FHIR IG Statistics: Measure/CMS996FHIRAptTxforSTEMI

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Narrative

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define "Initial Population":
  "ED Encounter with STEMI Diagnosis"

define "Initial Population":
  "ED Encounter with STEMI Diagnosis"

define "Denominator":
  "Initial Population"

define "Denominator Exclusions":
  "Allergy or Intolerance to Thrombolytic Medications Overlaps ED Encounter"
    union "Adverse Effect to Thrombolytic Medications Before End of ED Encounter"
    union "Active Exclusion Diagnosis at Start of ED Encounter"
    union "Active use of Anticoagulants"
    union "Exclusion Diagnosis During ED Encounter or Within 24 Hours of ED Encounter Start"
    union "Major Surgical Procedure 21 Days or Less Before Start of or Starts During ED Encounter"
    union "Intubation or Mechanical Circulatory Assist Device Placement or Removal Procedure During ED Encounter or Within 24 Hours of ED Encounter Start"
    union "Active Exclusion Diagnosis Within 90 Days Before or At the Start of ED Encounter"
    union "Intracranial or Intraspinal Procedure 90 Days or Less Before Start of ED Encounter"
    union "ED Encounter with Discharge Disposition as Patient Expired"
    union "ED Encounter with Discharge Disposition as Left Against Medical Advice"
    union "ED Encounter with Hospice Services"
    union "Currently Pregnant"

define "Numerator":
  "Fibrinolytic Therapy Administration within 30 Minutes of Arrival"
    union "PCI within 90 Minutes of Arrival"
    union "ED Departure with Discharge to Acute Care Facility Within 45 Minutes Of Arrival"

define "Denominator Exceptions":
  "Received tPA in Another Facility within 24 hours Prior to Admission"
    union "ED Encounter with a Documented Reason for No PCI Performed"
    union "ED Encounter with a Documented Reason for Not Administering Fibrinolytic Therapy"

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

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

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

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

define 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 [CodeableConcept](https://hl7.org/fhir/datatypes.html#CodeableConcept) value to a CQL Concept.
*/
define function ToConcept(concept FHIR.CodeableConcept):
    if concept is null then
        null
    else
        System.Concept {
            codes: concept.coding C return ToCode(C),
            display: concept.text.value
        }

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

/*  
@description: Returns the Condition resources referenced by the diagnosis element of the Encounter  
*/
define fluent function encounterDiagnosis(Encounter Encounter ):
  Encounter.reasonReference D
    return singleton from (([ConditionEncounterDiagnosis] union [ConditionProblemsHealthConcerns]) C where D.references(C.id))

/*
@description: Returns the Location resource specified by the given reference
@deprecated: This function is deprecated. Use the fluent function `getLocation()` instead.
*/
define function "GetLocation"(reference Reference):
  singleton from (
    [Location] L where reference.references(L)
  )

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

define "ED Encounter During MP":
  ["Encounter": "Emergency Department Evaluation and Management Visit"] EDEncounter
    where EDEncounter.period ends during day of "Measurement Period"
      and EDEncounter.status = 'finished'
      and AgeInYearsAt(date from start of(EDEncounter.period)) >= 18

define "ED Encounter with STEMI Diagnosis":
  "ED Encounter During MP" EDEncounterinMP
    where ( EDEncounterinMP.reasonCode in "STEMI"
        or exists ( ( [ConditionProblemsHealthConcerns: "STEMI"]
            union [ConditionEncounterDiagnosis: "STEMI"] ) DxSTEMI
            where ( EDEncounterinMP.encounterDiagnosis ( ).code in "STEMI"
                or ( DxSTEMI.prevalenceInterval ( ) starts during EDEncounterinMP.period )
            )
              and ( DxSTEMI.verificationStatus is not null implies ( DxSTEMI.verificationStatus ~ QICoreCommon."confirmed"
                    or DxSTEMI.verificationStatus ~ QICoreCommon."unconfirmed"
                    or DxSTEMI.verificationStatus ~ QICoreCommon."provisional"
                    or DxSTEMI.verificationStatus ~ QICoreCommon."differential"
                )
              )
        )
    )

define "Fibrinolytic Therapy Administration within 30 Minutes of Arrival":
  "ED Encounter with STEMI Diagnosis" EDwithSTEMI
    with ["MedicationAdministration": "Fibrinolytic Therapy"] Fibrinolytic
      such that Fibrinolytic.status = 'completed'
        and start of ( Fibrinolytic.effective.toInterval ( ) ) 30 minutes or less after EDwithSTEMI.currentemergencyDepartmentArrivalTime ( )

define "PCI within 90 Minutes of Arrival":
  "ED Encounter with STEMI Diagnosis" EDwithSTEMI
    with ["Procedure": "Percutaneous Coronary Intervention"] PCI
      such that PCI.performed.toInterval ( ) starts 90 minutes or less after EDwithSTEMI.currentemergencyDepartmentArrivalTime ( )
        and PCI.status = 'completed'

define "ED Departure with Discharge to Acute Care Facility Within 45 Minutes Of Arrival":
  "ED Encounter with STEMI Diagnosis" EDwithSTEMI
    where EDwithSTEMI.currentemergencyDepartmentDepartTime ( ) 45 minutes or less after EDwithSTEMI.currentemergencyDepartmentArrivalTime ( )
      and EDwithSTEMI.hospitalization.dischargeDisposition in "Discharge To Acute Care Facility"

define "Numerator":
  "Fibrinolytic Therapy Administration within 30 Minutes of Arrival"
    union "PCI within 90 Minutes of Arrival"
    union "ED Departure with Discharge to Acute Care Facility Within 45 Minutes Of Arrival"

define "Initial Population":
  "ED Encounter with STEMI Diagnosis"

define "Denominator":
  "Initial Population"

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

define "Initial Population":
  "ED Encounter with STEMI Diagnosis"

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

define "Allergy or Intolerance to Thrombolytic Medications Overlaps ED Encounter":
  "ED Encounter with STEMI Diagnosis" EDwSTEMI
    with ["AllergyIntolerance": "Thrombolytic medications"] ThrombolyticAllergy
      such that ThrombolyticAllergy.clinicalStatus ~ QICoreCommon."allergy-active"
        and ( ThrombolyticAllergy.verificationStatus is not null implies ( ThrombolyticAllergy.verificationStatus ~ QICoreCommon."allergy-confirmed"
              or ThrombolyticAllergy.verificationStatus ~ QICoreCommon."allergy-unconfirmed"
          )
        )
        and ( ThrombolyticAllergy.onset.toInterval ( ) overlaps ( EDwSTEMI.period ) )

define "Adverse Effect to Thrombolytic Medications Before End of ED Encounter":
  "ED Encounter with STEMI Diagnosis" EDwSTEMI
    with [AdverseEvent: "Thrombolytics Adverse Event"] ThrombolyticAdverseEvent
      such that Coalesce(ThrombolyticAdverseEvent.date, ThrombolyticAdverseEvent.detected, ThrombolyticAdverseEvent.recordedDate) before end of ( EDwSTEMI.period )
        and ThrombolyticAdverseEvent.actuality = 'actual'

define "Active Exclusion Diagnosis at Start of ED Encounter":
  "ED Encounter with STEMI Diagnosis" EDwithSTEMI
    with ( ["ConditionProblemsHealthConcerns": "Active Bleeding or Bleeding Diathesis, Excluding Menses"]
      union ["ConditionProblemsHealthConcerns": "Malignant Intracranial Neoplasm Group"]
      union ["ConditionProblemsHealthConcerns": "Cerebral Vascular Lesion"]
      union ["ConditionProblemsHealthConcerns": "Dementia and Related Intracranial Pathologies"]
      union ["ConditionProblemsHealthConcerns": "Pregnant State"]
      union ["ConditionProblemsHealthConcerns": "Allergy to thrombolytics"] ) ActiveExclusionDx
      such that ActiveExclusionDx.prevalenceInterval ( ) overlaps before ( EDwithSTEMI.period )
        and ( ActiveExclusionDx.verificationStatus is not null implies ( ActiveExclusionDx.verificationStatus ~ QICoreCommon."confirmed"
              or ActiveExclusionDx.verificationStatus ~ QICoreCommon."unconfirmed"
              or ActiveExclusionDx.verificationStatus ~ QICoreCommon."provisional"
              or ActiveExclusionDx.verificationStatus ~ QICoreCommon."differential"
          )
        )

define "Active Oral Anticoagulant Medication at the Start of ED Encounter":
  "ED Encounter with STEMI Diagnosis" EDwithSTEMI
    with ["MedicationRequest": "Oral Anticoagulant Medications"] OralAnticoagulant
      such that OralAnticoagulant.status in { 'active', 'completed' }
        and OralAnticoagulant.intent = 'order'
        and OralAnticoagulant.authoredOn 90 days or less before or on start of EDwithSTEMI.period

define "Active Long Term use of Anticoagulants":
  "ED Encounter with STEMI Diagnosis" EDwithSTEMI
    with ["ConditionProblemsHealthConcerns": "Long term (current) use of anticoagulants"] LongTermAnticoagulant
      such that ( LongTermAnticoagulant.prevalenceInterval ( ) starts before or on start of EDwithSTEMI.period
          and LongTermAnticoagulant.prevalenceInterval ( ) ends on or after start of EDwithSTEMI.period
      )
        and ( LongTermAnticoagulant.verificationStatus is not null implies ( LongTermAnticoagulant.verificationStatus ~ QICoreCommon."confirmed"
              or LongTermAnticoagulant.verificationStatus ~ QICoreCommon."unconfirmed"
              or LongTermAnticoagulant.verificationStatus ~ QICoreCommon."provisional"
              or LongTermAnticoagulant.verificationStatus ~ QICoreCommon."differential"
          )
        )

define "Active use of Anticoagulants":
  "Active Oral Anticoagulant Medication at the Start of ED Encounter"
    union "Active Long Term use of Anticoagulants"

