySequence",
              "valueInteger": 39
            }
          ],
          "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": 40
            }
          ],
          "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 CQMCommon",
          "resource": "Library/CQMCommon|4.1.000"
        },
        {
          "type": "depends-on",
          "display": "Library QICoreCommon",
          "resource": "Library/QICoreCommon|4.0.000"
        },
        {
          "type": "depends-on",
          "display": "Library FHIRHelpers",
          "resource": "Library/FHIRHelpers|4.4.000"
        },
        {
          "type": "depends-on",
          "display": "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 LOINC",
          "resource": "http://loinc.org"
        },
        {
          "type": "depends-on",
          "display": "Value set Encounter Inpatient",
          "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.666.5.307"
        },
        {
          "type": "depends-on",
          "display": "Value set Pressure Injury Deep Tissue Diagnoses",
          "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1147.194"
        },
        {
          "type": "depends-on",
          "display": "Value set Not Present On Admission or Documentation Insufficient to Determine",
          "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1147.198"
        },
        {
          "type": "depends-on",
          "display": "Value set Observation Services",
          "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1111.143"
        },
        {
          "type": "depends-on",
          "display": "Value set Emergency Department Visit",
          "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.292"
        },
        {
          "type": "depends-on",
          "display": "Value set Pressure Injury Stage 2, 3, 4 or Unstageable",
          "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1147.113"
        },
        {
          "type": "depends-on",
          "display": "Value set Pressure Injury Stage 2, 3, 4, or Unstageable Diagnoses",
          "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1147.196"
        },
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          "url": "guidance",
          "valueString": "For every patient evaluated by this measure, also identify payer, race, ethnicity and sex"
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      "value": "3498e",
      "assigner": {
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      "system": "https://madie.cms.gov/measure/cmsId",
      "value": "826FHIR",
      "assigner": {
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  "version": "0.3.000",
  "name": "CMS826FHIRHHPI",
  "title": "Hospital Harm - Pressure InjuryFHIR",
  "status": "active",
  "experimental": false,
  "date": "2025-07-15T13:37:41+00:00",
  "publisher": "Centers for Medicare & Medicaid Services (CMS)",
  "contact": [
    {
      "telecom": [
        {
          "system": "url",
          "value": "https://www.cms.gov/"
        }
      ]
    }
  ],
  "description": "The measure assesses the number of inpatient hospitalizations for patients aged 18 and older who suffer the harm of developing a new stage 2, stage 3. stage 4. deep tissue, or unstageable pressure injury",
  "usage": "This dQM is an episode-based measure. An episode is defined as each inpatient hospitalization or encounter that ends during the measurement period.  This FHIR-based measure has been derived from the QDM-based measure: CMS826v3. Please refer to the HL7 QI-Core Implementation Guide (https://hl7.org/fhir/us/qicore/STU6/) for more information on QI-Core and mapping recommendations from QDM to QI-Core STU 6 (https://hl7.org/fhir/us/qicore/STU6/qdm-to-qicore.html).",
  "copyright": "Limited proprietary coding is contained in the Measure specifications for user convenience. Users of proprietary code sets should obtain all necessary licenses from the owners of the code sets. Mathematica disclaims all liability for use or accuracy of any third-party codes contained in the specifications. 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 Organization. ICD-10 copyright 2024 World Health Organization. All Rights Reserved.",
  "effectivePeriod": {
    "start": "2026-01-01",
    "end": "2026-12-31"
  },
  "author": [
    {
      "name": "Mathematica",
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          "value": "https://www.mathematica.org/"
        }
      ]
    }
  ],
  "relatedArtifact": [
    {
      "type": "citation",
      "citation": "CITATION - American College of Physicians (ACP). (2015). Risk assessment and prevention of pressure ulcers: a clinical practice guideline. "
    },
    {
      "type": "citation",
      "citation": "CITATION - Bly, D., Schallom, M., Sona, C., & Klinkenberg, D. (2016). A model of pressure, oxygenation, and perfusion risk factors for pressure ulcers in the intensive care unit. American Journal of Critical Care, 25(2), 156–154 "
    },
    {
      "type": "citation",
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      "type": "citation",
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    },
    {
      "type": "citation",
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    },
    {
      "type": "citation",
