The Measure resource provides the definition of a quality measure.

An absolute URI that is used to identify this measure when it is referenced in a specification, model, design or an instance; also called its canonical identifier. This SHOULD be globally unique and SHOULD be a literal address at which an authoritative instance of this measure is (or will be) published. This URL can be the target of a canonical reference. It SHALL remain the same when the measure is stored on different servers.

Allows the measure to be referenced by a single globally unique identifier.

Can be a urn:uuid: or a urn:oid: but real http: addresses are preferred. Multiple instances may share the same URL if they have a distinct version.

The determination of when to create a new version of a resource (same url, new version) vs. defining a new artifact is up to the author. Considerations for making this decision are found in Technical and Business Versions.

In some cases, the resource can no longer be found at the stated url, but the url itself cannot change. Implementations can use the meta.source element to indicate where the current master source of the resource can be found.

A formal identifier that is used to identify this measure when it is represented in other formats, or referenced in a specification, model, design or an instance.

Allows externally provided and/or usable business identifiers to be easily associated with the module.

Typically, this is used for identifiers that can go in an HL7 V3 II (instance identifier) data type, and can then identify this measure outside of FHIR, where it is not possible to use the logical URI.

The identifier that is used to identify this version of the measure when it is referenced in a specification, model, design or instance. This is an arbitrary value managed by the measure author and is not expected to be globally unique. For example, it might be a timestamp (e.g. yyyymmdd) if a managed version is not available. There is also no expectation that versions can be placed in a lexicographical sequence. To provide a version consistent with the Decision Support Service specification, use the format Major.Minor.Revision (e.g. 1.0.0). For more information on versioning knowledge assets, refer to the Decision Support Service specification. Note that a version is required for non-experimental active artifacts.

There may be different measure instances that have the same identifier but different versions. The version can be appended to the url in a reference to allow a reference to a particular business version of the measure with the format [url]|[version]. The version SHOULD NOT contain a '#' - see Business Version.

Indicates the mechanism used to compare versions to determine which is more current.

If set as a string, this is a FHIRPath expression that has two additional context variables passed in - %version1 and %version2 and will return a negative number if version1 is newer, a positive number if version2 and a 0 if the version ordering can't be successfully be determined.

A natural language name identifying the measure. This name should be usable as an identifier for the module by machine processing applications such as code generation.

Support human navigation and code generation.

The name is not expected to be globally unique. The name should be a simple alphanumeric type name to ensure that it is machine-processing friendly.

A short, descriptive, user-friendly title for the measure.

This name does not need to be machine-processing friendly and may contain punctuation, white-space, etc.

An explanatory or alternate title for the measure giving additional information about its content.

The status of this measure. Enables tracking the life-cycle of the content.

Allows filtering of measures that are appropriate for use versus not.

See guidance around (not) making local changes to elements here.

A Boolean value to indicate that this measure is authored for testing purposes (or education/evaluation/marketing) and is not intended to be used for genuine usage.

Enables experimental content to be developed following the same lifecycle that would be used for a production-level measure.

Allows filtering of measures that are appropriate for use versus not.

The intended subjects for the measure. If this element is not provided, a Patient subject is assumed, but the subject of the measure can be anything.

The subject of the measure is critical in interpreting the criteria definitions, as the logic in the measures is evaluated with respect to a particular subject. This corresponds roughly to the notion of a Compartment in that it limits what content is available based on its relationship to the subject. In CQL, this corresponds to the context declaration.

The population basis specifies the type of elements in the population. For a subject-based measure, this is boolean (because the subject and the population basis are the same, and the population criteria define yes/no values for each individual in the population). For measures that have a population basis that is different than the subject, this element specifies the type of the population basis. For example, an encounter-based measure has a subject of Patient and a population basis of Encounter, and the population criteria all return lists of Encounters.

Allows non-subject-based measures to be specified. Note that because the binding is to all fhir types, it is possible to specify abstract types such as Resource or DomainResource as the basis for a measure. Authoring environments may wish to constrain this further, depending on content needs.