define "Exclusion Diagnosis During ED Encounter or Within 24 Hours of ED Encounter Start":
  "ED Encounter with STEMI Diagnosis" EDwithSTEMI
    with ( ["ConditionProblemsHealthConcerns": "Aortic Dissection or Ruptured Aortic Aneurysm"]
      union ["ConditionProblemsHealthConcerns": "Neurologic impairment"]
      union ["ConditionProblemsHealthConcerns": "Angina pectoris with documented spasm"]
      union ["ConditionProblemsHealthConcerns": "Ventricular aneurysm due to and following acute myocardial infarction (disorder)"]
      union ["ConditionProblemsHealthConcerns": "Aneurysm of heart"]
      union ["ConditionProblemsHealthConcerns": "Takotsubo cardiomyopathy (disorder)"]
      union ["ConditionProblemsHealthConcerns": "Takotsubo syndrome"]
      union ["ConditionProblemsHealthConcerns": "Cardiopulmonary Emergency"] ) ExclusionDiagnosis
      such that ( ( ExclusionDiagnosis.prevalenceInterval ( ) starts during EDwithSTEMI.period )
          or ( ExclusionDiagnosis.prevalenceInterval ( ) starts 24 hours or less before start of EDwithSTEMI.period )
      )
        and ( ExclusionDiagnosis.verificationStatus is not null implies ( ExclusionDiagnosis.verificationStatus ~ QICoreCommon."confirmed"
              or ExclusionDiagnosis.verificationStatus ~ QICoreCommon."unconfirmed"
              or ExclusionDiagnosis.verificationStatus ~ QICoreCommon."provisional"
              or ExclusionDiagnosis.verificationStatus ~ QICoreCommon."differential"
          )
        )

define "Major Surgical Procedure 21 Days or Less Before Start of or Starts During ED Encounter":
  "ED Encounter with STEMI Diagnosis" EDwithSTEMI
    with ["Procedure": "Major Surgical Procedure"] MajorSurgery
      such that ( MajorSurgery.performed.toInterval ( ) starts 21 days or less before start of EDwithSTEMI.period
          or MajorSurgery.performed.toInterval ( ) starts during EDwithSTEMI.period
      )
        and MajorSurgery.status = 'completed'

define "Intubation or Mechanical Circulatory Assist Device Placement or Removal Procedure During ED Encounter or Within 24 Hours of ED Encounter Start":
  "ED Encounter with STEMI Diagnosis" EDwithSTEMI
    with ( ["Procedure": "Endotracheal Intubation"]
      union ["Procedure": "Mechanical Circulatory Assist Device"] ) AirwayProcedure
      such that ( ( AirwayProcedure.performed.toInterval ( ) starts during ( EDwithSTEMI.period ) )
          or ( AirwayProcedure.performed.toInterval ( ) starts 24 hours or less before start of ( EDwithSTEMI.period ) )
      )
        and AirwayProcedure.status = 'completed'

define "Active Exclusion Diagnosis Within 90 Days Before or At the Start of ED Encounter":
  "ED Encounter with STEMI Diagnosis" EDwSTEMI
    with ( ["ConditionProblemsHealthConcerns": "Ischemic Stroke"]
      union ["ConditionProblemsHealthConcerns": "Closed Head and Facial Trauma"]
      union ["ConditionProblemsHealthConcerns": "Active Peptic Ulcer"] ) ExclusionCondition
      such that ExclusionCondition.prevalenceInterval ( ) starts during Interval[start of ( EDwSTEMI.period ) - 90 days, start of ( EDwSTEMI.period )]
        and ( ExclusionCondition.verificationStatus is not null implies ( ExclusionCondition.verificationStatus ~ QICoreCommon."confirmed"
              or ExclusionCondition.verificationStatus ~ QICoreCommon."unconfirmed"
              or ExclusionCondition.verificationStatus ~ QICoreCommon."provisional"
              or ExclusionCondition.verificationStatus ~ QICoreCommon."differential"
          )
        )

define "Intracranial or Intraspinal Procedure 90 Days or Less Before Start of ED Encounter":
  "ED Encounter with STEMI Diagnosis" EDwithSTEMI
    with ["Procedure": "Intracranial or Intraspinal surgery"] CranialorSpinalSurgery
      such that CranialorSpinalSurgery.performed.toInterval ( ) starts 90 days or less before start of ( EDwithSTEMI.period )
        and CranialorSpinalSurgery.status = 'completed'

define "ED Encounter with Discharge Disposition as Patient Expired":
  "ED Encounter with STEMI Diagnosis" EDwithSTEMI
    where EDwithSTEMI.hospitalization.dischargeDisposition in "Patient Expired"

define "ED Encounter with Discharge Disposition as Left Against Medical Advice":
  "ED Encounter with STEMI Diagnosis" EDwSTEMI
    where EDwSTEMI.hospitalization.dischargeDisposition in "Left Against Medical Advice"

define "ED Encounter with Hospice Services":
  from
    "ED Encounter with STEMI Diagnosis" EDwSTEMI
    let SixMonthsBeforeToEndOfSTEMI: Interval[start of ( EDwSTEMI.period ) - 6 months, end of ( EDwSTEMI.period )]
    where ( exists ( ( [Encounter: "Encounter Inpatient"] ) InpatientEncounter
          where ( InpatientEncounter.hospitalization.dischargeDisposition ~ "Discharge to home for hospice care (procedure)"
              or InpatientEncounter.hospitalization.dischargeDisposition ~ "Discharge to healthcare facility for hospice care (procedure)"
          )
            and InpatientEncounter.status = 'finished'
            and InpatientEncounter.period starts before or on start of ( EDwSTEMI.period )
            and InpatientEncounter.period overlaps day of SixMonthsBeforeToEndOfSTEMI
      )
        or exists ( ( [Encounter: "Hospice Encounter"] ) HospiceEncounter
            where HospiceEncounter.period starts before or on start of ( EDwSTEMI.period )
              and ( HospiceEncounter.period overlaps day of SixMonthsBeforeToEndOfSTEMI )
              and HospiceEncounter.status = 'finished'
        )
        or exists ( ( ( [ObservationScreeningAssessment: "Hospice care [Minimum Data Set]"] ).isAssessmentPerformed ( ) ) HospiceAssessment
            where ( HospiceAssessment as ObservationScreeningAssessment ).value ~ "Yes (qualifier value)"
              and HospiceAssessment.effective.toInterval ( ) starts before or on start of ( EDwSTEMI.period )
              and ( HospiceAssessment.effective.toInterval ( ) overlaps day of SixMonthsBeforeToEndOfSTEMI )
        )
        or exists ( ( ( [ServiceRequest: "Hospice Care Ambulatory"] ).isInterventionOrder ( ) ) HospiceOrder
            where HospiceOrder.authoredOn 6 months or less before start of ( EDwSTEMI.period )
        )
        or exists ( ( ( [Procedure: "Hospice Care Ambulatory"] ).isInterventionPerformed ( ) ) HospicePerformed
            where HospicePerformed.performed.toInterval ( ) starts before or on start of ( EDwSTEMI.period )
              and ( HospicePerformed.performed.toInterval ( ) overlaps day of SixMonthsBeforeToEndOfSTEMI )
        )
        or exists ( ( [ConditionProblemsHealthConcerns: "Hospice Diagnosis"] ) HospiceCareDiagnosis
            where HospiceCareDiagnosis.prevalenceInterval ( ) ends on or after start of ( EDwSTEMI.period )
              and ( HospiceCareDiagnosis.verificationStatus is not null implies ( HospiceCareDiagnosis.verificationStatus ~ QICoreCommon."confirmed"
                    or HospiceCareDiagnosis.verificationStatus ~ QICoreCommon."unconfirmed"
                    or HospiceCareDiagnosis.verificationStatus ~ QICoreCommon."provisional"
                    or HospiceCareDiagnosis.verificationStatus ~ QICoreCommon."differential"
                )
              )
        )
    )

define "Currently Pregnant":
  "ED Encounter with STEMI Diagnosis" EDwSTEMI
    with ( ["USCoreObservationPregnancyStatusProfile"] ) PregStatus
      such that PregStatus.status = 'final'
        and ( PregStatus.value in "Pregnant State" )
        and ( PregStatus.effective.toInterval ( ) overlaps EDwSTEMI.period )

define "Denominator Exclusions":
  "Allergy or Intolerance to Thrombolytic Medications Overlaps ED Encounter"
    union "Adverse Effect to Thrombolytic Medications Before End of ED Encounter"
    union "Active Exclusion Diagnosis at Start of ED Encounter"
    union "Active use of Anticoagulants"
    union "Exclusion Diagnosis During ED Encounter or Within 24 Hours of ED Encounter Start"
    union "Major Surgical Procedure 21 Days or Less Before Start of or Starts During ED Encounter"
    union "Intubation or Mechanical Circulatory Assist Device Placement or Removal Procedure During ED Encounter or Within 24 Hours of ED Encounter Start"
    union "Active Exclusion Diagnosis Within 90 Days Before or At the Start of ED Encounter"
    union "Intracranial or Intraspinal Procedure 90 Days or Less Before Start of ED Encounter"
    union "ED Encounter with Discharge Disposition as Patient Expired"
    union "ED Encounter with Discharge Disposition as Left Against Medical Advice"
    union "ED Encounter with Hospice Services"
    union "Currently Pregnant"

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

define "Received tPA in Another Facility within 24 hours Prior to Admission":
  "ED Encounter with STEMI Diagnosis" EDwithSTEMI
    with ( ["ConditionProblemsHealthConcerns": "Status post administration of tPA (rtPA) in a different facility within the last 24 hours prior to admission to current facility"] ) TPA
      such that TPA.prevalenceInterval ( ) starts during EDwithSTEMI.period
        and ( TPA.verificationStatus is not null implies ( TPA.verificationStatus ~ QICoreCommon."confirmed"
              or TPA.verificationStatus ~ QICoreCommon."unconfirmed"
              or TPA.verificationStatus ~ QICoreCommon."provisional"
              or TPA.verificationStatus ~ QICoreCommon."differential"
          )
        )

define "ED Encounter with a Documented Reason for No PCI Performed":
  "ED Encounter with STEMI Diagnosis" EDwSTEMI
    with ["ProcedureNotDone": "Percutaneous Coronary Intervention"] PCINotDone
      such that ( PCINotDone.statusReason in "Patient Refusal"
          or PCINotDone.statusReason in "Procedure Not Indicated/Contraindicated"
      )
        and PCINotDone.recorded during EDwSTEMI.period

define "ED Encounter with a Documented Reason for Not Administering Fibrinolytic Therapy":
  "ED Encounter with STEMI Diagnosis" EDwSTEMI
    with ["MedicationAdministrationNotDone": "Fibrinolytic Therapy"] FibrinolyticNoMed
      such that ( FibrinolyticNoMed.statusReason in "Patient Refusal"
          or FibrinolyticNoMed.statusReason in "Drug Intervention Not Indicated/Contraindicated"
      )
        and FibrinolyticNoMed.recorded during EDwSTEMI.period

define "Denominator Exceptions":
  "Received tPA in Another Facility within 24 hours Prior to Admission"
    union "ED Encounter with a Documented Reason for No PCI Performed"
    union "ED Encounter with a Documented Reason for Not Administering Fibrinolytic Therapy"

define fluent function currentemergencyDepartmentArrivalTime(EDEncounter Encounter):
  First(EDEncounter.location EDLocation
      where exists((CQMCommon.GetLocation(EDLocation.location).type) LocationType
          where(LocationType in "Emergency Department Visit"
              or LocationType ~ "Emergency room"
          )
            and start of EDLocation.period is not null
      )
      return start of EDLocation.period
      sort ascending
  )

define fluent function currentemergencyDepartmentDepartTime(EDEncounter Encounter):
  Last(EDEncounter.location EDLocation
      where exists((CQMCommon.GetLocation(EDLocation.location).type) LocationType
          where(LocationType in "Emergency Department Visit"
              or LocationType ~ "Emergency room"
          )
            and 
            end of EDLocation.period is not null
      )
      return 
      end of EDLocation.period
      sort ascending
  )