      "citation": "CITATION - European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance. (2019). Prevention and treatment of pressure ulcers/injuries: clinical practice guideline. The International Guideline: Haesler (Ed.). EPUAP/NPIAP/PPPIA. "
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      "type": "citation",
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  ],
  "library": [
    "https://madie.cms.gov/Library/CMS826FHIRHHPI"
  ],
  "disclaimer": "This performance measure is not a clinical guideline, 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": "This safety dQM captures the number of patients who experience harm in the form of a pressure injury during their inpatient hospitalization. The incidence of pressure injuries in hospitalized patients has been estimated at 5.4 per 10,000 patient-days, and the rate of hospital-acquired pressure injuries (HAPIs) has been estimated at 8.4% (Li et al., 2020). Over 50% of reported pressure injuries in hospitals were stage 2 or higher (Li et al., 2020). HAPIs are serious events and one of the most common patient harms. Pressure injuries commonly cause local infection, osteomyelitis, anemia, and sepsis in addition to causing significant depression, pain, and discomfort to patients (Shui et al., 2021). Pressure injury is considered a serious reportable event by the National Quality Forum (NQF) (NQF, 2011).   Studies have shown that age, severity of illness, comorbidity indexes, and Braden scores are predictors of HAPIs (Rondinelli et al., 2018). However, even after risk adjustment for patient risk factors, significant variation in rates of HAPI exist between hospitals (Rondinelli et al., 2018). It is widely accepted that the risk of developing a pressure injury can be reduced through best practices. Hospital controlled factors that have been found to be significantly associated with an increase in pressure ulcer risk include infrequent repositioning (p=0.005) and number of days to bed change (OR, 2.89 [95% CI, 1.26-6.63]) (Tayyib et al., 2016; Bly et al., 2016). Nurse staffing, measured as hours per patient day (HPPD), skill mix, and expertise are also significant predictors of HAPI development; patients who require more nursing activity have actually been found to have a lower risk for HAPIs (Tschannen & Anderson, 2020). Systematically measuring patients who develop new pressure injuries while in the hospital setting will provide hospitals with a reliable and timely measurement to more reliably assess harm reduction efforts and modify their improvement efforts in near real-time. This dQM fills a gap in measurement and provides incentives for hospitals’ quality improvement. The intent of this measure is to incentivize greater achievements in reducing harms and enhance hospital performance on patient safety outcomes.   Stage 2 pressure injuries, characterized by partial-thickness skin loss, carry a less serious burden in terms of patient harm than stage 3, stage 4, unstageable, and deep tissue pressure injuries (DTPI). Partial-thickness wounds heal primarily as a result of epidermal regeneration and often heal without untoward consequences, loss of skin function, or scar tissue formation. Based on the healing capabilities inherent in these partial-thickness wounds, it is the expert opinion of the National Pressure Ulcer Advisory Panel (NPUAP) that the presentation of stage 2 pressure injuries does not carry the same potential longstanding negative consequences to patients as do full thickness pressure injuries. Stage 2 pressure injuries constitute a very real patient harm that should be monitored and addressed; however, the relative level of harm is less than with stage 3, stage 4, unstageable pressure injuries and potentially DTPI (NPUAP, 2019).  The accurate and timely identification of DTPI is important for several reasons. Early discovery of DTPI allows prompt identification of possible causes, initiation of treatment, and potential development of preventive strategies. In addition, 24 to 72 hours can lapse between the precipitating pressure event and the onset of purple or maroon skin. This delayed manifestation becomes particularly important when the precipitating event occurred before the patient’s admission, yet the DTPI appears beyond the 24-hour window for present-on-admission status (Tescher et al., 2018).",
  "clinicalRecommendationStatement": "The Clinical Guidelines Committee for the American College of Physicians (ACP) presents the available evidence on the comparative effectiveness of various risk assessment instruments and benefits and harms of strategies to prevent pressure ulcers (Qaseem et al., 2015).  Recommendation 1: ACP recommends that clinicians should perform a risk assessment to identify patients who are at risk of developing pressure ulcers.   Recommendation 2: ACP recommends that clinicians should choose advanced static mattresses or advanced static overlays in patients who are at an increased risk of developing pressure ulcers.  Recommendation 3: ACP recommends against using alternating-air mattresses or alternating-air overlays in patients who are at an increased risk of developing pressure ulcers.  The European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel, and Pan Pacific Pressure Injury Alliance’s Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline (The International Guideline) provides guidance for categorizing pressure injuries and recommendations for structured skin and risk assessment (European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel, and Pan Pacific Pressure Injury Alliance, 2019).  