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FHIR IG Statistics: Measure/EXM146-FHIR

Packagehl7.fhir.us.cqfmeasures
Resource TypeMeasure
IdEXM146-FHIR
FHIR VersionR4
Sourcehttp://hl7.org/fhir/us/cqfmeasures/http://hl7.org/fhir/us/cqfmeasures/STU5/Measure-EXM146-FHIR.html
URLhttp://hl7.org/fhir/us/cqfmeasures/Measure/EXM146-FHIR
Version4.0.0
Statusactive
Date2022-02-22
NameEXM146
TitleEXM146 - Appropriate Testing for Children with Pharyngitis
Realmus
Authorityhl7
DescriptionPercentage of children 2-18 years of age who were diagnosed with pharyngitis, ordered an antibiotic and received a group A streptococcus (strep) test for the episode.
PurposeThis measure has been developed to support improvement in clinical care.
CopyrightPhysician Performance Measure (Measures) and related data specifications were developed by the National Committee for Quality Assurance (NCQA). The Measures are copyrighted but can be reproduced and distributed, without modification, for noncommercial purposes (eg, use by healthcare providers in connection with their practices). Commercial use is defined as the sale, licensing, or distribution of the Measures for commercial gain, or incorporation of the Measures into a product or service that is sold, licensed or distributed for commercial gain. Commercial use of the Measures requires a license agreement between the user and NCQA. NCQA is not responsible for any use of the Measures. (c) 2008 -2014 National Committee for Quality Assurance. All Rights Reserved. Limited proprietary coding is contained in the Measure specifications for user convenience. Users of proprietary code sets should obtain all necessary licenses from the owners of the code sets. NCQA disclaims all liability for use or accuracy of any CPT or other codes contained in the specifications. CPT(R) contained in the Measure specifications is copyright 2004-2013 American Medical Association. LOINC(R) copyright 2004-2013 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2013 International Health Terminology Standards Development Organisation. ICD-10 copyright 2013 World Health Organization. All Rights Reserved.

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Narrative

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Title: EXM146 - Appropriate Testing for Children with Pharyngitis
Id: EXM146-FHIR
Version: 4.0.0
Url: EXM146 - Appropriate Testing for Children with Pharyngitis
Official

146

Effective Period: 2018-01-01..2018-12-31
Experimental: true
Publisher: HL7 International / Clinical Quality Information
Description:

Percentage of children 2-18 years of age who were diagnosed with pharyngitis, ordered an antibiotic and received a group A streptococcus (strep) test for the episode.

Use Context:
code value
venue
Jurisdiction: US
Topic: 57024-2
Purpose:

This measure has been developed to support improvement in clinical care.

Copyright:

Physician Performance Measure (Measures) and related data specifications were developed by the National Committee for Quality Assurance (NCQA). The Measures are copyrighted but can be reproduced and distributed, without modification, for noncommercial purposes (eg, use by healthcare providers in connection with their practices). Commercial use is defined as the sale, licensing, or distribution of the Measures for commercial gain, or incorporation of the Measures into a product or service that is sold, licensed or distributed for commercial gain. Commercial use of the Measures requires a license agreement between the user and NCQA. NCQA is not responsible for any use of the Measures. (c) 2008 -2014 National Committee for Quality Assurance. All Rights Reserved. Limited proprietary coding is contained in the Measure specifications for user convenience. Users of proprietary code sets should obtain all necessary licenses from the owners of the code sets. NCQA disclaims all liability for use or accuracy of any CPT or other codes contained in the specifications. CPT(R) contained in the Measure specifications is copyright 2004-2013 American Medical Association. LOINC(R) copyright 2004-2013 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2013 International Health Terminology Standards Development Organisation. ICD-10 copyright 2013 World Health Organization. All Rights Reserved.

Disclaimer:

The performance Measure is not a clinical guideline and does not establish a standard of medical care, and has not been tested for all potential applications. THE MEASURE AND SPECIFICATIONS ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND. Due to technical limitations, registered trademarks are indicated by (R) or [R] and unregistered trademarks are indicated by (TM) or [TM].

