FHIR IG Statistics: Measure/EXM108-FHIR

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Narrative

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

define "Initial Population":
  "Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions"

define "Numerator":
    "Encounter With VTE Prophylaxis Received on Day of or Day After Admission or Procedure"
    union ( "Encounter With Medication Oral Factor Xa Inhibitor Administered on Day of or Day After Admission or Procedure"
    			  intersect ( "Encounter With Prior or Present Diagnosis of Atrial Fibrillation or VTE"
    						    union "Encounter With Prior or Present Procedure of Hip or Knee Replacement Surgery"
    			            )
          )
    union "Encounter With Low Risk for VTE or Anticoagulant Administered"
    union "Encounter With No VTE Prophylaxis Due to Medical Reason"
    union "Encounter With No VTE Prophylaxis Due to Patient Refusal"

define "Denominator":
      "Initial Population"

define "Denominator Exclusion":
    "Encounter Less Than 2 Days"
     union "Encounter With ICU Location Stay 1 Day or More"
     union "Encounter With Principal Diagnosis of Mental Disorder or Stroke"
     union "Encounter With Principal Procedure of SCIP VTE Selected Surgery"
     union "Encounter With Intervention Comfort Measures From Day of Start of Hospitalization To Day After Admission"
     union "Encounter With Intervention Comfort Measures on Day of or Day After Procedure"

define "Inpatient Encounter":
	[Encounter: "Encounter Inpatient"] EncounterInpatient
		where EncounterInpatient.status = 'finished'
		    and "LengthInDays"(EncounterInpatient.period) <= 120
			and EncounterInpatient.period ends during "Measurement Period"

// 10/29: Replaced DeviceUseStatement with Procedure with a new value set and procedure.usdCode for specifying devices
define "VTE Prophylaxis by Medication Administered or Device Applied":
  ( ["MedicationAdministration": medication in "Low Dose Unfractionated Heparin for VTE Prophylaxis"] VTEMedication
      where VTEMedication.status ='completed'
			     and VTEMedication.dosage.route in "Subcutaneous route"
  )
   union (["MedicationAdministration": medication in "Low Molecular Weight Heparin for VTE Prophylaxis"] LMWH where LMWH.status = 'completed')
    union (["MedicationAdministration": medication in "Injectable Factor Xa Inhibitor for VTE Prophylaxis"] FactorXa where FactorXa.status = 'completed')
     union (["MedicationAdministration": medication in "Warfarin"] Warfarin where Warfarin.status = 'completed')
      union (
          ["Procedure": "Device Application"] DeviceApplied
          where DeviceApplied.status = 'complete'
                and (DeviceApplied.usedCode in "Intermittent pneumatic compression devices (IPC)"
                    or DeviceApplied.usedCode in"Venous foot pumps (VFP)"
                    or DeviceApplied.usedCode in "Graduated compression stockings (GCS)"
                    )
          )

define "SDE Sex":
  case
      when Patient.gender = 'male' then Code { code: 'M', system: 'http://hl7.org/fhir/v3/AdministrativeGender', display: 'Male' }
      when Patient.gender = 'female' then Code { code: 'F', system: 'http://hl7.org/fhir/v3/AdministrativeGender', display: 'Female' }
      else null
    end

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

define "SDE Ethnicity":
  (flatten (
      Patient.extension Extension
        where Extension.url = 'http://hl7.org/fhir/us/core/StructureDefinition/us-core-ethnicity'
          return Extension.extension
    )) E
      where E.url = 'ombCategory'
        or E.url = 'detailed'
      return E.value as Coding

define "SDE Race":
  (flatten (
      Patient.extension Extension
        where Extension.url = 'http://hl7.org/fhir/us/core/StructureDefinition/us-core-race'
          return Extension.extension
    )) E
      where E.url = 'ombCategory'
        or E.url = 'detailed'
      return E.value as Coding

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

define "Admission Without VTE or Obstetrical Conditions":
	  	Global."Inpatient Encounter" InpatientEncounter
		    where not (exists (Global.EncounterDiagnosis(InpatientEncounter)) EncounterDiagnosis
              where (EncounterDiagnosis.code in "Obstetrics"
								or EncounterDiagnosis.code in "Venous Thromboembolism"
								or EncounterDiagnosis.code in "Obstetrics VTE"
			         )
        )

// Note: added FHIRHelpers.ToDate() in R4
define "Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions":
    ( Global."Inpatient Encounter" InpatientEncounter
    		with ["Patient"] BirthDate
    			such that Global."CalendarAgeInYearsAt"(FHIRHelpers.ToDate(BirthDate.birthDate), start of InpatientEncounter.period) >= 18
    )
    intersect "Admission Without VTE or Obstetrical Conditions"

define "Encounter With VTE Prophylaxis Received on Day of or Day After Admission or Procedure":
 	( from
   			"Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter,
   			"VTE Prophylaxis by Medication Administered or Device Applied" VTEProphylaxis
  		where Coalesce(Global."Normalize Interval"(VTEProphylaxis.effective), Global."Normalize Interval"(VTEProphylaxis.performed)) starts during TJC."CalendarDayOfOrDayAfter"(start of QualifyingEncounter.period)
  		return QualifyingEncounter
 	)
 	union (
    from
  			"Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter,
  			["Procedure": "General or Neuraxial Anesthesia"] AnesthesiaProcedure,
  			"VTE Prophylaxis by Medication Administered or Device Applied" VTEProphylaxis
			where Global."Normalize Interval"(AnesthesiaProcedure.performed) ends 1 day after day of start of QualifyingEncounter.period
				and Coalesce(Global."Normalize Interval"(VTEProphylaxis.effective), Global."Normalize Interval"(VTEProphylaxis.performed)) starts during TJC."CalendarDayOfOrDayAfter"(end of Global."Normalize Interval"(AnesthesiaProcedure.performed))
			return QualifyingEncounter
	)

define "Encounter With Medication Oral Factor Xa Inhibitor Administered on Day of or Day After Admission or Procedure":
	( from
    		"Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter,
  			["MedicationAdministration": medication in "Oral Factor Xa Inhibitor for VTE Prophylaxis or VTE Treatment"] FactorXaMedication
    where FactorXaMedication.status = 'completed'
      and Global."Normalize Interval"(FactorXaMedication.effective) starts during TJC."CalendarDayOfOrDayAfter"(start of QualifyingEncounter.period)
    return QualifyingEncounter
    )
    union ( from
    				  "Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter,
      				["Procedure": "General or Neuraxial Anesthesia"] AnesthesiaProcedure,
      				["MedicationAdministration": medication in "Oral Factor Xa Inhibitor for VTE Prophylaxis or VTE Treatment"] FactorXaMedication
      			where FactorXaMedication.status = 'completed'
                and AnesthesiaProcedure.status = 'completed'
      			    and Global."Normalize Interval"(AnesthesiaProcedure.performed) ends 1 day after day of start of QualifyingEncounter.period
      					and Global."Normalize Interval"(FactorXaMedication.effective) starts during TJC."CalendarDayOfOrDayAfter"(end of Global."Normalize Interval"(AnesthesiaProcedure.performed))
      			return QualifyingEncounter
      		)

/*NOTE: Feedback at Digitial Quality Summit 2019 indicates verificationStatus may be difficult for implementers to retrieve
        both condition.clinicalStatus and condition.verificationStatus = 'confirmed'
*/
define "Encounter With Prior or Present Diagnosis of Atrial Fibrillation or VTE":
	( "Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter
		with ["Condition": code in "Atrial Fibrillation/Flutter"] AtrialFibrillation
		such that FHIRHelpers.ToConcept(AtrialFibrillation.clinicalStatus) in { Global."active", Global."recurrence", Global."relapse" }
			and Global."Normalize Interval"(AtrialFibrillation.onset) starts on or before end of QualifyingEncounter.period
    )
    union ( "Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter
    				where Global.EncounterDiagnosis(QualifyingEncounter).code in "Atrial Fibrillation/Flutter"
    			)
    union ( "Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter
    				with ["Condition": code in "Venous Thromboembolism"] VTEDiagnosis
    				such that  FHIRHelpers.ToConcept(VTEDiagnosis.clinicalStatus) in { Global."inactive", Global."remission", Global."resolved" }
      					//and VTEDiagnosis.verificationStatus = 'confirmed'
    				and Global."Normalize Interval"(VTEDiagnosis.onset) before start of QualifyingEncounter.period
      		)

define "Encounter With Prior or Present Procedure of Hip or Knee Replacement Surgery":
	"Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter
	with ( ["Procedure": "Hip Replacement Surgery"]
    			union ["Procedure": "Knee Replacement Surgery"] ) HipKneeProcedure
	such that HipKneeProcedure.status = 'completed'
	     and Global."Normalize Interval"(HipKneeProcedure.performed) starts on or before end of QualifyingEncounter.period

define "Is In Low Risk for VTE or On Anticoagulant":
	  ( ["Observation": "Risk for venous thromboembolism"] VTERiskAssessment
			  where VTERiskAssessment.value in "Low Risk"
        and VTERiskAssessment.status in {'final','amended', 'corrected'}
	  )
  union ( ["Observation": "INR"] INRLabTest
        where INRLabTest.value as Quantity > 3.0
            and INRLabTest.status in {'final','amended', 'corrected'}
        return "Observation" { id: INRLabTest.id, effective: INRLabTest.issued }
        )
  union ((( ["MedicationAdministration": "Unfractionated Heparin"] UnfractionatedHeparin
          where UnfractionatedHeparin.dosage.route in "Intravenous route"
         )
         union ["MedicationAdministration": "Direct Thrombin Inhibitor"]
         union ["MedicationAdministration": "Glycoprotein IIb/IIIa Inhibitors"] ) AnticoagulantMedication
         where AnticoagulantMedication.status = 'complete'
         return "Observation" { id: AnticoagulantMedication.id, effective: AnticoagulantMedication.effective }
      )