/*
@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, '/'))

/*
@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: 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

/*
@description: Returns an interval representing the normalized prevalence period of a given Condition.
@comment: Uses the ToInterval and ToAbatementInterval functions to determine the widest potential interval from
onset to abatement as specified in the given Condition. If the condition is active, or has an abatement date the resulting 
interval will have a closed ending boundary. Otherwise, the resulting interval will have an open ending boundary.
*/
define fluent function prevalenceInterval(condition Choice<"ConditionEncounterDiagnosis", "ConditionProblemsHealthConcerns">):
if condition.clinicalStatus ~ "active"
  or condition.clinicalStatus ~ "recurrence"
  or condition.clinicalStatus ~ "relapse" then
  Interval[start of condition.onset.toInterval(), end of condition.abatementInterval()]
else
    (end of condition.abatementInterval()) abatementDate
    return if abatementDate is null then
      Interval[start of condition.onset.toInterval(), abatementDate)
    else
      Interval[start of condition.onset.toInterval(), abatementDate]

/*
@description: Returns an interval representing the normalized abatement of a given Condition.
@comment: If the abatement element of the Condition is represented as a DateTime, the result
is an interval beginning and ending on that DateTime.
If the abatement is represented as a Quantity, the quantity is expected to be a calendar-duration and is interpreted as the age of the patient. The
result is an interval from the date the patient turned that age to immediately before one year later.
If the abatement is represented as a Quantity Interval, the quantities are expected to be calendar-durations and are interpreted as an age range during
which the abatement occurred. The result is an interval from the date the patient turned the starting age of the quantity interval, and ending immediately
before one year later than the date the patient turned the ending age of the quantity interval.
*/
define fluent function abatementInterval(condition Choice<"ConditionEncounterDiagnosis", "ConditionProblemsHealthConcerns">):
	if condition.abatement is DateTime then
	  Interval[condition.abatement as DateTime, condition.abatement as DateTime]
	else if condition.abatement is Quantity then
		Interval[Patient.birthDate + (condition.abatement as Quantity),
			Patient.birthDate + (condition.abatement as Quantity) + 1 year)
	else if condition.abatement is Interval<Quantity> then
	  Interval[Patient.birthDate + (condition.abatement.low as Quantity),
		  Patient.birthDate + (condition.abatement.high as Quantity) + 1 year)
	else if condition.abatement is Interval<DateTime> then
	  Interval[condition.abatement.low, condition.abatement.high)
	else null as Interval<DateTime>

//This library contains functions used to constrain FHIR resource elements for measures authored by NCQA, based on QICore 6.0.0 resources including IG and authoring patterns. The functions may appear similar to some QICoreCommon functions but differ in that they have constraints that are relevant for measures authored by NCQA.