For a subject-based measure, the population basis is simply boolean; all the criteria are expressed as true/false conditions that determine membership of an individual case in the population. For non-subject-based measures, the population basis can be any resource type, and the criteria are queries that return the subject's contribution to the population as a list of that resource type. For example, for a procedure-based measure, the population criteria would return lists of procedures that should be included in each population.

The date (and optionally time) when the measure was last significantly changed. The date must change when the business version changes and it must change if the status code changes. In addition, it should change when the substantive content of the measure changes.

The date is often not tracked until the resource is published, but may be present on draft content. Note that this is not the same as the resource last-modified-date, since the resource may be a secondary representation of the measure. Additional specific dates may be added as extensions or be found by consulting Provenances associated with past versions of the resource.

See guidance around (not) making local changes to elements here.

The name of the organization or individual responsible for the release and ongoing maintenance of the measure.

Helps establish the "authority/credibility" of the measure. May also allow for contact.

Usually an organization but may be an individual. The publisher (or steward) of the measure is the organization or individual primarily responsible for the maintenance and upkeep of the measure. This is not necessarily the same individual or organization that developed and initially authored the content. The publisher is the primary point of contact for questions or issues with the measure. This item SHOULD be populated unless the information is available from context.

Contact details to assist a user in finding and communicating with the publisher.

May be a web site, an email address, a telephone number, etc.

See guidance around (not) making local changes to elements here.

A free text natural language description of the measure from a consumer's perspective.

This description can be used to capture details such as comments about misuse, instructions for clinical use and interpretation, literature references, examples from the paper world, etc. It is not a rendering of the measure as conveyed in the 'text' field of the resource itself. This item SHOULD be populated unless the information is available from context (e.g. the language of the measure is presumed to be the predominant language in the place the measure was created).

The content was developed with a focus and intent of supporting the contexts that are listed. These contexts may be general categories (gender, age, ...) or may be references to specific programs (insurance plans, studies, ...) and may be used to assist with indexing and searching for appropriate measure instances.

Assist in searching for appropriate content.

When multiple useContexts are specified, there is no expectation that all or any of the contexts apply.

A legal or geographic region in which the measure is intended to be used.

It may be possible for the measure to be used in jurisdictions other than those for which it was originally designed or intended.

DEPRECATION NOTE: For consistency, implementations are encouraged to migrate to using the new 'jurisdiction' code in the useContext element. (I.e. useContext.code indicating http://terminology.hl7.org/CodeSystem/usage-context-type#jurisdiction and useContext.valueCodeableConcept indicating the jurisdiction.)

Explanation of why this measure is needed and why it has been designed as it has.

This element does not describe the usage of the measure. Instead, it provides traceability of ''why'' the resource is either needed or ''why'' it is defined as it is. This may be used to point to source materials or specifications that drove the structure of this measure.

A detailed description, from a clinical perspective, of how the measure is used.

Measure developers must be able to provide additional guidance for implementers to understand the intent with greater specificity than that provided in the population criteria of the measure. This element provides detailed guidance, where the usage element provides a summary of the guidance.

This metadata element was typically referred to as Guidance in HQMF

A copyright statement relating to the measure and/or its contents. Copyright statements are generally legal restrictions on the use and publishing of the measure.

Consumers must be able to determine any legal restrictions on the use of the measure and/or its content.

The short copyright declaration (e.g. (c) '2015+ xyz organization' should be sent in the copyrightLabel element.

A short string (<50 characters), suitable for inclusion in a page footer that identifies the copyright holder, effective period, and optionally whether rights are resctricted. (e.g. 'All rights reserved', 'Some rights reserved').

Defines the content expected to be rendered in all representations of the artifact.

The (c) symbol should NOT be included in this string. It will be added by software when rendering the notation. Full details about licensing, restrictions, warrantees, etc. goes in the more general 'copyright' element.

The date on which the resource content was approved by the publisher. Approval happens once when the content is officially approved for usage.

The 'date' element may be more recent than the approval date because of minor changes or editorial corrections.

See guidance around (not) making local changes to elements here.

The date on which the resource content was last reviewed. Review happens periodically after approval but does not change the original approval date.

Gives a sense of how "current" the content is. Resources that have not been reviewed in a long time may have a risk of being less appropriate/relevant.