define "Low Risk for VTE or Anticoagulant Administered From Day of Start of Hospitalization To Day After Admission":
 	"Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter
    with "Is In Low Risk for VTE or On Anticoagulant" VTERiskAssessment
    such that Global."Normalize Interval"(VTERiskAssessment.effective) starts during VTEICU."FromDayOfStartOfHospitalizationToDayAfterAdmission"(QualifyingEncounter)

define "Low Risk for VTE or Anticoagulant Administered on Day of or Day After Procedure":
 	from
   		"Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter,
   		["Procedure": "General or Neuraxial Anesthesia"] AnesthesiaProcedure,
   		"Is In Low Risk for VTE or On Anticoagulant" VTERiskAssessment
	where Global."Normalize Interval"(AnesthesiaProcedure.performed) ends 1 day after day of start of QualifyingEncounter.period
 			and Global."Normalize Interval"(VTERiskAssessment.effective) starts during TJC."CalendarDayOfOrDayAfter"(end of Global."Normalize Interval"(AnesthesiaProcedure.performed))
	return QualifyingEncounter

define "Encounter With Low Risk for VTE or Anticoagulant Administered":
   "Low Risk for VTE or Anticoagulant Administered From Day of Start of Hospitalization To Day After Admission"
   	 union "Low Risk for VTE or Anticoagulant Administered on Day of or Day After Procedure"

define "No VTE Prophylaxis Medication Administered or Ordered":
   ((	["MedicationAdministration": medication in "Low Dose Unfractionated Heparin for VTE Prophylaxis"]
     union
	    ["MedicationAdministration": medication in "Low Molecular Weight Heparin for VTE Prophylaxis"]
     union
	    ["MedicationAdministration": medication in "Injectable Factor Xa Inhibitor for VTE Prophylaxis"]
     union
	    ["MedicationAdministration": medication in "Warfarin"]
       ) MedicationAdm
       where MedicationAdm.status = 'not-done'
        )
  union
	   ((	["MedicationRequest": medication in "Low Dose Unfractionated Heparin for VTE Prophylaxis"]
  	union
  	 ["MedicationRequest": medication in "Low Molecular Weight Heparin for VTE Prophylaxis"]
    union
    	["MedicationRequest": medication in "Injectable Factor Xa Inhibitor for VTE Prophylaxis"]
    union
    	["MedicationRequest": medication in "Warfarin"]
    ) MedicationOrder
    	where	MedicationOrder.doNotPerform is true
        and MedicationOrder.status in {'completed', 'cancelled'}
        //11/5 discussion: all expressions for QI-Core must include a status.
        //Therefore, we need ServiceRequest.status = completed; and MedicationRequest.status = cancelled (or completed, since cancelled indicates it was once ordered but intentionally never filled).
        //So the not done issue is handled by ServiceRequest.doNotPerform = True  Or MedicationRequest.doNotPerform = True
    )

define "No VTE Prophylaxis Medication Due to Medical Reason From Day of Start of Hospitalization To Day After Admission":
   	"Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter
       with	"No VTE Prophylaxis Medication Administered or Ordered" NoVTEMedication
     	such that Coalesce(NoVTEMedication.statusReason,NoVTEMedication.reasonCode) in "Medical Reason"
      			and Coalesce(NoVTEMedication.authoredOn, start of Global."Normalize Interval"(NoVTEMedication.effective)) during VTEICU."FromDayOfStartOfHospitalizationToDayAfterAdmission"(QualifyingEncounter)

define "No VTE Prophylaxis Device Applied or Ordered":
  ((
    ["ServiceRequest": "Venous foot pumps (VFP)"]
    union ["ServiceRequest": "Intermittent pneumatic compression devices (IPC)"]
    union ["ServiceRequest": "Graduated compression stockings (GCS)"]
    ) DeviceOrder
    where DeviceOrder.status = 'completed'
    //11/5 discussion: all expressions for QI-Core must include a status
    //ServiceRequest.status -  draft | active | suspended | completed | entered-in-error | cancelled
        and DeviceOrder.doNotPerform is true
    return {id: DeviceOrder.id, requestStatusReason: GetStatusReason(DeviceOrder), authoredOn: DeviceOrder.authoredOn}
    )
  union
    (
      ["Procedure": "Device Application"] DeviceApplied
      let DeviceNotDoneTiming: Global.GetExtension(DeviceApplied, 'qicore-recorded').value
      where (DeviceApplied.usedCode in "Intermittent pneumatic compression devices (IPC)"
            or DeviceApplied.usedCode in "Venous foot pumps (VFP)"
            or DeviceApplied.usedCode in "Graduated compression stockings (GCS)"
            )
         and  DeviceApplied.status = 'not-done'
         return {id: DeviceApplied.id, requestStatusReason: DeviceApplied.statusReason, authoredOn: DeviceNotDoneTiming}

    )

define "No VTE Prophylaxis Device Due to Medical Reason From Day of Start of Hospitalization To Day After Admission":
  "Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter
  	with "No VTE Prophylaxis Device Applied or Ordered" NoVTEDevice
      such that NoVTEDevice.requestStatusReason in "Medical Reason"
        and  NoVTEDevice.authoredOn during VTEICU."FromDayOfStartOfHospitalizationToDayAfterAdmission"(QualifyingEncounter)

define "No VTE Prophylaxis Medication Due to Medical Reason on Day of or Day After Procedure":
	from
  		"Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter,
  		["Procedure": "General or Neuraxial Anesthesia"] AnesthesiaProcedure,
  		"No VTE Prophylaxis Medication Administered or Ordered" NoVTEMedication
	where Coalesce(NoVTEMedication.statusReason,NoVTEMedication.reasonCode) in "Medical Reason"
			and AnesthesiaProcedure.status = 'completed'
			and Global."Normalize Interval"(AnesthesiaProcedure.performed) ends 1 day after day of start of QualifyingEncounter.period
			and Coalesce(NoVTEMedication.authoredOn, start of Global."Normalize Interval"(NoVTEMedication.effective)) during TJC."CalendarDayOfOrDayAfter"(end of Global."Normalize Interval"(AnesthesiaProcedure.performed))
  return QualifyingEncounter

define "No VTE Prophylaxis Device Due to Medical Reason on Day of or Day After Procedure":
  from
  		"Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter,
  		["Procedure": "General or Neuraxial Anesthesia"] AnesthesiaProcedure,
  		"No VTE Prophylaxis Device Applied or Ordered" NoVTEDevice
  where  NoVTEDevice.requestStatusReason in "Medical Reason"
      and AnesthesiaProcedure.status = 'completed'
  		and Global."Normalize Interval"(AnesthesiaProcedure.performed) ends 1 day after day of start of QualifyingEncounter.period
      and NoVTEDevice.authoredOn during TJC."CalendarDayOfOrDayAfter"(end of Global."Normalize Interval"(AnesthesiaProcedure.performed))
  return QualifyingEncounter

define "Encounter With No VTE Prophylaxis Due to Medical Reason":
   ( "No VTE Prophylaxis Medication Due to Medical Reason From Day of Start of Hospitalization To Day After Admission"
     intersect "No VTE Prophylaxis Device Due to Medical Reason From Day of Start of Hospitalization To Day After Admission"
   )
   union ( "No VTE Prophylaxis Medication Due to Medical Reason on Day of or Day After Procedure"
       intersect "No VTE Prophylaxis Device Due to Medical Reason on Day of or Day After Procedure"
       )

define "No VTE Prophylaxis Medication or Device Due to Patient Refusal":
    ( "No VTE Prophylaxis Medication Administered or Ordered" NoVTEMedication
        where Coalesce(NoVTEMedication.statusReason,NoVTEMedication.reasonCode) in "Patient Refusal"
    )
  union ("No VTE Prophylaxis Device Applied or Ordered" NoVTEDevice
           where NoVTEDevice.requestStatusReason in "Patient Refusal"
        )

define "No VTE Prophylaxis Due to Patient Refusal From Day of Start of Hospitalization To Day After Admission":
 	"Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter
	 with "No VTE Prophylaxis Medication or Device Due to Patient Refusal" PatientRefusal
   such that Coalesce(start of Global."Normalize Interval"(PatientRefusal.effective), PatientRefusal.authoredOn)
         during VTEICU."FromDayOfStartOfHospitalizationToDayAfterAdmission"(QualifyingEncounter)

define "No VTE Prophylaxis Due to Patient Refusal on Day of or Day After Procedure":
 	from
   		"Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter,
   		["Procedure": "General or Neuraxial Anesthesia"] AnesthesiaProcedure,
   		"No VTE Prophylaxis Medication or Device Due to Patient Refusal" PatientRefusal
	where Global."Normalize Interval"(AnesthesiaProcedure.performed) ends 1 day after day of start of QualifyingEncounter.period
 			and Coalesce(start of Global."Normalize Interval"(PatientRefusal.effective), PatientRefusal.authoredOn)
             during TJC."CalendarDayOfOrDayAfter"(end of Global."Normalize Interval"(AnesthesiaProcedure.performed))
	return QualifyingEncounter

define "Encounter With No VTE Prophylaxis Due to Patient Refusal":
 "No VTE Prophylaxis Due to Patient Refusal From Day of Start of Hospitalization To Day After Admission"
 	union "No VTE Prophylaxis Due to Patient Refusal on Day of or Day After Procedure"

define "Numerator":
    "Encounter With VTE Prophylaxis Received on Day of or Day After Admission or Procedure"
    union ( "Encounter With Medication Oral Factor Xa Inhibitor Administered on Day of or Day After Admission or Procedure"
    			  intersect ( "Encounter With Prior or Present Diagnosis of Atrial Fibrillation or VTE"
    						    union "Encounter With Prior or Present Procedure of Hip or Knee Replacement Surgery"
    			            )
          )
    union "Encounter With Low Risk for VTE or Anticoagulant Administered"
    union "Encounter With No VTE Prophylaxis Due to Medical Reason"
    union "Encounter With No VTE Prophylaxis Due to Patient Refusal"

define "Initial Population":
  "Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions"

define "Denominator":
      "Initial Population"