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

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

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

Source

{
  "resourceType": "Measure",
  "id": "CMS996FHIRAptTxforSTEMI",
  "meta": {
    "profile": [
      "http://hl7.org/fhir/uv/crmi/StructureDefinition/crmi-shareablemeasure",
      "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/computable-measure-cqfm",
      "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/publishable-measure-cqfm",
      "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/executable-measure-cqfm",
      "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cql-measure-cqfm",
      "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/elm-measure-cqfm",
      "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/proportion-measure-cqfm"
    ]
  },
  "text": {
    "status": "extensions",
    "div": "<!-- snip (see above) -->"
  },
  "contained": [
    {
      "resourceType": "Library",
      "id": "effective-data-requirements",
      "extension": [
        {
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-directReferenceCode",
          "valueCoding": {
            "system": "http://snomed.info/sct",
            "code": "248153007",
            "display": "Male (finding)"
          }
        },
        {
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-directReferenceCode",
          "valueCoding": {
            "system": "http://snomed.info/sct",
            "code": "248152002",
            "display": "Female (finding)"
          }
        },
        {
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-directReferenceCode",
          "valueCoding": {
            "system": "http://terminology.hl7.org/CodeSystem/condition-ver-status",
            "code": "confirmed",
            "display": "Confirmed"
          }
        },
        {
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-directReferenceCode",
          "valueCoding": {
            "system": "http://terminology.hl7.org/CodeSystem/condition-ver-status",
            "code": "unconfirmed",
            "display": "Unconfirmed"
          }
        },
        {
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-directReferenceCode",
          "valueCoding": {
            "system": "http://terminology.hl7.org/CodeSystem/condition-ver-status",
            "code": "provisional",
            "display": "Provisional"
          }
        },
        {
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-directReferenceCode",
          "valueCoding": {
            "system": "http://terminology.hl7.org/CodeSystem/condition-ver-status",
            "code": "differential",
            "display": "Differential"
          }
        },
        {
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-directReferenceCode",
          "valueCoding": {
            "system": "http://terminology.hl7.org/CodeSystem/v3-RoleCode",
            "code": "ER",
            "display": "Emergency room"
          }
        },
        {
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-directReferenceCode",
          "valueCoding": {
            "system": "http://terminology.hl7.org/CodeSystem/allergyintolerance-clinical",
            "code": "active",
            "display": "Active"
          }
        },
        {
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-directReferenceCode",
          "valueCoding": {
            "system": "http://terminology.hl7.org/CodeSystem/allergyintolerance-verification",
            "code": "confirmed",
            "display": "Confirmed"
          }
        },
        {
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-directReferenceCode",
          "valueCoding": {
            "system": "http://terminology.hl7.org/CodeSystem/allergyintolerance-verification",
            "code": "unconfirmed",
            "display": "Unconfirmed"
          }
        },
        {
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-directReferenceCode",
          "valueCoding": {
            "system": "http://terminology.hl7.org/CodeSystem/condition-clinical",
            "code": "active",
            "display": "Active"
          }
        },
        {
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-directReferenceCode",
          "valueCoding": {
            "system": "http://terminology.hl7.org/CodeSystem/condition-clinical",
            "code": "recurrence",
            "display": "Recurrence"
          }
        },
        {
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-directReferenceCode",
          "valueCoding": {
            "system": "http://terminology.hl7.org/CodeSystem/condition-clinical",
            "code": "relapse",
            "display": "Relapse"
          }
        },
        {
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-directReferenceCode",
          "valueCoding": {
            "system": "http://hl7.org/fhir/sid/icd-10-cm",
            "code": "Z79.01",
            "display": "Long term (current) use of anticoagulants"
          }
        },
        {
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-directReferenceCode",
          "valueCoding": {
            "system": "http://hl7.org/fhir/sid/icd-10-cm",
            "code": "I20.1",
            "display": "Angina pectoris with documented spasm"
          }
        },
        {
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-directReferenceCode",
          "valueCoding": {
            "system": "http://snomed.info/sct",
            "code": "723858002",
            "display": "Ventricular aneurysm due to and following acute myocardial infarction (disorder)"
          }
        },
        {
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-directReferenceCode",
          "valueCoding": {
            "system": "http://hl7.org/fhir/sid/icd-10-cm",
            "code": "I25.3",
            "display": "Aneurysm of heart"
          }
        },
        {
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-directReferenceCode",
          "valueCoding": {
            "system": "http://snomed.info/sct",
            "code": "441541008",
            "display": "Takotsubo cardiomyopathy (disorder)"
          }
        },
        {
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-directReferenceCode",
          "valueCoding": {
            "system": "http://hl7.org/fhir/sid/icd-10-cm",
            "code": "I51.81",
            "display": "Takotsubo syndrome"
          }
        },
        {
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-directReferenceCode",
          "valueCoding": {
            "system": "http://snomed.info/sct",
            "code": "428361000124107",
            "display": "Discharge to home for hospice care (procedure)"
          }
        },
        {
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-directReferenceCode",
          "valueCoding": {
            "system": "http://snomed.info/sct",
            "code": "428371000124100",
            "display": "Discharge to healthcare facility for hospice care (procedure)"
          }
        },
        {
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-directReferenceCode",
          "valueCoding": {
            "system": "http://loinc.org",
            "code": "45755-6",
            "display": "Hospice care [Minimum Data Set]"
          }
        },
        {
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-directReferenceCode",
          "valueCoding": {
            "system": "http://snomed.info/sct",
            "code": "373066001",
            "display": "Yes (qualifier value)"
          }
        },
        {
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-directReferenceCode",
          "valueCoding": {
            "system": "http://hl7.org/fhir/sid/icd-10-cm",
            "code": "Z92.82",
            "display": "Status post administration of tPA (rtPA) in a different facility within the last 24 hours prior to admission to current facility"
          }
        },
        {
          "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": "CMS996FHIRAptTxforSTEMI"
            },
            {
              "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": "CMS996FHIRAptTxforSTEMI"
            },
            {
              "url": "name",
              "valueString": "ED Encounter During MP"
            },
            {
              "url": "statement",
              "valueString": "define \"ED Encounter During MP\":\n  [\"Encounter\": \"Emergency Department Evaluation and Management Visit\"] EDEncounter\n    where EDEncounter.period ends during day of \"Measurement Period\"\n      and EDEncounter.status = 'finished'\n      and AgeInYearsAt(date from start of(EDEncounter.period)) >= 18"
            },
            {
              "url": "displaySequence",
              "valueInteger": 2
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS996FHIRAptTxforSTEMI"
            },
            {
              "url": "name",
              "valueString": "ED Encounter with STEMI Diagnosis"
            },
            {
              "url": "statement",
              "valueString": "define \"ED Encounter with STEMI Diagnosis\":\n  \"ED Encounter During MP\" EDEncounterinMP\n    where ( EDEncounterinMP.reasonCode in \"STEMI\"\n        or exists ( ( [ConditionProblemsHealthConcerns: \"STEMI\"]\n            union [ConditionEncounterDiagnosis: \"STEMI\"] ) DxSTEMI\n            where ( EDEncounterinMP.encounterDiagnosis ( ).code in \"STEMI\"\n                or ( DxSTEMI.prevalenceInterval ( ) starts during EDEncounterinMP.period )\n            )\n              and ( DxSTEMI.verificationStatus is not null implies ( DxSTEMI.verificationStatus ~ QICoreCommon.\"confirmed\"\n                    or DxSTEMI.verificationStatus ~ QICoreCommon.\"unconfirmed\"\n                    or DxSTEMI.verificationStatus ~ QICoreCommon.\"provisional\"\n                    or DxSTEMI.verificationStatus ~ QICoreCommon.\"differential\"\n                )\n              )\n        )\n    )"
            },
            {
              "url": "displaySequence",
              "valueInteger": 3
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS996FHIRAptTxforSTEMI"
            },
            {
              "url": "name",
              "valueString": "Fibrinolytic Therapy Administration within 30 Minutes of Arrival"
            },
            {
              "url": "statement",
              "valueString": "define \"Fibrinolytic Therapy Administration within 30 Minutes of Arrival\":\n  \"ED Encounter with STEMI Diagnosis\" EDwithSTEMI\n    with [\"MedicationAdministration\": \"Fibrinolytic Therapy\"] Fibrinolytic\n      such that Fibrinolytic.status = 'completed'\n        and start of ( Fibrinolytic.effective.toInterval ( ) ) 30 minutes or less after EDwithSTEMI.currentemergencyDepartmentArrivalTime ( )"
            },
            {
              "url": "displaySequence",
              "valueInteger": 4
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS996FHIRAptTxforSTEMI"
            },
            {
              "url": "name",
              "valueString": "PCI within 90 Minutes of Arrival"
            },
            {
              "url": "statement",
              "valueString": "define \"PCI within 90 Minutes of Arrival\":\n  \"ED Encounter with STEMI Diagnosis\" EDwithSTEMI\n    with [\"Procedure\": \"Percutaneous Coronary Intervention\"] PCI\n      such that PCI.performed.toInterval ( ) starts 90 minutes or less after EDwithSTEMI.currentemergencyDepartmentArrivalTime ( )\n        and PCI.status = 'completed'"
            },
            {
              "url": "displaySequence",
              "valueInteger": 5
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS996FHIRAptTxforSTEMI"
            },
            {
              "url": "name",
              "valueString": "ED Departure with Discharge to Acute Care Facility Within 45 Minutes Of Arrival"
            },
            {
              "url": "statement",
              "valueString": "define \"ED Departure with Discharge to Acute Care Facility Within 45 Minutes Of Arrival\":\n  \"ED Encounter with STEMI Diagnosis\" EDwithSTEMI\n    where EDwithSTEMI.currentemergencyDepartmentDepartTime ( ) 45 minutes or less after EDwithSTEMI.currentemergencyDepartmentArrivalTime ( )\n      and EDwithSTEMI.hospitalization.dischargeDisposition in \"Discharge To Acute Care Facility\""
            },
            {
              "url": "displaySequence",
              "valueInteger": 6
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS996FHIRAptTxforSTEMI"
            },
            {
              "url": "name",
              "valueString": "Numerator"
            },
            {
              "url": "statement",
              "valueString": "define \"Numerator\":\n  \"Fibrinolytic Therapy Administration within 30 Minutes of Arrival\"\n    union \"PCI within 90 Minutes of Arrival\"\n    union \"ED Departure with Discharge to Acute Care Facility Within 45 Minutes Of Arrival\""
            },
            {
              "url": "displaySequence",
              "valueInteger": 7
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS996FHIRAptTxforSTEMI"
            },
            {
              "url": "name",
              "valueString": "Initial Population"
            },
            {
              "url": "statement",
              "valueString": "define \"Initial Population\":\n  \"ED Encounter with STEMI Diagnosis\""
            },
            {
              "url": "displaySequence",
              "valueInteger": 8
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS996FHIRAptTxforSTEMI"
            },
            {
              "url": "name",
              "valueString": "Denominator"
            },
            {
              "url": "statement",
              "valueString": "define \"Denominator\":\n  \"Initial Population\""
            },
            {
              "url": "displaySequence",
              "valueInteger": 9
            }
          ],
          "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": 10
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS996FHIRAptTxforSTEMI"
            },
            {
              "url": "name",
              "valueString": "SDE Payer"
            },
            {
              "url": "statement",
              "valueString": "define \"SDE Payer\":\n  SDE.\"SDE Payer\""
            },