Basis: Encounter
Scoring:

Proportion

Type:

process

Rationale:

Group A streptococcal bacterial infections and other infections that cause pharyngitis (which are most often viral) often produce the same signs and symptoms (IDSA 2002). The American Academy of Pediatrics, the Centers for Disease Control and Prevention, and the Infectious Diseases Society of America all recommend a diagnostic test for Strep A to improve diagnostic accuracy and avoid unnecessary antibiotic treatment (Linder et al. 2005). A study on antibiotic treatment of children with sore throat found that although only 15 to 36 percent of children with sore throat have Strep A pharyngitis, physicians prescribed antibiotics to 53 percent of children with a chief complaint of sore throat between 1995 and 2003 (Linder et al. 2005).

Clinical recommendation statement:

Institute for Clinical Systems Improvement (ICSI) (2007) Reduce unnecessary use of antibiotics. Antibiotic treatment should be reserved for a bacterial illness. Diagnosis of group A beta streptococcal Pharyngitis should be made by laboratory testing rather than clinically. Infectious Disease Society of America (Bisno et al. 2002) The signs and symptoms of group A streptococcal and other (most frequently viral) pharyngitides overlap broadly. Therefore, unless the physician is able with confidence to exclude the diagnosis of streptococcal pharyngitis on epidemiological and clinical grounds alone, a laboratory test should be done to determine whether group A streptococci are present in the pharynx. With the exception of very rare infections by certain other pharyngeal bacterial pathogens (eg, Corynebacterium diphtheriae and Neisseria gonorrhoeae), antimicrobial therapy is of no proven benefit as treatment for acute pharyngitis due to bacteria other than group A streptococci. Therefore, it is extremely important that physicians exclude the diagnosis of group A streptococcal pharyngitis to prevent inappropriate administration of antimicrobials to large numbers of patients with pharyngitis. Michigan Quality Improvement Consortium (2007) Probability of group A beta hemolytic streptococci (GABHS): Low; Testing: None; Treatment: Symptomatic treatment only. Avoid antibiotics. Probability of GABHS: Intermediate or High; Testing: Throat Culture (TC) OR Rapid Screen; Treatment: If TC is positive, use antibiotics. If TC is negative, use symptomatic treatment only. Avoid antibiotics. If treatment is started and culture result is negative, stop antibiotics. If Rapid Screen is positive, use antibiotics. If Rapid Screen is negative, culture (Culture is optional for age 16 and over) and only use antibiotics if throat culture is positive. (Michigan, 2007)

Improvement Notation:

Increased score indicates improvement

Libraries:
EXM146 - Example Proportion Measure Library
Terminology and Other Dependencies:
  • http://fhir.org/guides/cqf/common/Library/FHIRHelpers|4.0.1
  • MAT Global Common Functions FHIR Libraryversion: null5.0.000)
  • Common Libraryversion: null2.0.0)
  • Condition Clinical Status Codes
  • ConditionVerificationStatus
  • http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1061
  • http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.102.12.1011
  • http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.102.12.1012
  • http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.196.12.1001
  • http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1012
  • Parameters:
    name use min max type
    Measurement Period In 0 1 Period
    Numerator Out 0 * Encounter
    Initial Population Out 0 * Encounter
    DataRequirements:
    Resource Type Resource Elements Valueset Name Valueset
    Condition(Condition) code Acute Pharyngitis http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.102.12.1011
    Condition(Condition) code Acute Tonsillitis http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.102.12.1012
    Observation(Observation) effective code value Group A Streptococcus Test http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1012
    Patient(Patient)
    Encounter(Encounter) period type status Ambulatory/ED Visit http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1061
    MedicationRequest(MedicationRequest) authoredOn medication intent status Antibiotic Medications http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.196.12.1001
    Direct Reference Codes:
    display code system
    active http://terminology.hl7.org/CodeSystem/condition-clinical
    confirmed http://terminology.hl7.org/CodeSystem/condition-ver-status
    Logic Definitions:
    Group Scoring Population Criteria Expression
    Measure scoring:

    Proportion

    Initial Population
    define "Initial Population":
       "Pharyngitis Encounters With Antibiotics"
    Numerator
    define "Numerator":
       "Strep Test Encounters"
    Denominator
    Denominator Exclusion
    Library Name Name
    EXM146-FHIR Is Between 2 and 17 Years of Age at Start of Measurement Period
    // Region: Initial Population
    define "Is Between 2 and 17 Years of Age at Start of Measurement Period":
       AgeInYearsAt(start of "Measurement Period") >= 2
          and AgeInYearsAt(start of "Measurement Period") <= 17
    Library Name Name
    EXM146-FHIR Measurement Period Encounters
    define "Measurement Period Encounters":
       [Encounter: "Ambulatory/ED Visit"] Encounter
          where Encounter.period during "Measurement Period"
            and Encounter.status = 'finished'
            and "Is Between 2 and 17 Years of Age at Start of Measurement Period"
    Library Name Name
    EXM146-FHIR Pharyngitis
    define "Pharyngitis":
       ([Condition: code in "Acute Pharyngitis"]
         union [Condition: code in "Acute Tonsillitis"]) Pharyngitis
         where Pharyngitis.clinicalStatus ~ Global.active
           and Pharyngitis.verificationStatus ~ Global.confirmed
    Library Name Name
    EXM146-FHIR Antibiotics
    define "Antibiotics":
       [MedicationRequest: medication in "Antibiotic Medications"] Prescription
         where Prescription.status = 'active'
           and Prescription.intent = 'order'
    Library Name Name
    EXM146-FHIR Pharyngitis Encounters With Antibiotics
    define "Pharyngitis Encounters With Antibiotics":
       "Measurement Period Encounters" Encounters
          with "Pharyngitis" Pharyngitis such that
             Common."Includes Or Starts During"(Pharyngitis, Encounters)
          with "Antibiotics" Antibiotics such that Antibiotics.authoredOn
             3 days or less after FHIRHelpers.ToInterval(Encounters.period)
    Library Name Name
    EXM146-FHIR Strep Test Encounters
    // EndRegion: Denominator Exclusions
    
    // Region: Denominator Exceptions
    
    // None
    
    // EndRegion: Denominator Exceptions
    
    // Region: Numerator
    define "Strep Test Encounters":
       "Pharyngitis Encounters With Antibiotics" Encounters
          with [Observation: code in "Group A Streptococcus Test"] Tests
             such that Tests.value is not null
                and Tests.effective starts during
                   Interval[start of FHIRHelpers.ToInterval(Encounters.period) - 3 days,
                     end of FHIRHelpers.ToInterval(Encounters.period) + 3 days]
    Library Name Name
    EXM146-FHIR Numerator
    define "Numerator":
       "Strep Test Encounters"
    Library Name Name
    EXM146-FHIR Initial Population
    define "Initial Population":
       "Pharyngitis Encounters With Antibiotics"