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

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

define "Encounter Less Than 2 Days":
  "Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter
  	where Global."LengthInDays"(QualifyingEncounter.period)< 2

define "Encounter With ICU Location Stay 1 Day or More":
  "Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter
    where exists ( QualifyingEncounter.location Location
    		where Global.GetLocation(Location.location).type in "Intensive Care Unit"
    			and Global."LengthInDays"(Location.period)>= 1
    			and Location.period starts during TJC."CalendarDayOfOrDayAfter"(start of QualifyingEncounter.period)
	    )

define "Encounter With Principal Diagnosis of Mental Disorder or Stroke":
  "Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter
    where Global."PrincipalDiagnosis"(QualifyingEncounter).code in "Mental Health Diagnoses"
        or Global."PrincipalDiagnosis"(QualifyingEncounter).code in "Hemorrhagic Stroke"
        or Global."PrincipalDiagnosis"(QualifyingEncounter).code in "Ischemic Stroke"

define "SCIP VTE Selected Surgery":
  (	["Procedure": "General Surgery"]
    union ["Procedure": "Gynecological Surgery"]
    union ["Procedure": "Hip Fracture Surgery"]
    union ["Procedure": "Hip Replacement Surgery"]
    union ["Procedure": "Intracranial Neurosurgery"]
    union ["Procedure": "Knee Replacement Surgery"]
    union ["Procedure": "Urological Surgery"] ) Procedure
  where Procedure.status = 'completed'

/* NOTE: 2 options to express Principal Procedure to retrive "encounter Procedure as an url" and proedure "rank as extension" in R4
          VTE-1 uses Option 1 - generic extension funtion
          VTE-2 uses Option 2 - Specific extension functions
  TODO:  Mapping Table needs revision on using "Encounter.procedure.code", "Encounter.procedure.sequence"
*/
define "Encounter With Principal Procedure of SCIP VTE Selected Surgery":
  from
      "Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter,
      "SCIP VTE Selected Surgery" SelectedProcedure
      let EncounterProcedure: Global.GetExtension(QualifyingEncounter, 'qicore-encounter-procedure')
  where FHIRHelpers.ToInteger(Global.GetExtension(EncounterProcedure, 'rank').value as FHIR.positiveInt) = 1
      and Global.GetId(FHIRHelpers.ToString((Global.GetExtension(EncounterProcedure, 'procedure').value as FHIR.Reference).reference)) = SelectedProcedure.id
      and Global."Normalize Interval"(SelectedProcedure.performed) during QualifyingEncounter.period

define "Intervention Comfort Measures":
	(["ServiceRequest": "Comfort Measures"] P
    		where P.intent = 'order'
  )
  	union
    	(["Procedure": "Comfort Measures"] InterventionPerformed
      	where InterventionPerformed.status in {'completed', 'in-progress'})

define "Encounter With Intervention Comfort Measures From Day of Start of Hospitalization To Day After Admission":
	"Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter
		with "Intervention Comfort Measures" ComfortMeasure
		such that Coalesce(start of Global."Normalize Interval"(ComfortMeasure.performed), ComfortMeasure.authoredOn) during VTEICU."FromDayOfStartOfHospitalizationToDayAfterAdmission"(QualifyingEncounter)

define "Encounter With Intervention Comfort Measures on Day of or Day After Procedure":
  from
  		"Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions" QualifyingEncounter,
  		["Procedure": "General or Neuraxial Anesthesia"] AnesthesiaProcedure,
  		"Intervention Comfort Measures" ComfortMeasure
		where AnesthesiaProcedure.status = 'completed'
				and Global."Normalize Interval"(AnesthesiaProcedure.performed) ends 1 day after day of start of QualifyingEncounter.period
        and Coalesce(start of Global."Normalize Interval"(ComfortMeasure.performed), ComfortMeasure.authoredOn) during TJC."CalendarDayOfOrDayAfter"(end of Global."Normalize Interval"(AnesthesiaProcedure.performed))
    return QualifyingEncounter

define "Denominator Exclusion":
    "Encounter Less Than 2 Days"
     union "Encounter With ICU Location Stay 1 Day or More"
     union "Encounter With Principal Diagnosis of Mental Disorder or Stroke"
     union "Encounter With Principal Procedure of SCIP VTE Selected Surgery"
     union "Encounter With Intervention Comfort Measures From Day of Start of Hospitalization To Day After Admission"
     union "Encounter With Intervention Comfort Measures on Day of or Day After Procedure"