            {
              "url": "displaySequence",
              "valueInteger": 11
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS996FHIRAptTxforSTEMI"
            },
            {
              "url": "name",
              "valueString": "Initial Population"
            },
            {
              "url": "statement",
              "valueString": "define \"Initial Population\":\n  \"ED Encounter with STEMI Diagnosis\""
            },
            {
              "url": "displaySequence",
              "valueInteger": 12
            }
          ],
          "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": 13
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS996FHIRAptTxforSTEMI"
            },
            {
              "url": "name",
              "valueString": "SDE Ethnicity"
            },
            {
              "url": "statement",
              "valueString": "define \"SDE Ethnicity\":\n  SDE.\"SDE Ethnicity\""
            },
            {
              "url": "displaySequence",
              "valueInteger": 14
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS996FHIRAptTxforSTEMI"
            },
            {
              "url": "name",
              "valueString": "Allergy or Intolerance to Thrombolytic Medications Overlaps ED Encounter"
            },
            {
              "url": "statement",
              "valueString": "define \"Allergy or Intolerance to Thrombolytic Medications Overlaps ED Encounter\":\n  \"ED Encounter with STEMI Diagnosis\" EDwSTEMI\n    with [\"AllergyIntolerance\": \"Thrombolytic medications\"] ThrombolyticAllergy\n      such that ThrombolyticAllergy.clinicalStatus ~ QICoreCommon.\"allergy-active\"\n        and ( ThrombolyticAllergy.verificationStatus is not null implies ( ThrombolyticAllergy.verificationStatus ~ QICoreCommon.\"allergy-confirmed\"\n              or ThrombolyticAllergy.verificationStatus ~ QICoreCommon.\"allergy-unconfirmed\"\n          )\n        )\n        and ( ThrombolyticAllergy.onset.toInterval ( ) overlaps ( EDwSTEMI.period ) )"
            },
            {
              "url": "displaySequence",
              "valueInteger": 15
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS996FHIRAptTxforSTEMI"
            },
            {
              "url": "name",
              "valueString": "Adverse Effect to Thrombolytic Medications Before End of ED Encounter"
            },
            {
              "url": "statement",
              "valueString": "define \"Adverse Effect to Thrombolytic Medications Before End of ED Encounter\":\n  \"ED Encounter with STEMI Diagnosis\" EDwSTEMI\n    with [AdverseEvent: \"Thrombolytics Adverse Event\"] ThrombolyticAdverseEvent\n      such that Coalesce(ThrombolyticAdverseEvent.date, ThrombolyticAdverseEvent.detected, ThrombolyticAdverseEvent.recordedDate) before end of ( EDwSTEMI.period )\n        and ThrombolyticAdverseEvent.actuality = 'actual'"
            },
            {
              "url": "displaySequence",
              "valueInteger": 16
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS996FHIRAptTxforSTEMI"
            },
            {
              "url": "name",
              "valueString": "Active Exclusion Diagnosis at Start of ED Encounter"
            },
            {
              "url": "statement",
              "valueString": "define \"Active Exclusion Diagnosis at Start of ED Encounter\":\n  \"ED Encounter with STEMI Diagnosis\" EDwithSTEMI\n    with ( [\"ConditionProblemsHealthConcerns\": \"Active Bleeding or Bleeding Diathesis, Excluding Menses\"]\n      union [\"ConditionProblemsHealthConcerns\": \"Malignant Intracranial Neoplasm Group\"]\n      union [\"ConditionProblemsHealthConcerns\": \"Cerebral Vascular Lesion\"]\n      union [\"ConditionProblemsHealthConcerns\": \"Dementia and Related Intracranial Pathologies\"]\n      union [\"ConditionProblemsHealthConcerns\": \"Pregnant State\"]\n      union [\"ConditionProblemsHealthConcerns\": \"Allergy to thrombolytics\"] ) ActiveExclusionDx\n      such that ActiveExclusionDx.prevalenceInterval ( ) overlaps before ( EDwithSTEMI.period )\n        and ( ActiveExclusionDx.verificationStatus is not null implies ( ActiveExclusionDx.verificationStatus ~ QICoreCommon.\"confirmed\"\n              or ActiveExclusionDx.verificationStatus ~ QICoreCommon.\"unconfirmed\"\n              or ActiveExclusionDx.verificationStatus ~ QICoreCommon.\"provisional\"\n              or ActiveExclusionDx.verificationStatus ~ QICoreCommon.\"differential\"\n          )\n        )"
            },
            {
              "url": "displaySequence",
              "valueInteger": 17
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS996FHIRAptTxforSTEMI"
            },
            {
              "url": "name",
              "valueString": "Active Oral Anticoagulant Medication at the Start of ED Encounter"
            },
            {
              "url": "statement",
              "valueString": "define \"Active Oral Anticoagulant Medication at the Start of ED Encounter\":\n  \"ED Encounter with STEMI Diagnosis\" EDwithSTEMI\n    with [\"MedicationRequest\": \"Oral Anticoagulant Medications\"] OralAnticoagulant\n      such that OralAnticoagulant.status in { 'active', 'completed' }\n        and OralAnticoagulant.intent = 'order'\n        and OralAnticoagulant.authoredOn 90 days or less before or on start of EDwithSTEMI.period"
            },
            {
              "url": "displaySequence",
              "valueInteger": 18
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS996FHIRAptTxforSTEMI"
            },
            {
              "url": "name",
              "valueString": "Active Long Term use of Anticoagulants"
            },
            {
              "url": "statement",
              "valueString": "define \"Active Long Term use of Anticoagulants\":\n  \"ED Encounter with STEMI Diagnosis\" EDwithSTEMI\n    with [\"ConditionProblemsHealthConcerns\": \"Long term (current) use of anticoagulants\"] LongTermAnticoagulant\n      such that ( LongTermAnticoagulant.prevalenceInterval ( ) starts before or on start of EDwithSTEMI.period\n          and LongTermAnticoagulant.prevalenceInterval ( ) ends on or after start of EDwithSTEMI.period\n      )\n        and ( LongTermAnticoagulant.verificationStatus is not null implies ( LongTermAnticoagulant.verificationStatus ~ QICoreCommon.\"confirmed\"\n              or LongTermAnticoagulant.verificationStatus ~ QICoreCommon.\"unconfirmed\"\n              or LongTermAnticoagulant.verificationStatus ~ QICoreCommon.\"provisional\"\n              or LongTermAnticoagulant.verificationStatus ~ QICoreCommon.\"differential\"\n          )\n        )"
            },
            {
              "url": "displaySequence",
              "valueInteger": 19
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS996FHIRAptTxforSTEMI"
            },
            {
              "url": "name",
              "valueString": "Active use of Anticoagulants"
            },
            {
              "url": "statement",
              "valueString": "define \"Active use of Anticoagulants\":\n  \"Active Oral Anticoagulant Medication at the Start of ED Encounter\"\n    union \"Active Long Term use of Anticoagulants\""
            },
            {
              "url": "displaySequence",
              "valueInteger": 20
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS996FHIRAptTxforSTEMI"
            },
            {
              "url": "name",
              "valueString": "Exclusion Diagnosis During ED Encounter or Within 24 Hours of ED Encounter Start"
            },
            {
              "url": "statement",
              "valueString": "define \"Exclusion Diagnosis During ED Encounter or Within 24 Hours of ED Encounter Start\":\n  \"ED Encounter with STEMI Diagnosis\" EDwithSTEMI\n    with ( [\"ConditionProblemsHealthConcerns\": \"Aortic Dissection or Ruptured Aortic Aneurysm\"]\n      union [\"ConditionProblemsHealthConcerns\": \"Neurologic impairment\"]\n      union [\"ConditionProblemsHealthConcerns\": \"Angina pectoris with documented spasm\"]\n      union [\"ConditionProblemsHealthConcerns\": \"Ventricular aneurysm due to and following acute myocardial infarction (disorder)\"]\n      union [\"ConditionProblemsHealthConcerns\": \"Aneurysm of heart\"]\n      union [\"ConditionProblemsHealthConcerns\": \"Takotsubo cardiomyopathy (disorder)\"]\n      union [\"ConditionProblemsHealthConcerns\": \"Takotsubo syndrome\"]\n      union [\"ConditionProblemsHealthConcerns\": \"Cardiopulmonary Emergency\"] ) ExclusionDiagnosis\n      such that ( ( ExclusionDiagnosis.prevalenceInterval ( ) starts during EDwithSTEMI.period )\n          or ( ExclusionDiagnosis.prevalenceInterval ( ) starts 24 hours or less before start of EDwithSTEMI.period )\n      )\n        and ( ExclusionDiagnosis.verificationStatus is not null implies ( ExclusionDiagnosis.verificationStatus ~ QICoreCommon.\"confirmed\"\n              or ExclusionDiagnosis.verificationStatus ~ QICoreCommon.\"unconfirmed\"\n              or ExclusionDiagnosis.verificationStatus ~ QICoreCommon.\"provisional\"\n              or ExclusionDiagnosis.verificationStatus ~ QICoreCommon.\"differential\"\n          )\n        )"
            },
            {
              "url": "displaySequence",
              "valueInteger": 21
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS996FHIRAptTxforSTEMI"
            },
            {
              "url": "name",
              "valueString": "Major Surgical Procedure 21 Days or Less Before Start of or Starts During ED Encounter"
            },
            {
              "url": "statement",
              "valueString": "define \"Major Surgical Procedure 21 Days or Less Before Start of or Starts During ED Encounter\":\n  \"ED Encounter with STEMI Diagnosis\" EDwithSTEMI\n    with [\"Procedure\": \"Major Surgical Procedure\"] MajorSurgery\n      such that ( MajorSurgery.performed.toInterval ( ) starts 21 days or less before start of EDwithSTEMI.period\n          or MajorSurgery.performed.toInterval ( ) starts during EDwithSTEMI.period\n      )\n        and MajorSurgery.status = 'completed'"
            },
            {
              "url": "displaySequence",
              "valueInteger": 22
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS996FHIRAptTxforSTEMI"
            },
            {
              "url": "name",
              "valueString": "Intubation or Mechanical Circulatory Assist Device Placement or Removal Procedure During ED Encounter or Within 24 Hours of ED Encounter Start"
            },
            {
              "url": "statement",
              "valueString": "define \"Intubation or Mechanical Circulatory Assist Device Placement or Removal Procedure During ED Encounter or Within 24 Hours of ED Encounter Start\":\n  \"ED Encounter with STEMI Diagnosis\" EDwithSTEMI\n    with ( [\"Procedure\": \"Endotracheal Intubation\"]\n      union [\"Procedure\": \"Mechanical Circulatory Assist Device\"] ) AirwayProcedure\n      such that ( ( AirwayProcedure.performed.toInterval ( ) starts during ( EDwithSTEMI.period ) )\n          or ( AirwayProcedure.performed.toInterval ( ) starts 24 hours or less before start of ( EDwithSTEMI.period ) )\n      )\n        and AirwayProcedure.status = 'completed'"
            },
            {
              "url": "displaySequence",
              "valueInteger": 23
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS996FHIRAptTxforSTEMI"
            },
            {
              "url": "name",
              "valueString": "Active Exclusion Diagnosis Within 90 Days Before or At the Start of ED Encounter"
            },
            {
              "url": "statement",
              "valueString": "define \"Active Exclusion Diagnosis Within 90 Days Before or At the Start of ED Encounter\":\n  \"ED Encounter with STEMI Diagnosis\" EDwSTEMI\n    with ( [\"ConditionProblemsHealthConcerns\": \"Ischemic Stroke\"]\n      union [\"ConditionProblemsHealthConcerns\": \"Closed Head and Facial Trauma\"]\n      union [\"ConditionProblemsHealthConcerns\": \"Active Peptic Ulcer\"] ) ExclusionCondition\n      such that ExclusionCondition.prevalenceInterval ( ) starts during Interval[start of ( EDwSTEMI.period ) - 90 days, start of ( EDwSTEMI.period )]\n        and ( ExclusionCondition.verificationStatus is not null implies ( ExclusionCondition.verificationStatus ~ QICoreCommon.\"confirmed\"\n              or ExclusionCondition.verificationStatus ~ QICoreCommon.\"unconfirmed\"\n              or ExclusionCondition.verificationStatus ~ QICoreCommon.\"provisional\"\n              or ExclusionCondition.verificationStatus ~ QICoreCommon.\"differential\"\n          )\n        )"
            },
            {
              "url": "displaySequence",
              "valueInteger": 24
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS996FHIRAptTxforSTEMI"
            },
            {
              "url": "name",
              "valueString": "Intracranial or Intraspinal Procedure 90 Days or Less Before Start of ED Encounter"
            },
            {
              "url": "statement",
              "valueString": "define \"Intracranial or Intraspinal Procedure 90 Days or Less Before Start of ED Encounter\":\n  \"ED Encounter with STEMI Diagnosis\" EDwithSTEMI\n    with [\"Procedure\": \"Intracranial or Intraspinal surgery\"] CranialorSpinalSurgery\n      such that CranialorSpinalSurgery.performed.toInterval ( ) starts 90 days or less before start of ( EDwithSTEMI.period )\n        and CranialorSpinalSurgery.status = 'completed'"
            },
            {
              "url": "displaySequence",
              "valueInteger": 25
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS996FHIRAptTxforSTEMI"
            },
            {
              "url": "name",
              "valueString": "ED Encounter with Discharge Disposition as Patient Expired"
            },
            {
              "url": "statement",
              "valueString": "define \"ED Encounter with Discharge Disposition as Patient Expired\":\n  \"ED Encounter with STEMI Diagnosis\" EDwithSTEMI\n    where EDwithSTEMI.hospitalization.dischargeDisposition in \"Patient Expired\""
            },
            {
              "url": "displaySequence",
              "valueInteger": 26
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS996FHIRAptTxforSTEMI"
            },