Guidelines focused on risk factors and risk assessment:  1.1: Consider individuals with limited mobility, limited activity and a high potential for friction and shear to be at risk of pressure injuries.  1.2: Consider individuals with a category/stage I pressure injury to be at risk of developing a category/stage II or greater pressure injury.  1.7: Consider the impact of diabetes mellitus on the risk of pressure injuries.  1.8: Consider the impact of perfusion and circulation deficits on the risk of pressure injuries.  1.12: Consider the impact of increased body temperature on the risk of pressure injuries.  1.17: Consider the impact of time spent immobilized before surgery, the duration of surgery and the American Society of Anesthesiologists (ASA) Physical Status Classification on surgery-related pressure injury risk.   Guidelines focused on skin and tissue assessment:  2.2: Inspect the skin of individuals at risk of pressure injuries to identify presence of erythema.  2.3: Differentiate blanchable from non-blanchable erythema using either finger pressure or the transparent disk method and evaluate the extent of erythema.   Guidelines focused on preventative skin care:  3.1: Implement a skin care regimen that includes:   - Keeping skin clean and appropriately hydrated   - Cleansing the skin promptly after episodes of incontinence   - Avoiding use of alkaline soaps and cleansers   - Protecting the skin from moisture with a barrier product  3.3: Use high absorbency incontinence products to protect the skin in individuals with or at risk of pressure injuries who have urinary incontinence.  3.4: Consider using textiles with low friction coefficients for individuals with or at risk of pressure injuries.   3.5: Use a soft silicone multi-layered foam dressing to protect the skin for individuals at risk of pressure injuries.   Guidelines focused on nutrition screening:   4.1: Conduct nutritional screening for individuals at risk of a pressure injury.  4.2: Conduct a comprehensive nutrition assessment for adults at risk of a pressure injury who are screened to be at risk of malnutrition and for all adults with a pressure injury.   4.3: Develop and implement an individualized nutrition care plan for individuals with or at risk of a pressure injury who are malnourished or who are at risk of malnutrition.   4.4: Optimize energy intake for individuals at risk of pressure injuries who are malnourished or at risk of malnutrition.   4.6: Provide 30 to 35 kcalories/kg body weight/day for adults with a pressure injury who are malnourished or at risk of malnutrition.   4.7: Provide 1.25 to 1.5 g protein/kg body weight/day for adults with a pressure injury who are malnourished or at risk of malnutrition.   4.9: Offer high calorie, high protein nutritional supplements in addition to the usual diet for adults with a pressure injury who are malnourished or at risk of malnutrition, if nutritional requirements cannot be achieved by normal dietary intake.   4.12: Discuss the benefits and harms of enteral or parenteral feeding to support pressure injury treatment in light of preferences and goals of care for individuals with pressure injuries who cannot meet their nutritional requirements through oral intake despite nutritional interventions.   Guidelines focused on repositioning and early mobilization:  5.1: Reposition all individuals with or at risk of pressure injuries on an individualized schedule, unless contraindicated.  5.2: Determine repositioning frequency with consideration to the individual’s level of activity and ability to independently reposition.   Guidelines focused on heel pressure injury:  6.1: Assess the vascular/perfusion status of the lower limbs, heels and feet when performing a skin and tissue assessment, and as part of a risk assessment.  6.2: For individuals at risk of heel pressure injuries and/or with category/stage I or II pressure injuries, elevate the heels using a specifically designed heel suspension device or a pillow/ foam cushion. Offload the heel completely in such a way as to distribute the weight of the leg along the calf without placing pressure on the Achilles tendon and the popliteal vein.  6.4: Use a prophylactic dressing as an adjunct to heel offloading and other strategies to prevent heel pressure injuries.   Guidelines focused on support surfaces:  7.4: Use a high specification reactive single layer foam mattress or overlay in preference to a foam mattress without high specification qualities for individuals at risk of developing pressure injuries.  7.7: Assess the relative benefits of using an alternating pressure air mattress or overlay for individuals at risk of pressure injuries.  7.8: Use a pressure redistribution support surface on the operating table for all individuals with or at risk of pressure injuries who are undergoing surgery.  7.12: Use a pressure redistribution cushion for preventing pressure injuries in people at high risk who are seated in a chair/wheelchair for prolonged periods, particularly if the individual is unable to perform pressure relieving maneuvers.  