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

Source

{
  "resourceType": "Measure",
  "id": "EXM108-FHIR",
  "meta": {
    "profile": [
      "http://hl7.org/fhir/uv/crmi/StructureDefinition/crmi-shareablemeasure",
      "http://hl7.org/fhir/uv/cqm/StructureDefinition/cqm-computablemeasure",
      "http://hl7.org/fhir/uv/cqm/StructureDefinition/cqm-proportionmeasure",
      "http://hl7.org/fhir/uv/cqm/StructureDefinition/cqm-cqlmeasure"
    ]
  },
  "text": {
    "status": "extensions",
    "div": "<!-- snip (see above) -->"
  },
  "contained": [
    {
      "resourceType": "Library",
      "id": "effective-data-requirements-exm108",
      "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-clinical",
            "code": "recurrence"
          }
        },
        {
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-directReferenceCode",
          "valueCoding": {
            "system": "http://terminology.hl7.org/CodeSystem/condition-clinical",
            "code": "relapse"
          }
        },
        {
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-directReferenceCode",
          "valueCoding": {
            "system": "http://terminology.hl7.org/CodeSystem/condition-clinical",
            "code": "inactive"
          }
        },
        {
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-directReferenceCode",
          "valueCoding": {
            "system": "http://terminology.hl7.org/CodeSystem/condition-clinical",
            "code": "remission"
          }
        },
        {
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-directReferenceCode",
          "valueCoding": {
            "system": "http://terminology.hl7.org/CodeSystem/condition-clinical",
            "code": "resolved"
          }
        },
        {
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-directReferenceCode",
          "valueCoding": {
            "system": "http://loinc.org",
            "code": "72136-5",
            "display": "Risk for venous thromboembolism"
          }
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "SupplementalDataElements"
            },
            {
              "url": "name",
              "valueString": "SDE Sex"
            },
            {
              "url": "statement",
              "valueString": "define \"SDE Sex\":\n  case\n      when Patient.gender = 'male' then Code { code: 'M', system: 'http://hl7.org/fhir/v3/AdministrativeGender', display: 'Male' }\n      when Patient.gender = 'female' then Code { code: 'F', system: 'http://hl7.org/fhir/v3/AdministrativeGender', display: 'Female' }\n      else null\n    end"
            },
            {
              "url": "displaySequence",
              "valueInteger": 0
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "EXM108-FHIR"
            },
            {
              "url": "name",
              "valueString": "SDE Sex"
            },
            {
              "url": "statement",
              "valueString": "define \"SDE Sex\":\n\tSDE.\"SDE Sex\""
            },
            {
              "url": "displaySequence",
              "valueInteger": 1
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "MATGlobalCommonFunctions"
            },
            {
              "url": "name",
              "valueString": "Inpatient Encounter"
            },
            {
              "url": "statement",
              "valueString": "define \"Inpatient Encounter\":\n\t[Encounter: \"Encounter Inpatient\"] EncounterInpatient\n\t\twhere EncounterInpatient.status = 'finished'\n\t\t    and \"LengthInDays\"(EncounterInpatient.period) <= 120\n\t\t\tand EncounterInpatient.period ends during \"Measurement Period\""
            },
            {
              "url": "displaySequence",
              "valueInteger": 2
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "EXM108-FHIR"
            },
            {
              "url": "name",
              "valueString": "Admission Without VTE or Obstetrical Conditions"
            },
            {
              "url": "statement",
              "valueString": "define \"Admission Without VTE or Obstetrical Conditions\":\n\t  \tGlobal.\"Inpatient Encounter\" InpatientEncounter\n\t\t    where not (exists (Global.EncounterDiagnosis(InpatientEncounter)) EncounterDiagnosis\n              where (EncounterDiagnosis.code in \"Obstetrics\"\n\t\t\t\t\t\t\t\tor EncounterDiagnosis.code in \"Venous Thromboembolism\"\n\t\t\t\t\t\t\t\tor EncounterDiagnosis.code in \"Obstetrics VTE\"\n\t\t\t         )\n        )"
            },
            {
              "url": "displaySequence",
              "valueInteger": 3
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "EXM108-FHIR"
            },
            {
              "url": "name",
              "valueString": "Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions"
            },
            {
              "url": "statement",
              "valueString": "// Note: added FHIRHelpers.ToDate() in R4\ndefine \"Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions\":\n    ( Global.\"Inpatient Encounter\" InpatientEncounter\n    \t\twith [\"Patient\"] BirthDate\n    \t\t\tsuch that Global.\"CalendarAgeInYearsAt\"(FHIRHelpers.ToDate(BirthDate.birthDate), start of InpatientEncounter.period) >= 18\n    )\n    intersect \"Admission Without VTE or Obstetrical Conditions\""
            },
            {
              "url": "displaySequence",
              "valueInteger": 4
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "EXM108"
            },
            {
              "url": "name",
              "valueString": "VTE Prophylaxis by Medication Administered or Device Applied"
            },
            {
              "url": "statement",
              "valueString": "// 10/29: Replaced DeviceUseStatement with Procedure with a new value set and procedure.usdCode for specifying devices\ndefine \"VTE Prophylaxis by Medication Administered or Device Applied\":\n  ( [\"MedicationAdministration\": medication in \"Low Dose Unfractionated Heparin for VTE Prophylaxis\"] VTEMedication\n      where VTEMedication.status ='completed'\n\t\t\t     and VTEMedication.dosage.route in \"Subcutaneous route\"\n  )\n   union ([\"MedicationAdministration\": medication in \"Low Molecular Weight Heparin for VTE Prophylaxis\"] LMWH where LMWH.status = 'completed')\n    union ([\"MedicationAdministration\": medication in \"Injectable Factor Xa Inhibitor for VTE Prophylaxis\"] FactorXa where FactorXa.status = 'completed')\n     union ([\"MedicationAdministration\": medication in \"Warfarin\"] Warfarin where Warfarin.status = 'completed')\n      union (\n          [\"Procedure\": \"Device Application\"] DeviceApplied\n          where DeviceApplied.status = 'complete'\n                and (DeviceApplied.usedCode in \"Intermittent pneumatic compression devices (IPC)\"\n                    or DeviceApplied.usedCode in\"Venous foot pumps (VFP)\"\n                    or DeviceApplied.usedCode in \"Graduated compression stockings (GCS)\"\n                    )\n          )"
            },
            {
              "url": "displaySequence",
              "valueInteger": 5
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "EXM108-FHIR"
            },
            {
              "url": "name",
              "valueString": "Encounter With VTE Prophylaxis Received on Day of or Day After Admission or Procedure"
            },
            {
              "url": "statement",
              "valueString": "define \"Encounter With VTE Prophylaxis Received on Day of or Day After Admission or Procedure\":\n \t( from\n   \t\t\t\"Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions\" QualifyingEncounter,\n   \t\t\t\"VTE Prophylaxis by Medication Administered or Device Applied\" VTEProphylaxis\n  \t\twhere Coalesce(Global.\"Normalize Interval\"(VTEProphylaxis.effective), Global.\"Normalize Interval\"(VTEProphylaxis.performed)) starts during TJC.\"CalendarDayOfOrDayAfter\"(start of QualifyingEncounter.period)\n  \t\treturn QualifyingEncounter\n \t)\n \tunion (\n    from\n  \t\t\t\"Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions\" QualifyingEncounter,\n  \t\t\t[\"Procedure\": \"General or Neuraxial Anesthesia\"] AnesthesiaProcedure,\n  \t\t\t\"VTE Prophylaxis by Medication Administered or Device Applied\" VTEProphylaxis\n\t\t\twhere Global.\"Normalize Interval\"(AnesthesiaProcedure.performed) ends 1 day after day of start of QualifyingEncounter.period\n\t\t\t\tand Coalesce(Global.\"Normalize Interval\"(VTEProphylaxis.effective), Global.\"Normalize Interval\"(VTEProphylaxis.performed)) starts during TJC.\"CalendarDayOfOrDayAfter\"(end of Global.\"Normalize Interval\"(AnesthesiaProcedure.performed))\n\t\t\treturn QualifyingEncounter\n\t)"
            },
            {
              "url": "displaySequence",
              "valueInteger": 6
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "EXM108-FHIR"
            },
            {
              "url": "name",
              "valueString": "Encounter With Medication Oral Factor Xa Inhibitor Administered on Day of or Day After Admission or Procedure"
            },
            {
              "url": "statement",
              "valueString": "define \"Encounter With Medication Oral Factor Xa Inhibitor Administered on Day of or Day After Admission or Procedure\":\n\t( from\n    \t\t\"Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions\" QualifyingEncounter,\n  \t\t\t[\"MedicationAdministration\": medication in \"Oral Factor Xa Inhibitor for VTE Prophylaxis or VTE Treatment\"] FactorXaMedication\n    where FactorXaMedication.status = 'completed'\n      and Global.\"Normalize Interval\"(FactorXaMedication.effective) starts during TJC.\"CalendarDayOfOrDayAfter\"(start of QualifyingEncounter.period)\n    return QualifyingEncounter\n    )\n    union ( from\n    \t\t\t\t  \"Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions\" QualifyingEncounter,\n      \t\t\t\t[\"Procedure\": \"General or Neuraxial Anesthesia\"] AnesthesiaProcedure,\n      \t\t\t\t[\"MedicationAdministration\": medication in \"Oral Factor Xa Inhibitor for VTE Prophylaxis or VTE Treatment\"] FactorXaMedication\n      \t\t\twhere FactorXaMedication.status = 'completed'\n                and AnesthesiaProcedure.status = 'completed'\n      \t\t\t    and Global.\"Normalize Interval\"(AnesthesiaProcedure.performed) ends 1 day after day of start of QualifyingEncounter.period\n      \t\t\t\t\tand Global.\"Normalize Interval\"(FactorXaMedication.effective) starts during TJC.\"CalendarDayOfOrDayAfter\"(end of Global.\"Normalize Interval\"(AnesthesiaProcedure.performed))\n      \t\t\treturn QualifyingEncounter\n      \t\t)"
            },
            {
              "url": "displaySequence",
              "valueInteger": 7
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "EXM108-FHIR"
            },
            {
              "url": "name",
              "valueString": "Encounter With Prior or Present Diagnosis of Atrial Fibrillation or VTE"
            },
            {
              "url": "statement",
              "valueString": "/*NOTE: Feedback at Digitial Quality Summit 2019 indicates verificationStatus may be difficult for implementers to retrieve\n        both condition.clinicalStatus and condition.verificationStatus = 'confirmed'\n*/\ndefine \"Encounter With Prior or Present Diagnosis of Atrial Fibrillation or VTE\":\n\t( \"Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions\" QualifyingEncounter\n\t\twith [\"Condition\": code in \"Atrial Fibrillation/Flutter\"] AtrialFibrillation\n\t\tsuch that FHIRHelpers.ToConcept(AtrialFibrillation.clinicalStatus) in { Global.\"active\", Global.\"recurrence\", Global.\"relapse\" }\n\t\t\tand Global.\"Normalize Interval\"(AtrialFibrillation.onset) starts on or before end of QualifyingEncounter.period\n    )\n    union ( \"Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions\" QualifyingEncounter\n    \t\t\t\twhere Global.EncounterDiagnosis(QualifyingEncounter).code in \"Atrial Fibrillation/Flutter\"\n    \t\t\t)\n    union ( \"Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions\" QualifyingEncounter\n    \t\t\t\twith [\"Condition\": code in \"Venous Thromboembolism\"] VTEDiagnosis\n    \t\t\t\tsuch that  FHIRHelpers.ToConcept(VTEDiagnosis.clinicalStatus) in { Global.\"inactive\", Global.\"remission\", Global.\"resolved\" }\n      \t\t\t\t\t//and VTEDiagnosis.verificationStatus = 'confirmed'\n    \t\t\t\tand Global.\"Normalize Interval\"(VTEDiagnosis.onset) before start of QualifyingEncounter.period\n      \t\t)"