    Source

    {
      "resourceType": "Measure",
      "id": "EXM146-FHIR",
      "meta": {
        "profile": [
          "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/proportion-measure-cqfm",
          "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/computable-measure-cqfm",
          "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cql-measure-cqfm"
        ]
      },
      "text": {
        "status": "extensions",
        "div": "<!-- snip (see above) -->"
      },
      "contained": [
        {
          "resourceType": "Library",
          "id": "effective-data-requirements-exm146",
          "meta": {
            "profile": [
              "http://hl7.org/fhir/uv/crmi/StructureDefinition/crmi-moduledefinitionlibrary"
            ]
          },
          "extension": [
            {
              "url": "http://hl7.org/fhir/StructureDefinition/cqf-directReferenceCode",
              "valueCoding": {
                "system": "http://terminology.hl7.org/CodeSystem/condition-clinical",
                "code": "active"
              }
            },
            {
              "url": "http://hl7.org/fhir/StructureDefinition/cqf-directReferenceCode",
              "valueCoding": {
                "system": "http://terminology.hl7.org/CodeSystem/condition-ver-status",
                "code": "confirmed"
              }
            },
            {
              "extension": [
                {
                  "url": "libraryName",
                  "valueString": "EXM146-FHIR"
                },
                {
                  "url": "name",
                  "valueString": "Is Between 2 and 17 Years of Age at Start of Measurement Period"
                },
                {
                  "url": "statement",
                  "valueString": "// Region: Initial Population\ndefine \"Is Between 2 and 17 Years of Age at Start of Measurement Period\":\n   AgeInYearsAt(start of \"Measurement Period\") >= 2\n      and AgeInYearsAt(start of \"Measurement Period\") <= 17"
                },
                {
                  "url": "displaySequence",
                  "valueInteger": 0
                }
              ],
              "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
            },
            {
              "extension": [
                {
                  "url": "libraryName",
                  "valueString": "EXM146-FHIR"
                },
                {
                  "url": "name",
                  "valueString": "Measurement Period Encounters"
                },
                {
                  "url": "statement",
                  "valueString": "define \"Measurement Period Encounters\":\n   [Encounter: \"Ambulatory/ED Visit\"] Encounter\n      where Encounter.period during \"Measurement Period\"\n        and Encounter.status = 'finished'\n        and \"Is Between 2 and 17 Years of Age at Start of Measurement Period\""
                },
                {
                  "url": "displaySequence",
                  "valueInteger": 1
                }
              ],
              "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
            },
            {
              "extension": [
                {
                  "url": "libraryName",
                  "valueString": "EXM146-FHIR"
                },
                {
                  "url": "name",
                  "valueString": "Pharyngitis"
                },
                {
                  "url": "statement",
                  "valueString": "define \"Pharyngitis\":\n   ([Condition: code in \"Acute Pharyngitis\"]\n     union [Condition: code in \"Acute Tonsillitis\"]) Pharyngitis\n     where Pharyngitis.clinicalStatus ~ Global.active\n       and Pharyngitis.verificationStatus ~ Global.confirmed"
                },
                {
                  "url": "displaySequence",
                  "valueInteger": 2
                }
              ],
              "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
            },
            {
              "extension": [
                {
                  "url": "libraryName",
                  "valueString": "EXM146-FHIR"
                },
                {
                  "url": "name",
                  "valueString": "Antibiotics"
                },
                {
                  "url": "statement",
                  "valueString": "define \"Antibiotics\":\n   [MedicationRequest: medication in \"Antibiotic Medications\"] Prescription\n     where Prescription.status = 'active'\n       and Prescription.intent = 'order'"
                },
                {
                  "url": "displaySequence",
                  "valueInteger": 3
                }
              ],
              "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
            },
            {
              "extension": [
                {
                  "url": "libraryName",
                  "valueString": "EXM146-FHIR"
                },
                {
                  "url": "name",
                  "valueString": "Pharyngitis Encounters With Antibiotics"
                },
                {
                  "url": "statement",
                  "valueString": "define \"Pharyngitis Encounters With Antibiotics\":\n   \"Measurement Period Encounters\" Encounters\n      with \"Pharyngitis\" Pharyngitis such that\n         Common.\"Includes Or Starts During\"(Pharyngitis, Encounters)\n      with \"Antibiotics\" Antibiotics such that Antibiotics.authoredOn\n         3 days or less after FHIRHelpers.ToInterval(Encounters.period)"
                },
                {
                  "url": "displaySequence",
                  "valueInteger": 4
                }
              ],
              "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
            },
            {
              "extension": [
                {
                  "url": "libraryName",
                  "valueString": "EXM146-FHIR"
                },
                {
                  "url": "name",
                  "valueString": "Strep Test Encounters"
                },
                {