7.13: Assess the relative benefits of using an alternating pressure air cushion for supporting pressure injury healing in individuals who are seated in a chair/wheelchair for prolonged periods, particularly if the individual is unable to perform pressure relieving maneuvers.    Guidelines focused on device related pressure injury:  8.1: To reduce the risk of medical device related pressure injuries, review and select medical devices with consideration to:   - The device's ability to minimize tissue damage  - Correct sizing/shape of the device for the individual   - Ability to correctly apply the device according to manufacturer's instructions   - Ability to correctly secure the device  8.5: Use a prophylactic dressing beneath a medical device to reduce the risk of medical device related pressure injuries.     Guidelines focused on implementing best practices:  20.2: At the organizational level, assess the knowledge health professionals have about pressure injuries to facilitate implementation of an education program and a quality improvement program.   20.4: At an organizational level, assess and maximize the availability and quality of equipment and standards for its use as part of a quality improvement plan to reduce the incidence of pressure injuries.   20.5: At an organizational level, develop and implement a structured, tailored and multi-faceted quality improvement program to reduce the incidence of pressure injuries.   20.6: At an organizational level, engage all key stakeholders in oversight and implementation of the quality improvement program to reduce the incidence of pressure injuries.   20.7: At an organizational level, include evidence-based policies, procedures and protocols and standardized documentation systems to reduce the incidence of pressure injuries.   20.8: At an organizational level, provide clinical decision support tools as part of a quality improvement plan to reduce the incidence of pressure injuries.   20.9: Provide clinical leadership in pressure injury prevention and treatment as part of a quality improvement plan to reduce pressure injuries.   20.10: At a professional level, provide education in pressure injury prevention and treatment as part of a quality improvement plan to reduce the incidence of pressure injuries.   20.11: At an organizational level, regularly monitor, analyze and evaluate performance against quality indicators for pressure injury prevention and treatment.  20.12: At an organizational level, use feedback and reminder systems to promote the quality improvement program and its outcomes to stakeholders.   Guidelines focused on health professional education:  21.1: At the organizational level, assess the knowledge health professionals have about pressure injuries to facilitate implementation of an education program and a quality improvement program.   21.2: At an organizational level, develop and implement a multi-faceted education program for pressure injury prevention and treatment.",
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          "valueCode": "None"
        },
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      ],
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          "code": {
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                "display": "Initial Population"
              }
            ]
          },
          "description": "Inpatient hospitalizations that end during the measurement period for patients aged 18 and older",
          "criteria": {
            "language": "text/cql-identifier",
            "expression": "Initial Population"
          }
        },
        {
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            ]
          },
          "description": "Equals Initial Population",
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        {
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          "code": {
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                "code": "denominator-exclusion",
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              }
            ]
          },
          "description": "Inpatient hospitalizations for patients with a DTPI or stage 2, 3, 4 or unstageable pressure injury diagnosis present on admission as indicated by a present on admission indicator of Y or W.  Inpatient hospitalizations for patients with a DTPI found on exam within 72 hours after the start of the encounter  Inpatient hospitalizations for patients with a stage 2, 3, 4, or unstageable pressure injury found on exam within 24 hours after the start of the encounter",
          "criteria": {
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        },
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            ]
          },
          "description": "Inpatient hospitalizations for patients with a new deep tissue pressure injury (DTPI) or stage 2, 3, 4, or unstageable pressure injury, as evidenced by any of the following:  A DTPI or stage 2, 3, 4, or unstageable pressure injury diagnosis not present on admission as indicated by a present on admission indicator of N  or U.  A DTPI found on exam greater than 72 hours after the start of the encounter  A stage 2, 3, 4 or unstageable pressure injury found on exam greater than 24 hours after the start of the encounter  Only one harm (new qualifying pressure injury) is counted per hospitalization.",
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