            },
            {
              "url": "displaySequence",
              "valueInteger": 8
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "EXM108-FHIR"
            },
            {
              "url": "name",
              "valueString": "Encounter With Prior or Present Procedure of Hip or Knee Replacement Surgery"
            },
            {
              "url": "statement",
              "valueString": "define \"Encounter With Prior or Present Procedure of Hip or Knee Replacement Surgery\":\n\t\"Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions\" QualifyingEncounter\n\twith ( [\"Procedure\": \"Hip Replacement Surgery\"]\n    \t\t\tunion [\"Procedure\": \"Knee Replacement Surgery\"] ) HipKneeProcedure\n\tsuch that HipKneeProcedure.status = 'completed'\n\t     and Global.\"Normalize Interval\"(HipKneeProcedure.performed) starts on or before end of QualifyingEncounter.period"
            },
            {
              "url": "displaySequence",
              "valueInteger": 9
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "EXM108-FHIR"
            },
            {
              "url": "name",
              "valueString": "Is In Low Risk for VTE or On Anticoagulant"
            },
            {
              "url": "statement",
              "valueString": "define \"Is In Low Risk for VTE or On Anticoagulant\":\n\t  ( [\"Observation\": \"Risk for venous thromboembolism\"] VTERiskAssessment\n\t\t\t  where VTERiskAssessment.value in \"Low Risk\"\n        and VTERiskAssessment.status in {'final','amended', 'corrected'}\n\t  )\n  union ( [\"Observation\": \"INR\"] INRLabTest\n        where INRLabTest.value as Quantity > 3.0\n            and INRLabTest.status in {'final','amended', 'corrected'}\n        return \"Observation\" { id: INRLabTest.id, effective: INRLabTest.issued }\n        )\n  union ((( [\"MedicationAdministration\": \"Unfractionated Heparin\"] UnfractionatedHeparin\n          where UnfractionatedHeparin.dosage.route in \"Intravenous route\"\n         )\n         union [\"MedicationAdministration\": \"Direct Thrombin Inhibitor\"]\n         union [\"MedicationAdministration\": \"Glycoprotein IIb/IIIa Inhibitors\"] ) AnticoagulantMedication\n         where AnticoagulantMedication.status = 'complete'\n         return \"Observation\" { id: AnticoagulantMedication.id, effective: AnticoagulantMedication.effective }\n      )"
            },
            {
              "url": "displaySequence",
              "valueInteger": 10
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "EXM108-FHIR"
            },
            {
              "url": "name",
              "valueString": "Low Risk for VTE or Anticoagulant Administered From Day of Start of Hospitalization To Day After Admission"
            },
            {
              "url": "statement",
              "valueString": "define \"Low Risk for VTE or Anticoagulant Administered From Day of Start of Hospitalization To Day After Admission\":\n \t\"Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions\" QualifyingEncounter\n    with \"Is In Low Risk for VTE or On Anticoagulant\" VTERiskAssessment\n    such that Global.\"Normalize Interval\"(VTERiskAssessment.effective) starts during VTEICU.\"FromDayOfStartOfHospitalizationToDayAfterAdmission\"(QualifyingEncounter)"
            },
            {
              "url": "displaySequence",
              "valueInteger": 11
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "EXM108-FHIR"
            },
            {
              "url": "name",
              "valueString": "Low Risk for VTE or Anticoagulant Administered on Day of or Day After Procedure"
            },
            {
              "url": "statement",
              "valueString": "define \"Low Risk for VTE or Anticoagulant Administered on Day of or Day After Procedure\":\n \tfrom\n   \t\t\"Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions\" QualifyingEncounter,\n   \t\t[\"Procedure\": \"General or Neuraxial Anesthesia\"] AnesthesiaProcedure,\n   \t\t\"Is In Low Risk for VTE or On Anticoagulant\" VTERiskAssessment\n\twhere Global.\"Normalize Interval\"(AnesthesiaProcedure.performed) ends 1 day after day of start of QualifyingEncounter.period\n \t\t\tand Global.\"Normalize Interval\"(VTERiskAssessment.effective) starts during TJC.\"CalendarDayOfOrDayAfter\"(end of Global.\"Normalize Interval\"(AnesthesiaProcedure.performed))\n\treturn QualifyingEncounter"
            },
            {
              "url": "displaySequence",
              "valueInteger": 12
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "EXM108-FHIR"
            },
            {
              "url": "name",
              "valueString": "Encounter With Low Risk for VTE or Anticoagulant Administered"
            },
            {
              "url": "statement",
              "valueString": "define \"Encounter With Low Risk for VTE or Anticoagulant Administered\":\n   \"Low Risk for VTE or Anticoagulant Administered From Day of Start of Hospitalization To Day After Admission\"\n   \t union \"Low Risk for VTE or Anticoagulant Administered on Day of or Day After Procedure\""
            },
            {
              "url": "displaySequence",
              "valueInteger": 13
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "EXM108-FHIR"
            },
            {
              "url": "name",
              "valueString": "No VTE Prophylaxis Medication Administered or Ordered"
            },
            {
              "url": "statement",
              "valueString": "define \"No VTE Prophylaxis Medication Administered or Ordered\":\n   ((\t[\"MedicationAdministration\": medication in \"Low Dose Unfractionated Heparin for VTE Prophylaxis\"]\n     union\n\t    [\"MedicationAdministration\": medication in \"Low Molecular Weight Heparin for VTE Prophylaxis\"]\n     union\n\t    [\"MedicationAdministration\": medication in \"Injectable Factor Xa Inhibitor for VTE Prophylaxis\"]\n     union\n\t    [\"MedicationAdministration\": medication in \"Warfarin\"]\n       ) MedicationAdm\n       where MedicationAdm.status = 'not-done'\n        )\n  union\n\t   ((\t[\"MedicationRequest\": medication in \"Low Dose Unfractionated Heparin for VTE Prophylaxis\"]\n  \tunion\n  \t [\"MedicationRequest\": medication in \"Low Molecular Weight Heparin for VTE Prophylaxis\"]\n    union\n    \t[\"MedicationRequest\": medication in \"Injectable Factor Xa Inhibitor for VTE Prophylaxis\"]\n    union\n    \t[\"MedicationRequest\": medication in \"Warfarin\"]\n    ) MedicationOrder\n    \twhere\tMedicationOrder.doNotPerform is true\n        and MedicationOrder.status in {'completed', 'cancelled'}\n        //11/5 discussion: all expressions for QI-Core must include a status.\n        //Therefore, we need ServiceRequest.status = completed; and MedicationRequest.status = cancelled (or completed, since cancelled indicates it was once ordered but intentionally never filled).\n        //So the not done issue is handled by ServiceRequest.doNotPerform = True  Or MedicationRequest.doNotPerform = True\n    )"
            },
            {
              "url": "displaySequence",
              "valueInteger": 14
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "EXM108-FHIR"
            },
            {
              "url": "name",
              "valueString": "No VTE Prophylaxis Medication Due to Medical Reason From Day of Start of Hospitalization To Day After Admission"
            },
            {
              "url": "statement",
              "valueString": "define \"No VTE Prophylaxis Medication Due to Medical Reason From Day of Start of Hospitalization To Day After Admission\":\n   \t\"Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions\" QualifyingEncounter\n       with\t\"No VTE Prophylaxis Medication Administered or Ordered\" NoVTEMedication\n     \tsuch that Coalesce(NoVTEMedication.statusReason,NoVTEMedication.reasonCode) in \"Medical Reason\"\n      \t\t\tand Coalesce(NoVTEMedication.authoredOn, start of Global.\"Normalize Interval\"(NoVTEMedication.effective)) during VTEICU.\"FromDayOfStartOfHospitalizationToDayAfterAdmission\"(QualifyingEncounter)"
            },
            {
              "url": "displaySequence",
              "valueInteger": 15
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "EXM108-FHIR"
            },
            {
              "url": "name",
              "valueString": "No VTE Prophylaxis Device Applied or Ordered"
            },
            {
              "url": "statement",
              "valueString": "define \"No VTE Prophylaxis Device Applied or Ordered\":\n  ((\n    [\"ServiceRequest\": \"Venous foot pumps (VFP)\"]\n    union [\"ServiceRequest\": \"Intermittent pneumatic compression devices (IPC)\"]\n    union [\"ServiceRequest\": \"Graduated compression stockings (GCS)\"]\n    ) DeviceOrder\n    where DeviceOrder.status = 'completed'\n    //11/5 discussion: all expressions for QI-Core must include a status\n    //ServiceRequest.status -  draft | active | suspended | completed | entered-in-error | cancelled\n        and DeviceOrder.doNotPerform is true\n    return {id: DeviceOrder.id, requestStatusReason: GetStatusReason(DeviceOrder), authoredOn: DeviceOrder.authoredOn}\n    )\n  union\n    (\n      [\"Procedure\": \"Device Application\"] DeviceApplied\n      let DeviceNotDoneTiming: Global.GetExtension(DeviceApplied, 'qicore-recorded').value\n      where (DeviceApplied.usedCode in \"Intermittent pneumatic compression devices (IPC)\"\n            or DeviceApplied.usedCode in \"Venous foot pumps (VFP)\"\n            or DeviceApplied.usedCode in \"Graduated compression stockings (GCS)\"\n            )\n         and  DeviceApplied.status = 'not-done'\n         return {id: DeviceApplied.id, requestStatusReason: DeviceApplied.statusReason, authoredOn: DeviceNotDoneTiming}\n\n    )"
            },
            {
              "url": "displaySequence",
              "valueInteger": 16
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "EXM108-FHIR"
            },
            {
              "url": "name",
              "valueString": "No VTE Prophylaxis Device Due to Medical Reason From Day of Start of Hospitalization To Day After Admission"
            },
            {
              "url": "statement",
              "valueString": "define \"No VTE Prophylaxis Device Due to Medical Reason From Day of Start of Hospitalization To Day After Admission\":\n  \"Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions\" QualifyingEncounter\n  \twith \"No VTE Prophylaxis Device Applied or Ordered\" NoVTEDevice\n      such that NoVTEDevice.requestStatusReason in \"Medical Reason\"\n        and  NoVTEDevice.authoredOn during VTEICU.\"FromDayOfStartOfHospitalizationToDayAfterAdmission\"(QualifyingEncounter)"
            },
            {
              "url": "displaySequence",
              "valueInteger": 17
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "EXM108-FHIR"
            },
            {
              "url": "name",
              "valueString": "No VTE Prophylaxis Medication Due to Medical Reason on Day of or Day After Procedure"
            },
            {
              "url": "statement",
              "valueString": "define \"No VTE Prophylaxis Medication Due to Medical Reason on Day of or Day After Procedure\":\n\tfrom\n  \t\t\"Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions\" QualifyingEncounter,\n  \t\t[\"Procedure\": \"General or Neuraxial Anesthesia\"] AnesthesiaProcedure,\n  \t\t\"No VTE Prophylaxis Medication Administered or Ordered\" NoVTEMedication\n\twhere Coalesce(NoVTEMedication.statusReason,NoVTEMedication.reasonCode) in \"Medical Reason\"\n\t\t\tand AnesthesiaProcedure.status = 'completed'\n\t\t\tand Global.\"Normalize Interval\"(AnesthesiaProcedure.performed) ends 1 day after day of start of QualifyingEncounter.period\n\t\t\tand Coalesce(NoVTEMedication.authoredOn, start of Global.\"Normalize Interval\"(NoVTEMedication.effective)) during TJC.\"CalendarDayOfOrDayAfter\"(end of Global.\"Normalize Interval\"(AnesthesiaProcedure.performed))\n  return QualifyingEncounter"