            {
              "url": "name",
              "valueString": "ED Encounter with Discharge Disposition as Left Against Medical Advice"
            },
            {
              "url": "statement",
              "valueString": "define \"ED Encounter with Discharge Disposition as Left Against Medical Advice\":\n  \"ED Encounter with STEMI Diagnosis\" EDwSTEMI\n    where EDwSTEMI.hospitalization.dischargeDisposition in \"Left Against Medical Advice\""
            },
            {
              "url": "displaySequence",
              "valueInteger": 27
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS996FHIRAptTxforSTEMI"
            },
            {
              "url": "name",
              "valueString": "ED Encounter with Hospice Services"
            },
            {
              "url": "statement",
              "valueString": "define \"ED Encounter with Hospice Services\":\n  from\n    \"ED Encounter with STEMI Diagnosis\" EDwSTEMI\n    let SixMonthsBeforeToEndOfSTEMI: Interval[start of ( EDwSTEMI.period ) - 6 months, end of ( EDwSTEMI.period )]\n    where ( exists ( ( [Encounter: \"Encounter Inpatient\"] ) InpatientEncounter\n          where ( InpatientEncounter.hospitalization.dischargeDisposition ~ \"Discharge to home for hospice care (procedure)\"\n              or InpatientEncounter.hospitalization.dischargeDisposition ~ \"Discharge to healthcare facility for hospice care (procedure)\"\n          )\n            and InpatientEncounter.status = 'finished'\n            and InpatientEncounter.period starts before or on start of ( EDwSTEMI.period )\n            and InpatientEncounter.period overlaps day of SixMonthsBeforeToEndOfSTEMI\n      )\n        or exists ( ( [Encounter: \"Hospice Encounter\"] ) HospiceEncounter\n            where HospiceEncounter.period starts before or on start of ( EDwSTEMI.period )\n              and ( HospiceEncounter.period overlaps day of SixMonthsBeforeToEndOfSTEMI )\n              and HospiceEncounter.status = 'finished'\n        )\n        or exists ( ( ( [ObservationScreeningAssessment: \"Hospice care [Minimum Data Set]\"] ).isAssessmentPerformed ( ) ) HospiceAssessment\n            where ( HospiceAssessment as ObservationScreeningAssessment ).value ~ \"Yes (qualifier value)\"\n              and HospiceAssessment.effective.toInterval ( ) starts before or on start of ( EDwSTEMI.period )\n              and ( HospiceAssessment.effective.toInterval ( ) overlaps day of SixMonthsBeforeToEndOfSTEMI )\n        )\n        or exists ( ( ( [ServiceRequest: \"Hospice Care Ambulatory\"] ).isInterventionOrder ( ) ) HospiceOrder\n            where HospiceOrder.authoredOn 6 months or less before start of ( EDwSTEMI.period )\n        )\n        or exists ( ( ( [Procedure: \"Hospice Care Ambulatory\"] ).isInterventionPerformed ( ) ) HospicePerformed\n            where HospicePerformed.performed.toInterval ( ) starts before or on start of ( EDwSTEMI.period )\n              and ( HospicePerformed.performed.toInterval ( ) overlaps day of SixMonthsBeforeToEndOfSTEMI )\n        )\n        or exists ( ( [ConditionProblemsHealthConcerns: \"Hospice Diagnosis\"] ) HospiceCareDiagnosis\n            where HospiceCareDiagnosis.prevalenceInterval ( ) ends on or after start of ( EDwSTEMI.period )\n              and ( HospiceCareDiagnosis.verificationStatus is not null implies ( HospiceCareDiagnosis.verificationStatus ~ QICoreCommon.\"confirmed\"\n                    or HospiceCareDiagnosis.verificationStatus ~ QICoreCommon.\"unconfirmed\"\n                    or HospiceCareDiagnosis.verificationStatus ~ QICoreCommon.\"provisional\"\n                    or HospiceCareDiagnosis.verificationStatus ~ QICoreCommon.\"differential\"\n                )\n              )\n        )\n    )"
            },
            {
              "url": "displaySequence",
              "valueInteger": 28
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS996FHIRAptTxforSTEMI"
            },
            {
              "url": "name",
              "valueString": "Currently Pregnant"
            },
            {
              "url": "statement",
              "valueString": "define \"Currently Pregnant\":\n  \"ED Encounter with STEMI Diagnosis\" EDwSTEMI\n    with ( [\"USCoreObservationPregnancyStatusProfile\"] ) PregStatus\n      such that PregStatus.status = 'final'\n        and ( PregStatus.value in \"Pregnant State\" )\n        and ( PregStatus.effective.toInterval ( ) overlaps EDwSTEMI.period )"
            },
            {
              "url": "displaySequence",
              "valueInteger": 29
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS996FHIRAptTxforSTEMI"
            },
            {
              "url": "name",
              "valueString": "Denominator Exclusions"
            },
            {
              "url": "statement",
              "valueString": "define \"Denominator Exclusions\":\n  \"Allergy or Intolerance to Thrombolytic Medications Overlaps ED Encounter\"\n    union \"Adverse Effect to Thrombolytic Medications Before End of ED Encounter\"\n    union \"Active Exclusion Diagnosis at Start of ED Encounter\"\n    union \"Active use of Anticoagulants\"\n    union \"Exclusion Diagnosis During ED Encounter or Within 24 Hours of ED Encounter Start\"\n    union \"Major Surgical Procedure 21 Days or Less Before Start of or Starts During ED Encounter\"\n    union \"Intubation or Mechanical Circulatory Assist Device Placement or Removal Procedure During ED Encounter or Within 24 Hours of ED Encounter Start\"\n    union \"Active Exclusion Diagnosis Within 90 Days Before or At the Start of ED Encounter\"\n    union \"Intracranial or Intraspinal Procedure 90 Days or Less Before Start of ED Encounter\"\n    union \"ED Encounter with Discharge Disposition as Patient Expired\"\n    union \"ED Encounter with Discharge Disposition as Left Against Medical Advice\"\n    union \"ED Encounter with Hospice Services\"\n    union \"Currently Pregnant\""
            },
            {
              "url": "displaySequence",
              "valueInteger": 30
            }
          ],
          "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": 31
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS996FHIRAptTxforSTEMI"
            },
            {
              "url": "name",
              "valueString": "SDE Race"
            },
            {
              "url": "statement",
              "valueString": "define \"SDE Race\":\n  SDE.\"SDE Race\""
            },
            {
              "url": "displaySequence",
              "valueInteger": 32
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS996FHIRAptTxforSTEMI"
            },
            {
              "url": "name",
              "valueString": "Received tPA in Another Facility within 24 hours Prior to Admission"
            },
            {
              "url": "statement",
              "valueString": "define \"Received tPA in Another Facility within 24 hours Prior to Admission\":\n  \"ED Encounter with STEMI Diagnosis\" EDwithSTEMI\n    with ( [\"ConditionProblemsHealthConcerns\": \"Status post administration of tPA (rtPA) in a different facility within the last 24 hours prior to admission to current facility\"] ) TPA\n      such that TPA.prevalenceInterval ( ) starts during EDwithSTEMI.period\n        and ( TPA.verificationStatus is not null implies ( TPA.verificationStatus ~ QICoreCommon.\"confirmed\"\n              or TPA.verificationStatus ~ QICoreCommon.\"unconfirmed\"\n              or TPA.verificationStatus ~ QICoreCommon.\"provisional\"\n              or TPA.verificationStatus ~ QICoreCommon.\"differential\"\n          )\n        )"
            },
            {
              "url": "displaySequence",
              "valueInteger": 33
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS996FHIRAptTxforSTEMI"
            },
            {
              "url": "name",
              "valueString": "ED Encounter with a Documented Reason for No PCI Performed"
            },
            {
              "url": "statement",
              "valueString": "define \"ED Encounter with a Documented Reason for No PCI Performed\":\n  \"ED Encounter with STEMI Diagnosis\" EDwSTEMI\n    with [\"ProcedureNotDone\": \"Percutaneous Coronary Intervention\"] PCINotDone\n      such that ( PCINotDone.statusReason in \"Patient Refusal\"\n          or PCINotDone.statusReason in \"Procedure Not Indicated/Contraindicated\"\n      )\n        and PCINotDone.recorded during EDwSTEMI.period"
            },
            {
              "url": "displaySequence",
              "valueInteger": 34
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS996FHIRAptTxforSTEMI"
            },
            {
              "url": "name",
              "valueString": "ED Encounter with a Documented Reason for Not Administering Fibrinolytic Therapy"
            },
            {
              "url": "statement",
              "valueString": "define \"ED Encounter with a Documented Reason for Not Administering Fibrinolytic Therapy\":\n  \"ED Encounter with STEMI Diagnosis\" EDwSTEMI\n    with [\"MedicationAdministrationNotDone\": \"Fibrinolytic Therapy\"] FibrinolyticNoMed\n      such that ( FibrinolyticNoMed.statusReason in \"Patient Refusal\"\n          or FibrinolyticNoMed.statusReason in \"Drug Intervention Not Indicated/Contraindicated\"\n      )\n        and FibrinolyticNoMed.recorded during EDwSTEMI.period"
            },
            {
              "url": "displaySequence",
              "valueInteger": 35
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS996FHIRAptTxforSTEMI"
            },
            {
              "url": "name",
              "valueString": "Denominator Exceptions"
            },
            {
              "url": "statement",
              "valueString": "define \"Denominator Exceptions\":\n  \"Received tPA in Another Facility within 24 hours Prior to Admission\"\n    union \"ED Encounter with a Documented Reason for No PCI Performed\"\n    union \"ED Encounter with a Documented Reason for Not Administering Fibrinolytic Therapy\""
            },
            {
              "url": "displaySequence",
              "valueInteger": 36
            }
          ],
          "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": 37
            }
          ],
          "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": 38
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "FHIRHelpers"
            },
            {
              "url": "name",
              "valueString": "ToConcept"
            },
            {
              "url": "statement",
              "valueString": "/*\n@description: Converts the given FHIR [CodeableConcept](https://hl7.org/fhir/datatypes.html#CodeableConcept) value to a CQL Concept.\n*/\ndefine function ToConcept(concept FHIR.CodeableConcept):\n    if concept is null then\n        null\n    else\n        System.Concept {\n            codes: concept.coding C return ToCode(C),\n            display: concept.text.value\n        }"
            },
            {
              "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"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CQMCommon"
            },
            {
              "url": "name",
              "valueString": "encounterDiagnosis"
            },
            {
              "url": "statement",
              "valueString": "/*  \n@description: Returns the Condition resources referenced by the diagnosis element of the Encounter  \n*/\ndefine fluent function encounterDiagnosis(Encounter Encounter ):\n  Encounter.reasonReference D\n    return singleton from (([ConditionEncounterDiagnosis] union [ConditionProblemsHealthConcerns]) C where D.references(C.id))"
            },
            {
              "url": "displaySequence",
              "valueInteger": 41
            }
          ],
          "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": 42
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS996FHIRAptTxforSTEMI"
            },
            {
              "url": "name",
              "valueString": "currentemergencyDepartmentArrivalTime"
            },
            {
              "url": "statement",
              "valueString": "define fluent function currentemergencyDepartmentArrivalTime(EDEncounter Encounter):\n  First(EDEncounter.location EDLocation\n      where exists((CQMCommon.GetLocation(EDLocation.location).type) LocationType\n          where(LocationType in \"Emergency Department Visit\"\n              or LocationType ~ \"Emergency room\"\n          )\n            and start of EDLocation.period is not null\n      )\n      return start of EDLocation.period\n      sort ascending\n  )"
            },
            {
              "url": "displaySequence",
              "valueInteger": 43
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CQMCommon"
            },
            {
              "url": "name",
              "valueString": "GetLocation"
            },
            {
              "url": "statement",
              "valueString": "/*\n@description: Returns the Location resource specified by the given reference\n@deprecated: This function is deprecated. Use the fluent function `getLocation()` instead.\n*/\ndefine function \"GetLocation\"(reference Reference):\n  singleton from (\n    [Location] L where reference.references(L)\n  )"
            },
            {
              "url": "displaySequence",
              "valueInteger": 44
            }
          ],
          "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": 45
            }
          ],
          "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": 46
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "CMS996FHIRAptTxforSTEMI"
            },
            {
              "url": "name",
              "valueString": "currentemergencyDepartmentDepartTime"
            },
            {
              "url": "statement",
              "valueString": "define fluent function currentemergencyDepartmentDepartTime(EDEncounter Encounter):\n  Last(EDEncounter.location EDLocation\n      where exists((CQMCommon.GetLocation(EDLocation.location).type) LocationType\n          where(LocationType in \"Emergency Department Visit\"\n              or LocationType ~ \"Emergency room\"\n          )\n            and \n            end of EDLocation.period is not null\n      )\n      return \n      end of EDLocation.period\n      sort ascending\n  )"