                  "url": "statement",
                  "valueString": "// EndRegion: Denominator Exclusions\n\n// Region: Denominator Exceptions\n\n// None\n\n// EndRegion: Denominator Exceptions\n\n// Region: Numerator\ndefine \"Strep Test Encounters\":\n   \"Pharyngitis Encounters With Antibiotics\" Encounters\n      with [Observation: code in \"Group A Streptococcus Test\"] Tests\n         such that Tests.value is not null\n            and Tests.effective starts during\n               Interval[start of FHIRHelpers.ToInterval(Encounters.period) - 3 days,\n                 end of FHIRHelpers.ToInterval(Encounters.period) + 3 days]"
                },
                {
                  "url": "displaySequence",
                  "valueInteger": 5
                }
              ],
              "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
            },
            {
              "extension": [
                {
                  "url": "libraryName",
                  "valueString": "EXM146-FHIR"
                },
                {
                  "url": "name",
                  "valueString": "Numerator"
                },
                {
                  "url": "statement",
                  "valueString": "define \"Numerator\":\n   \"Strep Test Encounters\""
                },
                {
                  "url": "displaySequence",
                  "valueInteger": 6
                }
              ],
              "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
            },
            {
              "extension": [
                {
                  "url": "libraryName",
                  "valueString": "EXM146-FHIR"
                },
                {
                  "url": "name",
                  "valueString": "Initial Population"
                },
                {
                  "url": "statement",
                  "valueString": "define \"Initial Population\":\n   \"Pharyngitis Encounters With Antibiotics\""
                },
                {
                  "url": "displaySequence",
                  "valueInteger": 7
                }
              ],
              "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
            }
          ],
          "url": "http://hl7.org/fhir/us/cqfmeasures/Library/effective-data-requirements-exm146",
          "version": "1.0.0",
          "name": "EffectiveDataRequirements",
          "title": "Module Definition Library - EXM146",
          "status": "active",
          "type": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/library-type",
                "code": "module-definition"
              }
            ]
          },
          "date": "2022-02-22T10:37:03-07:00",
          "description": "This library is used as an example module definition in the FHIR Quality Measure Implementation Guide",
          "relatedArtifact": [
            {
              "type": "depends-on",
              "display": "Library FHIRHelpers",
              "resource": "http://fhir.org/guides/cqf/common/Library/FHIRHelpers|4.0.1"
            },
            {
              "type": "depends-on",
              "display": "Library Global",
              "resource": "http://hl7.org/fhir/us/cqfmeasures/Library/MATGlobalCommonFunctions|5.0.000"
            },
            {
              "type": "depends-on",
              "display": "Library Common",
              "resource": "http://hl7.org/fhir/us/cqfmeasures/Library/Common|2.0.0"
            },
            {
              "type": "depends-on",
              "display": "Code system ConditionClinicalStatusCodes",
              "resource": "http://terminology.hl7.org/CodeSystem/condition-clinical"
            },
            {
              "type": "depends-on",
              "display": "Code system ConditionVerificationStatusCodes",
              "resource": "http://terminology.hl7.org/CodeSystem/condition-ver-status"
            },
            {
              "type": "depends-on",
              "display": "Value set Ambulatory/ED Visit",
              "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1061"
            },
            {
              "type": "depends-on",
              "display": "Value set Acute Pharyngitis",
              "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.102.12.1011"
            },
            {
              "type": "depends-on",
              "display": "Value set Acute Tonsillitis",
              "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.102.12.1012"
            },
            {
              "type": "depends-on",
              "display": "Value set Antibiotic Medications",
              "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.196.12.1001"
            },
            {
              "type": "depends-on",
              "display": "Value set Group A Streptococcus Test",
              "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1012"
            }
          ],
          "parameter": [
            {
              "name": "Measurement Period",
              "use": "in",
              "min": 0,
              "max": "1",
              "type": "Period"
            },
            {
              "name": "Numerator",
              "use": "out",
              "min": 0,
              "max": "*",
              "type": "Encounter"
            },
            {
              "name": "Initial Population",
              "use": "out",
              "min": 0,
              "max": "*",
              "type": "Encounter"
            }
          ],
          "dataRequirement": [
            {
              "type": "Condition",
              "profile": [
                "http://hl7.org/fhir/StructureDefinition/Condition"
              ],
              "mustSupport": [
                "code"
              ],
              "codeFilter": [
                {
                  "path": "code",
                  "valueSet": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.102.12.1011"
                }
              ]
            },
            {
              "type": "Condition",
              "profile": [
                "http://hl7.org/fhir/StructureDefinition/Condition"