            },
            {
              "url": "displaySequence",
              "valueInteger": 18
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "EXM108-FHIR"
            },
            {
              "url": "name",
              "valueString": "No VTE Prophylaxis Device Due to Medical Reason on Day of or Day After Procedure"
            },
            {
              "url": "statement",
              "valueString": "define \"No VTE Prophylaxis Device Due to Medical Reason on Day of or Day After Procedure\":\n  from\n  \t\t\"Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions\" QualifyingEncounter,\n  \t\t[\"Procedure\": \"General or Neuraxial Anesthesia\"] AnesthesiaProcedure,\n  \t\t\"No VTE Prophylaxis Device Applied or Ordered\" NoVTEDevice\n  where  NoVTEDevice.requestStatusReason in \"Medical Reason\"\n      and AnesthesiaProcedure.status = 'completed'\n  \t\tand Global.\"Normalize Interval\"(AnesthesiaProcedure.performed) ends 1 day after day of start of QualifyingEncounter.period\n      and NoVTEDevice.authoredOn during TJC.\"CalendarDayOfOrDayAfter\"(end of Global.\"Normalize Interval\"(AnesthesiaProcedure.performed))\n  return QualifyingEncounter"
            },
            {
              "url": "displaySequence",
              "valueInteger": 19
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "EXM108-FHIR"
            },
            {
              "url": "name",
              "valueString": "Encounter With No VTE Prophylaxis Due to Medical Reason"
            },
            {
              "url": "statement",
              "valueString": "define \"Encounter With No VTE Prophylaxis Due to Medical Reason\":\n   ( \"No VTE Prophylaxis Medication Due to Medical Reason From Day of Start of Hospitalization To Day After Admission\"\n     intersect \"No VTE Prophylaxis Device Due to Medical Reason From Day of Start of Hospitalization To Day After Admission\"\n   )\n   union ( \"No VTE Prophylaxis Medication Due to Medical Reason on Day of or Day After Procedure\"\n       intersect \"No VTE Prophylaxis Device Due to Medical Reason on Day of or Day After Procedure\"\n       )"
            },
            {
              "url": "displaySequence",
              "valueInteger": 20
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "EXM108-FHIR"
            },
            {
              "url": "name",
              "valueString": "No VTE Prophylaxis Medication or Device Due to Patient Refusal"
            },
            {
              "url": "statement",
              "valueString": "define \"No VTE Prophylaxis Medication or Device Due to Patient Refusal\":\n    ( \"No VTE Prophylaxis Medication Administered or Ordered\" NoVTEMedication\n        where Coalesce(NoVTEMedication.statusReason,NoVTEMedication.reasonCode) in \"Patient Refusal\"\n    )\n  union (\"No VTE Prophylaxis Device Applied or Ordered\" NoVTEDevice\n           where NoVTEDevice.requestStatusReason in \"Patient Refusal\"\n        )"
            },
            {
              "url": "displaySequence",
              "valueInteger": 21
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "EXM108-FHIR"
            },
            {
              "url": "name",
              "valueString": "No VTE Prophylaxis Due to Patient Refusal From Day of Start of Hospitalization To Day After Admission"
            },
            {
              "url": "statement",
              "valueString": "define \"No VTE Prophylaxis Due to Patient Refusal From Day of Start of Hospitalization To Day After Admission\":\n \t\"Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions\" QualifyingEncounter\n\t with \"No VTE Prophylaxis Medication or Device Due to Patient Refusal\" PatientRefusal\n   such that Coalesce(start of Global.\"Normalize Interval\"(PatientRefusal.effective), PatientRefusal.authoredOn)\n         during VTEICU.\"FromDayOfStartOfHospitalizationToDayAfterAdmission\"(QualifyingEncounter)"
            },
            {
              "url": "displaySequence",
              "valueInteger": 22
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "EXM108-FHIR"
            },
            {
              "url": "name",
              "valueString": "No VTE Prophylaxis Due to Patient Refusal on Day of or Day After Procedure"
            },
            {
              "url": "statement",
              "valueString": "define \"No VTE Prophylaxis Due to Patient Refusal on Day of or Day After Procedure\":\n \tfrom\n   \t\t\"Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions\" QualifyingEncounter,\n   \t\t[\"Procedure\": \"General or Neuraxial Anesthesia\"] AnesthesiaProcedure,\n   \t\t\"No VTE Prophylaxis Medication or Device Due to Patient Refusal\" PatientRefusal\n\twhere Global.\"Normalize Interval\"(AnesthesiaProcedure.performed) ends 1 day after day of start of QualifyingEncounter.period\n \t\t\tand Coalesce(start of Global.\"Normalize Interval\"(PatientRefusal.effective), PatientRefusal.authoredOn)\n             during TJC.\"CalendarDayOfOrDayAfter\"(end of Global.\"Normalize Interval\"(AnesthesiaProcedure.performed))\n\treturn QualifyingEncounter"
            },
            {
              "url": "displaySequence",
              "valueInteger": 23
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "EXM108-FHIR"
            },
            {
              "url": "name",
              "valueString": "Encounter With No VTE Prophylaxis Due to Patient Refusal"
            },
            {
              "url": "statement",
              "valueString": "define \"Encounter With No VTE Prophylaxis Due to Patient Refusal\":\n \"No VTE Prophylaxis Due to Patient Refusal From Day of Start of Hospitalization To Day After Admission\"\n \tunion \"No VTE Prophylaxis Due to Patient Refusal on Day of or Day After Procedure\""
            },
            {
              "url": "displaySequence",
              "valueInteger": 24
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "EXM108-FHIR"
            },
            {
              "url": "name",
              "valueString": "Numerator"
            },
            {
              "url": "statement",
              "valueString": "define \"Numerator\":\n    \"Encounter With VTE Prophylaxis Received on Day of or Day After Admission or Procedure\"\n    union ( \"Encounter With Medication Oral Factor Xa Inhibitor Administered on Day of or Day After Admission or Procedure\"\n    \t\t\t  intersect ( \"Encounter With Prior or Present Diagnosis of Atrial Fibrillation or VTE\"\n    \t\t\t\t\t\t    union \"Encounter With Prior or Present Procedure of Hip or Knee Replacement Surgery\"\n    \t\t\t            )\n          )\n    union \"Encounter With Low Risk for VTE or Anticoagulant Administered\"\n    union \"Encounter With No VTE Prophylaxis Due to Medical Reason\"\n    union \"Encounter With No VTE Prophylaxis Due to Patient Refusal\""
            },
            {
              "url": "displaySequence",
              "valueInteger": 25
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "EXM108-FHIR"
            },
            {
              "url": "name",
              "valueString": "Initial Population"
            },
            {
              "url": "statement",
              "valueString": "define \"Initial Population\":\n  \"Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions\""
            },
            {
              "url": "displaySequence",
              "valueInteger": 26
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "EXM108-FHIR"
            },
            {
              "url": "name",
              "valueString": "Denominator"
            },
            {
              "url": "statement",
              "valueString": "define \"Denominator\":\n      \"Initial Population\""
            },
            {
              "url": "displaySequence",
              "valueInteger": 27
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "SupplementalDataElements"
            },
            {
              "url": "name",
              "valueString": "SDE Payer"
            },
            {
              "url": "statement",
              "valueString": "define \"SDE Payer\":\n  [Coverage: type in \"Payer\"] Payer\n        return {\n          code: Payer.type,\n          period: Payer.period\n        }"
            },
            {
              "url": "displaySequence",
              "valueInteger": 28
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "EXM108-FHIR"
            },
            {
              "url": "name",
              "valueString": "SDE Payer"
            },
            {
              "url": "statement",
              "valueString": "define \"SDE Payer\":\n\tSDE.\"SDE Payer\""
            },
            {
              "url": "displaySequence",
              "valueInteger": 29
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "SupplementalDataElements"
            },
            {
              "url": "name",
              "valueString": "SDE Ethnicity"
            },
            {
              "url": "statement",
              "valueString": "define \"SDE Ethnicity\":\n  (flatten (\n      Patient.extension Extension\n        where Extension.url = 'http://hl7.org/fhir/us/core/StructureDefinition/us-core-ethnicity'\n          return Extension.extension\n    )) E\n      where E.url = 'ombCategory'\n        or E.url = 'detailed'\n      return E.value as Coding"
            },
            {
              "url": "displaySequence",
              "valueInteger": 30
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "EXM108-FHIR"
            },
            {
              "url": "name",
              "valueString": "SDE Ethnicity"
            },
            {
              "url": "statement",
              "valueString": "define \"SDE Ethnicity\":\n  SDE.\"SDE Ethnicity\""
            },
            {
              "url": "displaySequence",
              "valueInteger": 31
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "EXM108-FHIR"
            },
            {
              "url": "name",
              "valueString": "Encounter Less Than 2 Days"
            },
            {
              "url": "statement",
              "valueString": "define \"Encounter Less Than 2 Days\":\n  \"Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions\" QualifyingEncounter\n  \twhere Global.\"LengthInDays\"(QualifyingEncounter.period)< 2"
            },
            {
              "url": "displaySequence",
              "valueInteger": 32
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "EXM108-FHIR"
            },
            {
              "url": "name",
              "valueString": "Encounter With ICU Location Stay 1 Day or More"
            },
            {
              "url": "statement",
              "valueString": "define \"Encounter With ICU Location Stay 1 Day or More\":\n  \"Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions\" QualifyingEncounter\n    where exists ( QualifyingEncounter.location Location\n    \t\twhere Global.GetLocation(Location.location).type in \"Intensive Care Unit\"\n    \t\t\tand Global.\"LengthInDays\"(Location.period)>= 1\n    \t\t\tand Location.period starts during TJC.\"CalendarDayOfOrDayAfter\"(start of QualifyingEncounter.period)\n\t    )"
            },
            {
              "url": "displaySequence",
              "valueInteger": 33
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "EXM108-FHIR"
            },
            {
              "url": "name",
              "valueString": "Encounter With Principal Diagnosis of Mental Disorder or Stroke"
            },
            {
              "url": "statement",
              "valueString": "define \"Encounter With Principal Diagnosis of Mental Disorder or Stroke\":\n  \"Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions\" QualifyingEncounter\n    where Global.\"PrincipalDiagnosis\"(QualifyingEncounter).code in \"Mental Health Diagnoses\"\n        or Global.\"PrincipalDiagnosis\"(QualifyingEncounter).code in \"Hemorrhagic Stroke\"\n        or Global.\"PrincipalDiagnosis\"(QualifyingEncounter).code in \"Ischemic Stroke\""
            },
            {
              "url": "displaySequence",
              "valueInteger": 34
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "EXM108-FHIR"
            },