            },
            {
              "url": "displaySequence",
              "valueInteger": 47
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "QICoreCommon"
            },
            {
              "url": "name",
              "valueString": "prevalenceInterval"
            },
            {
              "url": "statement",
              "valueString": "/*\n@description: Returns an interval representing the normalized prevalence period of a given Condition.\n@comment: Uses the ToInterval and ToAbatementInterval functions to determine the widest potential interval from\nonset to abatement as specified in the given Condition. If the condition is active, or has an abatement date the resulting \ninterval will have a closed ending boundary. Otherwise, the resulting interval will have an open ending boundary.\n*/\ndefine fluent function prevalenceInterval(condition Choice<\"ConditionEncounterDiagnosis\", \"ConditionProblemsHealthConcerns\">):\nif condition.clinicalStatus ~ \"active\"\n  or condition.clinicalStatus ~ \"recurrence\"\n  or condition.clinicalStatus ~ \"relapse\" then\n  Interval[start of condition.onset.toInterval(), end of condition.abatementInterval()]\nelse\n    (end of condition.abatementInterval()) abatementDate\n    return if abatementDate is null then\n      Interval[start of condition.onset.toInterval(), abatementDate)\n    else\n      Interval[start of condition.onset.toInterval(), abatementDate]"
            },
            {
              "url": "displaySequence",
              "valueInteger": 48
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "QICoreCommon"
            },
            {
              "url": "name",
              "valueString": "abatementInterval"
            },
            {
              "url": "statement",
              "valueString": "/*\n@description: Returns an interval representing the normalized abatement of a given Condition.\n@comment: If the abatement element of the Condition is represented as a DateTime, the result\nis an interval beginning and ending on that DateTime.\nIf the abatement is represented as a Quantity, the quantity is expected to be a calendar-duration and is interpreted as the age of the patient. The\nresult is an interval from the date the patient turned that age to immediately before one year later.\nIf the abatement is represented as a Quantity Interval, the quantities are expected to be calendar-durations and are interpreted as an age range during\nwhich the abatement occurred. The result is an interval from the date the patient turned the starting age of the quantity interval, and ending immediately\nbefore one year later than the date the patient turned the ending age of the quantity interval.\n*/\ndefine fluent function abatementInterval(condition Choice<\"ConditionEncounterDiagnosis\", \"ConditionProblemsHealthConcerns\">):\n\tif condition.abatement is DateTime then\n\t  Interval[condition.abatement as DateTime, condition.abatement as DateTime]\n\telse if condition.abatement is Quantity then\n\t\tInterval[Patient.birthDate + (condition.abatement as Quantity),\n\t\t\tPatient.birthDate + (condition.abatement as Quantity) + 1 year)\n\telse if condition.abatement is Interval<Quantity> then\n\t  Interval[Patient.birthDate + (condition.abatement.low as Quantity),\n\t\t  Patient.birthDate + (condition.abatement.high as Quantity) + 1 year)\n\telse if condition.abatement is Interval<DateTime> then\n\t  Interval[condition.abatement.low, condition.abatement.high)\n\telse null as Interval<DateTime>"
            },
            {
              "url": "displaySequence",
              "valueInteger": 49
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "Status"
            },
            {
              "url": "name",
              "valueString": "isAssessmentPerformed"
            },
            {
              "url": "statement",
              "valueString": "//This library contains functions used to constrain FHIR resource elements for measures authored by NCQA, based on QICore 6.0.0 resources including IG and authoring patterns. The functions may appear similar to some QICoreCommon functions but differ in that they have constraints that are relevant for measures authored by NCQA.\n\n//Assessment, Performed\ndefine fluent function isAssessmentPerformed(Obs List<ObservationScreeningAssessment>):\n  Obs O\n    where O.status in { 'final', 'amended', 'corrected' }"
            },
            {
              "url": "displaySequence",
              "valueInteger": 50
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "Status"
            },
            {
              "url": "name",
              "valueString": "isInterventionOrder"
            },
            {
              "url": "statement",
              "valueString": "//Intervention, Order\ndefine fluent function isInterventionOrder(ServiceRequest List<ServiceRequest>):\n  ServiceRequest S\n    where S.status in { 'active', 'completed' }\n      and S.intent = 'order'"
            },
            {
              "url": "displaySequence",
              "valueInteger": 51
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "Status"
            },
            {
              "url": "name",
              "valueString": "isInterventionPerformed"
            },
            {
              "url": "statement",
              "valueString": "//Intervention, Performed\ndefine fluent function isInterventionPerformed(Proc List<Procedure>):\n  Proc P\n    where P.status ~ 'completed'"
            },
            {
              "url": "displaySequence",
              "valueInteger": 52
            }
          ],
          "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 QICoreCommon",
          "resource": "Library/QICoreCommon|4.0.000"
        },
        {
          "type": "depends-on",
          "display": "Library FHIRHelpers",
          "resource": "Library/FHIRHelpers|4.4.000"
        },
        {
          "type": "depends-on",
          "display": "Library Status",
          "resource": "Library/Status|1.13.000"
        },
        {
          "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 Service Location Type",
          "resource": "http://terminology.hl7.org/CodeSystem/v3-RoleCode"
        },
        {
          "type": "depends-on",
          "display": "Code system AllergyIntoleranceClinicalStatusCodes",
          "resource": "http://terminology.hl7.org/CodeSystem/allergyintolerance-clinical"
        },
        {
          "type": "depends-on",
          "display": "Code system AllergyIntoleranceVerificationStatusCodes",
          "resource": "http://terminology.hl7.org/CodeSystem/allergyintolerance-verification"
        },
        {
          "type": "depends-on",
          "display": "Code system ConditionClinicalStatusCodes",
          "resource": "http://terminology.hl7.org/CodeSystem/condition-clinical"
        },
        {
          "type": "depends-on",
          "display": "Code system ICD10CM",
          "resource": "http://hl7.org/fhir/sid/icd-10-cm"
        },
        {
          "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 Emergency Department Evaluation and Management Visit",
          "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1010"
        },
        {
          "type": "depends-on",
          "display": "Value set STEMI",
          "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.3157.4017"
        },
        {
          "type": "depends-on",
          "display": "Value set Fibrinolytic Therapy",
          "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.3157.4019"
        },
        {
          "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 Percutaneous Coronary Intervention",
          "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.3157.2000.5"
        },
        {
          "type": "depends-on",
          "display": "Value set Discharge To Acute Care Facility",
          "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.87"
        },
        {
          "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 Thrombolytic medications",
          "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1170.4"
        },
        {
          "type": "depends-on",
          "display": "Value set Thrombolytics Adverse Event",
          "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1170.6"
        },
        {
          "type": "depends-on",
          "display": "Value set Active Bleeding or Bleeding Diathesis, Excluding Menses",
          "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.3157.4036"
        },
        {
          "type": "depends-on",
          "display": "Value set Malignant Intracranial Neoplasm Group",
          "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1170.3"
        },
        {
          "type": "depends-on",
          "display": "Value set Cerebral Vascular Lesion",
          "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.3157.4025"
        },
        {
          "type": "depends-on",
          "display": "Value set Dementia and Related Intracranial Pathologies",
          "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.3157.4043"
        },
        {
          "type": "depends-on",
          "display": "Value set Pregnant State",
          "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.3157.4055"
        },
        {
          "type": "depends-on",
          "display": "Value set Allergy to thrombolytics",
          "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1170.5"
        },
        {
          "type": "depends-on",
          "display": "Value set Oral Anticoagulant Medications",
          "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.3157.4045"
        },
        {
          "type": "depends-on",
          "display": "Value set Aortic Dissection or Ruptured Aortic Aneurysm",
          "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.3157.4028"
        },
        {
          "type": "depends-on",
          "display": "Value set Neurologic impairment",
          "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.114.12.1012"
        },
        {
          "type": "depends-on",
          "display": "Value set Cardiopulmonary Emergency",
          "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.3157.4048"
        },
        {
          "type": "depends-on",
          "display": "Value set Major Surgical Procedure",
          "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.3157.4056"
        },
        {
          "type": "depends-on",
          "display": "Value set Endotracheal Intubation",
          "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1045.69"
        },
        {
          "type": "depends-on",
          "display": "Value set Mechanical Circulatory Assist Device",
          "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.3157.4052"
        },
        {
          "type": "depends-on",
          "display": "Value set Ischemic Stroke",
          "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.247"
        },
        {
          "type": "depends-on",
          "display": "Value set Closed Head and Facial Trauma",
          "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.3157.4026"
        },
        {
          "type": "depends-on",
          "display": "Value set Active Peptic Ulcer",
          "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.3157.4031"
        },
        {
          "type": "depends-on",
          "display": "Value set Intracranial or Intraspinal surgery",
          "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1170.2"
        },
        {
          "type": "depends-on",
          "display": "Value set Patient Expired",
          "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.309"
        },
        {
          "type": "depends-on",
          "display": "Value set Left Against Medical Advice",
          "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.308"
        },
        {
          "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 Hospice Encounter",
          "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.1003"
        },
        {
          "type": "depends-on",
          "display": "Value set Hospice Care Ambulatory",
          "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.526.3.1584"
        },
        {
          "type": "depends-on",
          "display": "Value set Hospice Diagnosis",
          "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.1165"
        },
        {
          "type": "depends-on",
          "display": "Value set Patient Refusal",
          "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.93"
        },
        {
          "type": "depends-on",
          "display": "Value set Procedure Not Indicated/Contraindicated",
          "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1282.2"
        },
        {
          "type": "depends-on",
          "display": "Value set Drug Intervention Not Indicated/Contraindicated",
          "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1282.1"
        }
      ],
      "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": "*",
          "type": "Resource"
        },
        {
          "name": "Denominator",
          "use": "out",
          "min": 0,
          "max": "*",
          "type": "Resource"
        },
        {
          "name": "SDE Payer",
          "use": "out",
          "min": 0,
          "max": "*",
          "type": "Resource"
        },
        {
          "name": "Initial Population",
          "use": "out",
          "min": 0,
          "max": "*",
          "type": "Resource"
        },
        {
          "name": "SDE Ethnicity",
          "use": "out",
          "min": 0,
          "max": "1",
          "type": "Resource"
        },
        {
          "name": "Denominator Exclusions",
          "use": "out",
          "min": 0,
          "max": "*",
          "type": "Resource"
        },
        {
          "name": "SDE Race",
          "use": "out",
          "min": 0,
          "max": "1",
          "type": "Resource"
        },
        {
          "name": "Denominator Exceptions",
          "use": "out",
          "min": 0,
          "max": "*",
          "type": "Resource"
        }
      ],
      "dataRequirement": [
        {
          "type": "Patient",
          "profile": [