              ],
              "mustSupport": [
                "code"
              ],
              "codeFilter": [
                {
                  "path": "code",
                  "valueSet": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.102.12.1012"
                }
              ]
            },
            {
              "type": "Observation",
              "profile": [
                "http://hl7.org/fhir/StructureDefinition/Observation"
              ],
              "mustSupport": [
                "effective",
                "code",
                "value"
              ],
              "codeFilter": [
                {
                  "path": "code",
                  "valueSet": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1012"
                }
              ]
            },
            {
              "type": "Patient",
              "profile": [
                "http://hl7.org/fhir/StructureDefinition/Patient"
              ]
            },
            {
              "type": "Encounter",
              "profile": [
                "http://hl7.org/fhir/StructureDefinition/Encounter"
              ],
              "mustSupport": [
                "period",
                "type",
                "status"
              ],
              "codeFilter": [
                {
                  "path": "type",
                  "valueSet": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1061"
                }
              ]
            },
            {
              "type": "MedicationRequest",
              "profile": [
                "http://hl7.org/fhir/StructureDefinition/MedicationRequest"
              ],
              "mustSupport": [
                "authoredOn",
                "medication",
                "intent",
                "status"
              ],
              "codeFilter": [
                {
                  "path": "medication",
                  "valueSet": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.196.12.1001"
                }
              ]
            }
          ]
        }
      ],
      "extension": [
        {
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-populationBasis",
          "valueCode": "Encounter"
        },
        {
          "url": "http://hl7.org/fhir/uv/crmi/StructureDefinition/crmi-softwaresystem",
          "valueReference": {
            "reference": "Device/software-system-example"
          }
        },
        {
          "url": "http://hl7.org/fhir/uv/crmi/StructureDefinition/crmi-effectiveDataRequirements",
          "valueCanonical": "#effective-data-requirements-exm146"
        }
      ],
      "url": "http://hl7.org/fhir/us/cqfmeasures/Measure/EXM146-FHIR",
      "identifier": [
        {
          "use": "official",
          "system": "http://example.org/fhir/cqi/ecqm/Measure/Identifier/exm",
          "value": "146"
        }
      ],
      "version": "4.0.0",
      "name": "EXM146",
      "title": "EXM146 - Appropriate Testing for Children with Pharyngitis",
      "status": "active",
      "experimental": true,
      "date": "2022-02-22",
      "publisher": "HL7 International / Clinical Quality Information",
      "contact": [
        {
          "telecom": [
            {
              "system": "url",
              "value": "http://www.hl7.org/Special/committees/cqi"
            }
          ]
        }
      ],
      "description": "Percentage of children 2-18 years of age who were diagnosed with pharyngitis, ordered an antibiotic and received a group A streptococcus (strep) test for the episode.",
      "useContext": [
        {
          "code": {
            "system": "http://terminology.hl7.org/CodeSystem/usage-context-type",
            "code": "venue",
            "display": "Venue"
          },
          "valueCodeableConcept": {
            "coding": [
              {
                "system": "http://hl7.org/fhir/us/cqfmeasures/CodeSystem/intended-venue-codes",
                "code": "ec",
                "display": "EC"
              }
            ]
          }
        }
      ],
      "jurisdiction": [
        {
          "coding": [
            {
              "system": "urn:iso:std:iso:3166",
              "code": "US"
            }
          ]
        }
      ],
      "purpose": "This measure has been developed to support improvement in clinical care.",
      "copyright": "Physician Performance Measure (Measures) and related data specifications were developed by the National Committee for Quality Assurance (NCQA). \r\nThe Measures are copyrighted but can be reproduced and distributed, without modification, for noncommercial purposes (eg, use by healthcare providers in connection with their practices). Commercial use is defined as the sale, licensing, or distribution of the Measures for commercial gain, or incorporation of the Measures into a product or service that is sold, licensed or distributed for commercial gain. Commercial use of the Measures requires a license agreement between the user and NCQA. NCQA is not responsible for any use of the Measures. \r\n(c) 2008 -2014 National Committee for Quality Assurance. All Rights Reserved. \r\nLimited proprietary coding is contained in the Measure specifications for user convenience. Users of proprietary code sets should obtain all necessary licenses from the owners of the code sets.  NCQA disclaims all liability for use or accuracy of any CPT or other codes contained in the specifications.\r\nCPT(R) contained in the Measure specifications is copyright 2004-2013 American Medical Association. LOINC(R) copyright 2004-2013 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2013 International Health Terminology Standards Development Organisation. ICD-10 copyright 2013 World Health Organization. All Rights Reserved.",
      "approvalDate": "2016-01-01",
      "lastReviewDate": "2016-09-01",
      "effectivePeriod": {
        "start": "2018-01-01",
        "end": "2018-12-31"
      },
      "topic": [
        {
          "coding": [
            {
              "system": "http://loinc.org",
              "code": "57024-2",