            {
              "url": "name",
              "valueString": "SCIP VTE Selected Surgery"
            },
            {
              "url": "statement",
              "valueString": "define \"SCIP VTE Selected Surgery\":\n  (\t[\"Procedure\": \"General Surgery\"]\n    union [\"Procedure\": \"Gynecological Surgery\"]\n    union [\"Procedure\": \"Hip Fracture Surgery\"]\n    union [\"Procedure\": \"Hip Replacement Surgery\"]\n    union [\"Procedure\": \"Intracranial Neurosurgery\"]\n    union [\"Procedure\": \"Knee Replacement Surgery\"]\n    union [\"Procedure\": \"Urological Surgery\"] ) Procedure\n  where Procedure.status = 'completed'"
            },
            {
              "url": "displaySequence",
              "valueInteger": 35
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "EXM108-FHIR"
            },
            {
              "url": "name",
              "valueString": "Encounter With Principal Procedure of SCIP VTE Selected Surgery"
            },
            {
              "url": "statement",
              "valueString": "/* NOTE: 2 options to express Principal Procedure to retrive \"encounter Procedure as an url\" and proedure \"rank as extension\" in R4\n          VTE-1 uses Option 1 - generic extension funtion\n          VTE-2 uses Option 2 - Specific extension functions\n  TODO:  Mapping Table needs revision on using \"Encounter.procedure.code\", \"Encounter.procedure.sequence\"\n*/\ndefine \"Encounter With Principal Procedure of SCIP VTE Selected Surgery\":\n  from\n      \"Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions\" QualifyingEncounter,\n      \"SCIP VTE Selected Surgery\" SelectedProcedure\n      let EncounterProcedure: Global.GetExtension(QualifyingEncounter, 'qicore-encounter-procedure')\n  where FHIRHelpers.ToInteger(Global.GetExtension(EncounterProcedure, 'rank').value as FHIR.positiveInt) = 1\n      and Global.GetId(FHIRHelpers.ToString((Global.GetExtension(EncounterProcedure, 'procedure').value as FHIR.Reference).reference)) = SelectedProcedure.id\n      and Global.\"Normalize Interval\"(SelectedProcedure.performed) during QualifyingEncounter.period"
            },
            {
              "url": "displaySequence",
              "valueInteger": 36
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "EXM108-FHIR"
            },
            {
              "url": "name",
              "valueString": "Intervention Comfort Measures"
            },
            {
              "url": "statement",
              "valueString": "define \"Intervention Comfort Measures\":\n\t([\"ServiceRequest\": \"Comfort Measures\"] P\n    \t\twhere P.intent = 'order'\n  )\n  \tunion\n    \t([\"Procedure\": \"Comfort Measures\"] InterventionPerformed\n      \twhere InterventionPerformed.status in {'completed', 'in-progress'})"
            },
            {
              "url": "displaySequence",
              "valueInteger": 37
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "EXM108-FHIR"
            },
            {
              "url": "name",
              "valueString": "Encounter With Intervention Comfort Measures From Day of Start of Hospitalization To Day After Admission"
            },
            {
              "url": "statement",
              "valueString": "define \"Encounter With Intervention Comfort Measures From Day of Start of Hospitalization To Day After Admission\":\n\t\"Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions\" QualifyingEncounter\n\t\twith \"Intervention Comfort Measures\" ComfortMeasure\n\t\tsuch that Coalesce(start of Global.\"Normalize Interval\"(ComfortMeasure.performed), ComfortMeasure.authoredOn) during VTEICU.\"FromDayOfStartOfHospitalizationToDayAfterAdmission\"(QualifyingEncounter)"
            },
            {
              "url": "displaySequence",
              "valueInteger": 38
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "EXM108-FHIR"
            },
            {
              "url": "name",
              "valueString": "Encounter With Intervention Comfort Measures on Day of or Day After Procedure"
            },
            {
              "url": "statement",
              "valueString": "define \"Encounter With Intervention Comfort Measures on Day of or Day After Procedure\":\n  from\n  \t\t\"Encounter With Age Range and Without VTE Diagnosis or Obstetrical Conditions\" QualifyingEncounter,\n  \t\t[\"Procedure\": \"General or Neuraxial Anesthesia\"] AnesthesiaProcedure,\n  \t\t\"Intervention Comfort Measures\" ComfortMeasure\n\t\twhere AnesthesiaProcedure.status = 'completed'\n\t\t\t\tand Global.\"Normalize Interval\"(AnesthesiaProcedure.performed) ends 1 day after day of start of QualifyingEncounter.period\n        and Coalesce(start of Global.\"Normalize Interval\"(ComfortMeasure.performed), ComfortMeasure.authoredOn) during TJC.\"CalendarDayOfOrDayAfter\"(end of Global.\"Normalize Interval\"(AnesthesiaProcedure.performed))\n    return QualifyingEncounter"
            },
            {
              "url": "displaySequence",
              "valueInteger": 39
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "EXM108-FHIR"
            },
            {
              "url": "name",
              "valueString": "Denominator Exclusion"
            },
            {
              "url": "statement",
              "valueString": "define \"Denominator Exclusion\":\n    \"Encounter Less Than 2 Days\"\n     union \"Encounter With ICU Location Stay 1 Day or More\"\n     union \"Encounter With Principal Diagnosis of Mental Disorder or Stroke\"\n     union \"Encounter With Principal Procedure of SCIP VTE Selected Surgery\"\n     union \"Encounter With Intervention Comfort Measures From Day of Start of Hospitalization To Day After Admission\"\n     union \"Encounter With Intervention Comfort Measures on Day of or Day After Procedure\""
            },
            {
              "url": "displaySequence",
              "valueInteger": 40
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "SupplementalDataElements"
            },
            {
              "url": "name",
              "valueString": "SDE Race"
            },
            {
              "url": "statement",
              "valueString": "define \"SDE Race\":\n  (flatten (\n      Patient.extension Extension\n        where Extension.url = 'http://hl7.org/fhir/us/core/StructureDefinition/us-core-race'\n          return Extension.extension\n    )) E\n      where E.url = 'ombCategory'\n        or E.url = 'detailed'\n      return E.value as Coding"
            },
            {
              "url": "displaySequence",
              "valueInteger": 41
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        },
        {
          "extension": [
            {
              "url": "libraryName",
              "valueString": "EXM108-FHIR"
            },
            {
              "url": "name",
              "valueString": "SDE Race"
            },
            {
              "url": "statement",
              "valueString": "define \"SDE Race\":\n  SDE.\"SDE Race\""
            },
            {
              "url": "displaySequence",
              "valueInteger": 42
            }
          ],
          "url": "http://hl7.org/fhir/StructureDefinition/cqf-logicDefinition"
        }
      ],
      "url": "http://hl7.org/fhir/uv/cqm/Library/effective-data-requirements-exm108",
      "version": "1.0.0",
      "name": "EffectiveDataRequirements",
      "title": "Module Definition Library - EXM108",
      "status": "active",
      "type": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/library-type",
            "code": "module-definition"
          }
        ]
      },
      "date": "2022-02-22T10:37:04-07:00",
      "description": "This library is used as an example module definition in the FHIR Quality Measure Implementation Guide",
      "relatedArtifact": [
        {
          "type": "depends-on",
          "display": "Library SDE",
          "resource": "http://hl7.org/fhir/uv/cqm/Library/SupplementalDataElements|2.0.000"
        },
        {
          "type": "depends-on",
          "display": "Library FHIRHelpers",
          "resource": "http://ecqi.healthit.gov/ecqms/Library/FHIRHelpers|4.0.1"
        },
        {
          "type": "depends-on",
          "display": "Library Global",
          "resource": "http://hl7.org/fhir/uv/cqm/Library/MATGlobalCommonFunctions|5.0.000"
        },
        {
          "type": "depends-on",
          "display": "Library TJC",
          "resource": "http://hl7.org/fhir/uv/cqm/Library/TJCOverall|4.0.000"
        },
        {
          "type": "depends-on",
          "display": "Library VTEICU",
          "resource": "http://hl7.org/fhir/uv/cqm/Library/VTEICU|5.0.000"
        },
        {
          "type": "depends-on",
          "display": "Code system ConditionClinicalStatusCodes",
          "resource": "http://terminology.hl7.org/CodeSystem/condition-clinical"
        },
        {
          "type": "depends-on",
          "display": "Code system LOINC",
          "resource": "http://loinc.org"
        },
        {
          "type": "depends-on",
          "display": "Value set Encounter Inpatient",
          "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.666.5.307"
        },
        {
          "type": "depends-on",
          "display": "Value set Obstetrics",
          "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.263"
        },
        {
          "type": "depends-on",
          "display": "Value set Venous Thromboembolism",
          "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.279"
        },
        {
          "type": "depends-on",
          "display": "Value set Obstetrics VTE",
          "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.264"
        },
        {
          "type": "depends-on",
          "display": "Value set Low Dose Unfractionated Heparin for VTE Prophylaxis",
          "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1045.39"
        },
        {
          "type": "depends-on",
          "display": "Value set Subcutaneous route",
          "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.223"
        },
        {
          "type": "depends-on",
          "display": "Value set Low Molecular Weight Heparin for VTE Prophylaxis",
          "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.219"
        },
        {
          "type": "depends-on",
          "display": "Value set Injectable Factor Xa Inhibitor for VTE Prophylaxis",
          "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.211"
        },
        {
          "type": "depends-on",
          "display": "Value set Warfarin",
          "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.232"
        },
        {
          "type": "depends-on",
          "display": "Value set Device Application",
          "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1110.48"
        },
        {
          "type": "depends-on",
          "display": "Value set Intermittent pneumatic compression devices (IPC)",
          "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.214"
        },
        {
          "type": "depends-on",
          "display": "Value set Venous foot pumps (VFP)",
          "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.230"
        },
        {
          "type": "depends-on",
          "display": "Value set Graduated compression stockings (GCS)",
          "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.256"
        },
        {
          "type": "depends-on",
          "display": "Value set General or Neuraxial Anesthesia",
          "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.666.5.1743"
        },
        {
          "type": "depends-on",
          "display": "Value set Oral Factor Xa Inhibitor for VTE Prophylaxis or VTE Treatment",
          "resource": "http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.134"
        },
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  "publisher": "HL7 International / Clinical Quality Information",
  "contact": [
    {
      "telecom": [
        {
          "system": "url",
          "value": "http://www.hl7.org/Special/committees/cqi"
        }
      ]
    }
  ],