            "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-patient"
          ]
        },
        {
          "type": "Patient",
          "profile": [
            "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-patient"
          ],
          "mustSupport": [
            "url",
            "value.value"
          ]
        },
        {
          "type": "Patient",
          "profile": [
            "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-patient"
          ],
          "mustSupport": [
            "url",
            "value.value"
          ]
        },
        {
          "type": "Patient",
          "profile": [
            "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-patient"
          ]
        },
        {
          "type": "Encounter",
          "profile": [
            "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-encounter"
          ],
          "mustSupport": [
            "type",
            "period",
            "status",
            "status.value"
          ],
          "codeFilter": [
            {
              "path": "type",
              "valueSet": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1010"
            }
          ]
        },
        {
          "type": "Condition",
          "profile": [
            "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-condition-encounter-diagnosis"
          ]
        },
        {
          "type": "Condition",
          "profile": [
            "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-condition-problems-health-concerns"
          ]
        },
        {
          "type": "Condition",
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  ],
  "url": "https://madie.cms.gov/Measure/CMS996FHIRAptTxforSTEMI",
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      "value": "3613e",
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      "system": "https://madie.cms.gov/measure/cmsId",
      "value": "996FHIR",
      "assigner": {
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  ],
  "version": "1.4.001",
  "name": "CMS996FHIRAptTxforSTEMI",
  "title": "Appropriate Treatment for ST-Segment Elevation Myocardial Infarction (STEMI) Patients in the Emergency Department FHIR",
  "status": "active",
  "experimental": false,
  "date": "2025-07-15T13:37:39+00:00",
  "publisher": "Centers for Medicare & Medicaid Services (CMS)",
  "contact": [
    {
      "telecom": [
        {
          "system": "url",
          "value": "https://www.cms.gov/"
        }
      ]
    }
  ],
  "description": "Percentage of emergency department (ED) encounters for patients 18 years and older with a diagnosis of ST-segment elevation myocardial infarction (STEMI) that received appropriate treatment, defined as fibrinolytic therapy within 30 minutes of ED arrival, percutaneous coronary intervention (PCI) within 90 minutes of ED arrival, or discharge to an acute care facility within 45 minutes of ED arrival",
  "usage": "In order to support the best outcomes for patients and align with other guidelines, PCI device deployment time should be used for calculating the “PCI is performed within 90 minutes of ED arrival” numerator criteria and not the start time of the procedure.  This dQM is an episode-based measure and should be reported for each instance of an ED encounter during the measurement period for patients with a STEMI.  This FHIR-based measure has been derived from the QDM-based measure: CMS996v6. 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 these specifications for user convenience. Users of proprietary code sets should obtain all necessary licenses from the owners of the code sets.  This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2024 International Health Terminology Standards Development Organisation. All rights reserved.  LOINC(R) copyright 2004-2024 Regenstrief Institute, Inc.  CPT(R) contained in the measure specifications is copyright 2004-2024 American Medical Association.  ICD-10 is copyright 2024 World Health Organization. All Rights Reserved.",
  "effectivePeriod": {
    "start": "2026-01-01",
    "end": "2026-12-31"
  },
  "author": [
    {
      "name": "Acumen, LLC",
      "telecom": [
        {
          "system": "url",
          "value": "https://www.acumenllc.com/"
        }
      ]
    }
  ],
  "relatedArtifact": [
    {
      "type": "citation",
      "citation": "CITATION - Fibrinolytic Therapy Trialists' (FTT) Collaborative Group. (1994). Indications for fibrinolytic therapy in suspected acute myocardial infarction: collaborative overview of early mortality and major morbidity results from all randomised trials of more than 1000 patients. The Lancet, 343(8893):311-22.  "
    },
    {
      "type": "citation",
      "citation": "CITATION - O’Connor RE, Brady W, Brooks SC, Diercks D, Egan J, Ghaemmaghami C, Menon V, O’Neil BJ, Travers AH, Yannapoulos D. (2010) Part 10: Acute coronary syndromes: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation, 122(suppl 3): S787-S817. DOI: 10.1161/CIRCULATIONAHA.110.971028. "
    },
    {
      "type": "citation",
      "citation": "CITATION - O'Gara P, Kushner F, Ascheim D, Casey D, Chung M, de Lemos J, Ettinger S, Fang J, Fesmire F, Franklin B, Granger C, Krumholz H, Linderbaum J, Morrow D, Newby L, Ornato J, Ou N, Radford M, Tamis-Holland J, Tommaso C, Tracy C, Woo Y, Zhao D, Anderson J, Jacobs A, Halperin J, Albert N, Brindis R, Creager M, DeMets D, Guyton R, Hochman J, Kovacs R, Kushner F, Ohman E, Stevenson W, Yancy C. (2013). 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation, 127(4): e362-425.  "
    },
    {
      "type": "citation",
      "citation": "CITATION - Sohlpour A, Yusuf SW. (2014). Fibrinolytic therapy in patients with ST-elevation myocardial infarction. Expert Rev. Cardiovasc. Early online, 1-15. "
    }
  ],
  "library": [
    "https://madie.cms.gov/Library/CMS996FHIRAptTxforSTEMI"
  ],
  "disclaimer": "These performance specifications are not clinical guidelines, do not establish a standard of medical care, and have 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": "Studies have shown that delays in the treatment of acute myocardial infarction (AMI) leads to increased risk of in-hospital mortality and morbidity, with nearly two lives per 1,000 patients lost per hour of delay in treatment (Solhpour & Yusuf, 2013; Fibrinolytic Therapy Trialists’ Collaborative Group, 1994). For patients receiving fibrinolytic therapy, the American Heart Association (AHA) estimates that 65 lives will be saved per 1,000 patients if treatment is administered within the first hour of symptom onset, and 131 lives will be saved per 1,000 patients treated if fibrinolytic therapy is delivered within the first three hours (O’Connor et al., 2010).  The total ischemic time—that is, the time from onset of STEMI symptoms to the initiation of some form of reperfusion therapy—is the principal determinant of health outcomes for patients with an AMI, so timely care is essential to minimize disease morbidity and mortality. Primary PCI is the preferred treatment approach, with guidelines recommending initiation of PCI within 120 minutes from first medical contact (O’Gara et al., 2013). In situations where it is unlikely or impossible for a patient to receive primary PCI within the 120-minute timeframe, fibrinolytic therapy may be used for reperfusion and should be rapidly administered to reduce mortality and minimize morbidity; guidelines recommend that fibrinolytic therapy administration occur within 30 minutes of hospital arrival; this may also require rapid transfer for PCI (O’Gara et al., 2013). Implementation of an dQM addressing appropriateness and effectiveness of care for STEMI patients in the ED has the potential to improve the delivery of care furthering alignment with current clinical practice guidelines, while reducing adverse health outcomes such as mortality, bleeding events, and reinfarction. Use of the dQM could also reduce burden on facilities currently measured using the chart-abstracted Fibrinolytic Therapy Received within 30 Minutes of ED Arrival (OP-2) measure and broaden the population for which performance scores could be publicly reported.",
  "clinicalRecommendationStatement": "Primary PCI in STEMI: The 2013 ACCF/AHA clinical practice guideline for the management of STEMI recommends that: - \"Primary PCI should be performed in patients with STEMI and ischemic symptoms of less than 12 hours’ duration.\" - \"Primary PCI should be performed in patients with STEMI and ischemic symptoms of less than 12 hours’ duration who have contraindications to fibrinolytic therapy, irrespective of the time delay from first medical contact.\"   Fibrinolytic Therapy when there is an Anticipated Delay to Performing Primary PCI within 120 Minutes of First Medical Contact: The 2013 American College of Cardiology Foundation (ACCF)/American Heart Association (AHA) clinical practice guideline for the management of STEMI recommends that: - \"In the absence of contraindications, fibrinolytic therapy should be given to patients with STEMI and onset of ischemic symptoms within the previous 12 hours when it is anticipated that primary PCI cannot be performed within 120 minutes of first medical contact.”   Transfer to a PCI-Capable Hospital after Fibrinolytic Therapy: The 2013 ACCF/AHA clinical practice guideline for the management of STEMI recommends that: - Immediate transfer to a PCI-capable hospital for coronary angiography is recommended for suitable patients with STEMI who develop cardiogenic shock or acute severe heart failure (HF), irrespective of the time delay from MI onset. - Urgent transfer to a PCI-capable hospital for coronary angiography is reasonable for patients with STEMI who demonstrate evidence of failed reperfusion or reocclusion after fibrinolytic therapy.  - Transfer to a PCI-capable hospital for coronary angiography is reasonable for patients with STEMI who have received fibrinolytic therapy even when hemodynamically stable and with clinical evidence of successful reperfusion. Angiography can be performed as soon as logistically feasible at the receiving hospital, and ideally within 24 hours, but should not be performed within the first 2 to 3 hours after administration of fibrinolytic therapy.",
  "group": [
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        },
        {
          "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 emergency department encounters for patients 18 years and older at the start of the encounter with a diagnosis of ST-segment elevation myocardial infarction (STEMI) during an Emergency Department encounter that ends during 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": "Patients with the following conditions are excluded from measure denominator:  At some point during ED encounter: - Allergic reaction to alteplase, streptokinase, anistreplase, tenecteplase, or reteplase  Starts before the start of ED encounter and does not end before ED encounter: - Bleeding or bleeding diathesis (excluding menses) - Known malignant intracranial neoplasm (primary or metastatic) - Known structural cerebral vascular lesion (e.g., arteriovenous malformation) - Advanced dementia - Pregnancy - Diagnosis of allergy to thrombolytics  At the start of ED encounter or within 90 days or less of ED encounter: -Active oral anticoagulant therapy  Occurs 24 hours or less before start of ED encounter or during ED encounter: - Aortic dissection or ruptured aortic aneurysm, Angina pectoris with documented spasm, Aneurysm of heart, Ventricular aneurysm due to and following acute myocardial infarction, Takotsubo cardiomyopathy or syndrome - Severe neurologic impairment - Mechanical circulatory assist device placement or removal, including: aortic balloon pump, biventricular assist device, intra-aortic balloon, intra-aortic balloon counterpulsation, intra-aortic counterpulsation balloon pump, left ventricular device, percutaneous ventricular assist device, or ventricular assist device - Intubation, including endotracheal intubation, mechanical ventilation, nasotracheal intubation, or orotracheal intubation - Cardiopulmonary arrest, including: cardiac arrest, cardiopulmonary resuscitation (CPR), defibrillation, respiratory arrest, or ventricular fibrillation (V-fib), ventricular tachycardia (VT), or pulseless electrical activity (PEA); or, traumatic or prolonged (>10 minutes) CPR  Occurs 21 days or less before start of ED encounter or starts during ED encounter: - Major surgery   Occurs within 90 days before start of or at start of ED encounter: - Ischemic stroke  - Significant facial and/or closed head trauma  - Peptic ulcer  Occurs 90 days or less before start of ED encounter: - Intracranial or intraspinal surgery   With a discharge disposition of patient expired in the ED  With a discharge disposition of left against medical advice  With documentation of hospice services in the 6 months within start of ED encounter, or active hospice status at start of ED encounter",
          "criteria": {
            "language": "text/cql-identifier",
            "expression": "Denominator Exclusions"
          }
        },
        {
          "id": "Numerator_1",
          "code": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/measure-population",
                "code": "numerator",
                "display": "Numerator"
              }
            ]
          },
          "description": "Emergency department encounters with a diagnosis of STEMI:  - where time from ED arrival to fibrinolysis is 30 minutes or fewer; OR  - where PCI is performed within 90 minutes of arrival;  OR - where the patient is discharged to an acute care facility within 45 minutes of ED arrival",
          "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": "Emergency department encounters where the patient received fibrinolytic therapy at another facility within 24 hours. Emergency department encounters with a documented reason for not administering fibrinolytic therapy within 30 minutes of ED arrival. Emergency department encounters with a documented reason for not performing a PCI within 90 minutes of ED arrival.",
          "criteria": {
            "language": "text/cql-identifier",
            "expression": "Denominator Exceptions"
          }
        }
      ]
    }
  ],
  "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"
      }
    }
  ]
}