              "display": "Health Quality Measure Document"
            }
          ]
        }
      ],
      "library": [
        "http://hl7.org/fhir/us/cqfmeasures/Library/EXM146-FHIR"
      ],
      "disclaimer": "The performance Measure is not a clinical guideline and does not establish a standard of medical care, and has not been tested for all potential applications. THE MEASURE AND SPECIFICATIONS ARE PROVIDED \"AS IS\" WITHOUT WARRANTY OF ANY KIND. \n Due to technical limitations, registered trademarks are indicated by (R) or [R] and unregistered trademarks are indicated by (TM) or [TM].",
      "scoring": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/measure-scoring",
            "code": "proportion",
            "display": "Proportion"
          }
        ]
      },
      "type": [
        {
          "coding": [
            {
              "system": "http://terminology.hl7.org/CodeSystem/measure-type",
              "code": "process"
            }
          ]
        }
      ],
      "rationale": "Group A streptococcal bacterial infections and other infections that cause pharyngitis (which are most often viral) often produce the same signs and symptoms (IDSA 2002). The American Academy of Pediatrics, the Centers for Disease Control and Prevention, and the Infectious Diseases Society of America all recommend a diagnostic test for Strep A to improve diagnostic accuracy and avoid unnecessary antibiotic treatment (Linder et al. 2005).  A study on antibiotic treatment of children with sore throat found that although only 15 to 36 percent of children with sore throat have Strep A pharyngitis, physicians prescribed antibiotics to 53 percent of children with a chief complaint of sore throat between 1995 and 2003 (Linder et al. 2005).",
      "clinicalRecommendationStatement": "Institute for Clinical Systems Improvement (ICSI) (2007) \n Reduce unnecessary use of antibiotics. Antibiotic treatment should be reserved for a bacterial illness. Diagnosis of group A beta streptococcal Pharyngitis should be made by laboratory testing rather than clinically. \nInfectious Disease Society of America (Bisno et al. 2002) \nThe signs and symptoms of group A streptococcal and other (most frequently viral) pharyngitides overlap broadly. Therefore, unless the physician is able with confidence to exclude the diagnosis of streptococcal pharyngitis on epidemiological and clinical grounds alone, a laboratory test should be done to determine whether group A streptococci are present in the pharynx. \nWith the exception of very rare infections by certain other pharyngeal bacterial pathogens (eg, Corynebacterium diphtheriae and Neisseria gonorrhoeae), antimicrobial therapy is of no proven benefit as treatment for acute pharyngitis due to bacteria other than group A streptococci. Therefore, it is extremely important that physicians exclude the diagnosis of group A streptococcal pharyngitis to prevent inappropriate administration of antimicrobials to large numbers of patients with pharyngitis. \nMichigan Quality Improvement Consortium (2007)\nProbability of group A beta hemolytic streptococci (GABHS): Low; Testing: None; Treatment: Symptomatic treatment only. Avoid antibiotics. Probability of GABHS: Intermediate or High; Testing: Throat Culture (TC) OR Rapid Screen; Treatment: If TC is positive, use antibiotics. If TC is negative, use symptomatic treatment only. Avoid antibiotics. If treatment is started and culture result is negative, stop antibiotics. If Rapid Screen is positive, use antibiotics. If Rapid Screen is negative, culture (Culture is optional for age 16 and over) and only use antibiotics if throat culture is positive. (Michigan, 2007)",
      "improvementNotation": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/measure-improvement-notation",
            "code": "increase",
            "display": "Increased score indicates improvement"
          }
        ]
      },
      "guidance": "This is an episode of care measure that examines all eligible episodes for the patient during the measurement period. If the patient has more than one episode, include all episodes in the measure.",
      "group": [
        {
          "population": [
            {
              "code": {
                "coding": [
                  {
                    "system": "http://terminology.hl7.org/CodeSystem/measure-population",
                    "code": "initial-population",
                    "display": "Initial Population"
                  }
                ]
              },
              "criteria": {
                "language": "text/cql-identifier",
                "expression": "Initial Population"
              }
            },
            {
              "code": {
                "coding": [
                  {
                    "system": "http://terminology.hl7.org/CodeSystem/measure-population",
                    "code": "numerator",
                    "display": "Numerator"
                  }
                ]
              },
              "criteria": {
                "language": "text/cql-identifier",
                "expression": "Numerator"
              }
            },
            {
              "code": {
                "coding": [
                  {
                    "system": "http://terminology.hl7.org/CodeSystem/measure-population",
                    "code": "denominator",
                    "display": "Denominator"
                  }
                ]
              },
              "criteria": {
                "language": "text/cql-identifier",
                "expression": "Denominator"
              }
            },
            {
              "code": {
                "coding": [
                  {
                    "system": "http://terminology.hl7.org/CodeSystem/measure-population",
                    "code": "denominator-exclusion",
                    "display": "Denominator Exclusion"
                  }
                ]
              },
              "criteria": {
                "language": "text/cql-identifier",
                "expression": "Denominator Exclusion"
              }
            }
          ]
        }
      ]
    }