  "description": "This measure assesses the number of patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given the day of or the day after hospital admission or surgery end date for surgeries that start the day of or the day after hospital admission",
  "useContext": [
    {
      "code": {
        "system": "http://terminology.hl7.org/CodeSystem/usage-context-type",
        "code": "venue",
        "display": "Clinical Venue"
      },
      "valueCodeableConcept": {
        "coding": [
          {
            "system": "http://hl7.org/fhir/uv/cqm/CodeSystem/intended-venue-codes",
            "code": "eh",
            "display": "EH"
          }
        ]
      }
    }
  ],
  "jurisdiction": [
    {
      "coding": [
        {
          "system": "http://unstats.un.org/unsd/methods/m49/m49.htm",
          "code": "001"
        }
      ]
    }
  ],
  "copyright": "Measure specifications are in the Public Domain.\n\nLOINC(R) is a registered trademark of the Regenstrief Institute.\n\nThis material contains SNOMED Clinical Terms(R) (SNOMED CT(C)) copyright 2004-2017 International Health Terminology Standards Development Organization. All rights reserved.",
  "approvalDate": "2019-03-08",
  "lastReviewDate": "2019-03-08",
  "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/uv/cqm/Library/EXM108-FHIR"
  ],
  "disclaimer": "These performance measures are not clinical guidelines and do not establish a standard of medical care, and have not been tested for all potential applications. The measures and specifications are provided without warranty",
  "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": "Hospitalized patients at high-risk for VTE may develop an asymptomatic deep vein thrombosis (DVT), and die from pulmonary embolism (PE) even before the diagnosis is suspected. The majority of fatal events occur as sudden or abrupt death, underscoring the importance of prevention as the most critical action step for reducing death from PE (Geerts, et al, 2008).\n\nThe estimated annual incidence of deep-vein thrombosis (DVT) and pulmonary embolism (PE), known collectively as venous thromboembolism (VTE), is approximately 900,000 (Geerts, et al, 2008). Approximately two-thirds of cases of DVT or PE are associated with recent hospitalization. This is consistent with the 2001 report by The Agency for Healthcare Research and Quality (AHRQ). AHRQ indicates that \"the appropriate application of effective preventive measures in hospitals has major potential for improving patient safety by reducing the incidence of venous thromboembolism\" (Shojania, 2001).\n\nDespite its proven effectiveness, rates of appropriate thromboprophylaxis remain low in both medical and surgical patients. A recent analysis from the ENDORSE survey, which evaluated prophylaxis rates in 17,084 major surgery patients, found that more than one third of patients at risk for VTE (38%) did not receive prophylaxis and that rates varied by surgery type (Cohen, et al., 2008).\n\nIn a review of evidence-based patient safety practices, the Agency for Healthcare Research and Quality defined thromboprophylaxis against VTE as the \"number one patient safety practice\" for hospitalized patients (Shojania, 2001). Updated \"safe practices\" published by the National Quality Forum (NQF) recommend routine evaluation of hospitalized patients for risk of VTE and use of appropriate prophylaxis (National Quality Forum. National Voluntary Consensus Standards for Prevention and Care of Venous Thromboembolism, 2006).\n\nAs noted by the ACCP, a vast number of randomized clinical trials provide irrefutable evidence that thromboprophylaxis reduces VTE events, and there are studies that have also shown that fatal PE is prevented by thromboprophylaxis (Geerts, et al. 2008).\n\nSome select surgeries have previously been monitored in the Surgical Care Improvement Project; since performance on these surgeries has achieved very high levels, they are not included in this measure.",
  "clinicalRecommendationStatement": "Failure to recognize and protect patients at risk for venous thromboembolism (VTE) increases the chances for acutely ill hospitalized patients at high risk for developing a deep vein thrombosis or dying from a pulmonary emboli. Screening all patients is the only evidence based practice in reducing incidence of disease.  All hospitalized patients should be evaluated for primary VTE prophylaxis, and given appropriate prophylaxis when indicated.",
  "improvementNotation": {
    "coding": [
      {
        "system": "http://terminology.hl7.org/CodeSystem/measure-improvement-notation",
        "code": "increase",
        "display": "Increased score indicates improvement"
      }
    ]
  },
  "guidance": "When low dose unfractionated heparin is administered for VTE Prophylaxis, the intended administration route for low dose unfractionated heparin is subcutaneous.\n\nReasons for no pharmacological and no mechanical VTE prophylaxis must be explicitly documented by the MD/APN/PA or pharmacist and linked with VTE prophylaxis. Ambulation alone is not a sufficient reason for not administering VTE prophylaxis. In order for ambulation/patient ambulating to be considered as an acceptable reason, there needs to be explicit documentation, e.g., \"patient out of bed and ambulating in halls - no VTE prophylaxis needed.\"",
  "group": [
    {
      "id": "group-1",
      "extension": [
        {
          "url": "http://hl7.org/fhir/5.0/StructureDefinition/extension-Measure.group.linkId",
          "valueString": "primary"
        }
      ],
      "population": [
        {
          "extension": [
            {
              "url": "http://hl7.org/fhir/5.0/StructureDefinition/extension-Measure.group.population.linkId",
              "valueString": "primary-exm108-initial-population"
            }
          ],
          "code": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/measure-population",
                "code": "initial-population",
                "display": "Initial Population"
              }
            ]
          },
          "description": "Patients age 18 and older discharged from hospital inpatient acute care without a diagnosis of venous thromboembolism (VTE) or obstetrics with a length of stay less than or equal to 120 days that ends during the measurement period",
          "criteria": {
            "language": "text/cql-identifier",
            "expression": "Initial Population"
          }
        },
        {
          "extension": [
            {
              "url": "http://hl7.org/fhir/5.0/StructureDefinition/extension-Measure.group.population.linkId",
              "valueString": "primary-exm108-numerator"
            }
          ],
          "code": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/measure-population",
                "code": "numerator",
                "display": "Numerator"
              }
            ]
          },
          "description": "Patients who received VTE prophylaxis:\n- the day of or the day after hospital admission\n- the day of or the day after surgery end date for surgeries that end the day of or the day after hospital admission\n\nPatients who have documentation of a reason why no VTE prophylaxis was given:\n- between arrival and hospital admission\n- the day of or the day after hospital admission\n- the day of or the day after surgery end date (for surgeries that end the day of or the day after hospital admission)",
          "criteria": {
            "language": "text/cql-identifier",
            "expression": "Numerator"
          }
        },
        {
          "extension": [
            {
              "url": "http://hl7.org/fhir/5.0/StructureDefinition/extension-Measure.group.population.linkId",
              "valueString": "primary-exm108-denominator"
            }
          ],
          "code": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/measure-population",
                "code": "denominator",
                "display": "Denominator"
              }
            ]
          },
          "description": "All patients in the initial population",
          "criteria": {
            "language": "text/cql-identifier",
            "expression": "Denominator"
          }
        },
        {
          "extension": [
            {
              "url": "http://hl7.org/fhir/5.0/StructureDefinition/extension-Measure.group.population.linkId",
              "valueString": "primary-exm108-denominator-exclusion"
            }
          ],
          "code": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/measure-population",
                "code": "denominator-exclusion",
                "display": "Denominator Exclusion"
              }
            ]
          },
          "description": "* Patients who have a length of stay less than 2 days\n* Patients with comfort measures documented anytime between arrival and the day after hospital admission\n* Patients with comfort measures documented by the day after surgery end date for surgeries that start the day of or the day after hospital admission\n* Patients who are direct admits to intensive care unit (ICU), or transferred to ICU the day of or the day after hospital admission with ICU length of stay greater than or equal to one day\n* Patients with a principal diagnosis of mental disorders or stroke\n* Patients with a principal procedure of Surgical Care Improvement Project (SCIP) VTE selected surgeries",
          "criteria": {
            "language": "text/cql-identifier",
            "expression": "Denominator Exclusion"
          }
        }
      ]
    }
  ],
  "supplementalData": [
    {
      "extension": [
        {
          "url": "http://hl7.org/fhir/5.0/StructureDefinition/extension-Measure.supplementalData.linkId",
          "valueString": "primary-sde-ethnicity"
        },
        {
          "url": "http://hl7.org/fhir/uv/cqm/StructureDefinition/cqm-includeInReportType",
          "valueCode": "summary"
        }
      ],
      "usage": [
        {
          "coding": [
            {
              "system": "http://terminology.hl7.org/CodeSystem/measure-data-usage",
              "code": "supplemental-data"
            }
          ]
        }
      ],
      "criteria": {
        "language": "text/cql-identifier",
        "expression": "SDE Ethnicity"
      }
    },
    {
      "extension": [
        {
          "url": "http://hl7.org/fhir/5.0/StructureDefinition/extension-Measure.supplementalData.linkId",
          "valueString": "primary-sde-payer"
        },
        {
          "url": "http://hl7.org/fhir/uv/cqm/StructureDefinition/cqm-includeInReportType",
          "valueCode": "summary"
        }
      ],
      "usage": [
        {
          "coding": [
            {
              "system": "http://terminology.hl7.org/CodeSystem/measure-data-usage",
              "code": "supplemental-data"
            }
          ]
        }
      ],
      "criteria": {
        "language": "text/cql-identifier",
        "expression": "SDE Payer"
      }
    },
    {
      "extension": [
        {
          "url": "http://hl7.org/fhir/5.0/StructureDefinition/extension-Measure.supplementalData.linkId",
          "valueString": "primary-sde-race"
        },
        {
          "url": "http://hl7.org/fhir/uv/cqm/StructureDefinition/cqm-includeInReportType",
          "valueCode": "summary"
        }
      ],
      "usage": [
        {
          "coding": [
            {
              "system": "http://terminology.hl7.org/CodeSystem/measure-data-usage",
              "code": "supplemental-data"
            }
          ]
        }
      ],
      "criteria": {
        "language": "text/cql-identifier",
        "expression": "SDE Race"
      }
    },
    {
      "extension": [
        {
          "url": "http://hl7.org/fhir/5.0/StructureDefinition/extension-Measure.supplementalData.linkId",
          "valueString": "primary-sde-sex"
        },
        {
          "url": "http://hl7.org/fhir/uv/cqm/StructureDefinition/cqm-includeInReportType",
          "valueCode": "summary"
        }
      ],
      "usage": [
        {
          "coding": [
            {
              "system": "http://terminology.hl7.org/CodeSystem/measure-data-usage",
              "code": "supplemental-data"
            }
          ]
        }
      ],
      "criteria": {
        "language": "text/cql-identifier",
        "expression": "SDE Sex"
      }
    }
  ]
}