If specified, this date follows the original approval date.

See guidance around (not) making local changes to elements here.

The period during which the measure content was or is planned to be in active use.

Allows establishing a transition before a resource comes into effect and also allows for a sunsetting process when new versions of the measure are or are expected to be used instead.

The effective period for a measure determines when the content is applicable for usage and is independent of publication and review dates. For example, a measure intended to be used for the year 2016 might be published in 2015.

See guidance around (not) making local changes to elements here.

Descriptive topics related to the content of the measure. Topics provide a high-level categorization grouping types of measures that can be useful for filtering and searching.

Repositories must be able to determine how to categorize the measure so that it can be found by topical searches.

DEPRECATION NOTE: For consistency, implementations are encouraged to migrate to using the new 'topic' code in the useContext element. (I.e. useContext.code indicating http://terminology.hl7.org/CodeSystem/usage-context-type#topic and useContext.valueCodeableConcept indicating the topic)

An individiual or organization primarily involved in the creation and maintenance of the content.

An individual or organization primarily responsible for internal coherence of the content.

An individual or organization asserted by the publisher to be primarily responsible for review of some aspect of the content.

See guidance around (not) making local changes to elements here.

An individual or organization asserted by the publisher to be responsible for officially endorsing the content for use in some setting.

See guidance around (not) making local changes to elements here.

Related artifacts such as additional documentation, justification, or bibliographic references.

Measures must be able to provide enough information for consumers of the content (and/or interventions or results produced by the content) to be able to determine and understand the justification for and evidence in support of the content.

Each related artifact is either an attachment, or a reference to another resource, but not both.

A reference to a Library resource containing the formal logic used by the measure.

Notices and disclaimers regarding the use of the measure or related to intellectual property (such as code systems) referenced by the measure.

Some organizations require that notices and disclosures be included when publishing measures that reference their intellecutal property.

Indicates how the calculation is performed for the measure, including proportion, ratio, continuous-variable, and cohort. The value set is extensible, allowing additional measure scoring types to be represented.

Defines the expected units of measure for the measure score. This element SHOULD be specified as a UCUM unit.

When the unit cannot be inferred directly from the calculation logic, this element allows the specification of the desired units of measure of the output.

When this element is specified, implementations are expected to report measure scores in the specified units. Note that this may involve unit conversion if the expected units are different than the units of the resulting score calculation. In this case, unit conversions SHALL be performed according to the unit conversion semantics specified by UCUM.

If this is a composite measure, the scoring method used to combine the component measures to determine the composite score.

Indicates whether the measure is used to examine a process, an outcome over time, a patient-reported outcome, or a structure measure such as utilization.

A description of the risk adjustment factors that may impact the resulting score for the measure and how they may be accounted for when computing and reporting measure results.

Describes the method of adjusting for clinical severity and conditions present at the start of care that can influence patient outcomes for making valid comparisons of outcome measures across providers. Indicates whether a measure is subject to the statistical process for reducing, removing, or clarifying the influences of confounding factors to allow for more useful comparisons.

Describes how to combine the information calculated, based on logic in each of several populations, into one summarized result.

The measure rate for an organization or clinician is based upon the entities’ aggregate data and summarizes the performance of the entity over a given time period (e.g., monthly, quarterly, yearly). The aggregated data are derived from the results of a specific measure algorithm and, if appropriate, the application of specific risk adjustment models. Can also be used to describe how to risk adjust the data based on supplemental data elements described in the eMeasure (e.g., pneumonia hospital measures antibiotic selection in the ICU versus non-ICU and then the roll-up of the two). This could be applied to aggregated cohort measure definitions (e.g., CDC's aggregate reporting for TB at the state level).

Provides a succinct statement of the need for the measure. Usually includes statements pertaining to importance criterion: impact, gap in care, and evidence.

Measure developers need to be able to provide a detailed description of the purpose of the measure. This element provides detailed rationale, where the purpose element provides a summary of the rationale.

Provides a summary of relevant clinical guidelines or other clinical recommendations supporting the measure.

Information on whether an increase or decrease in score is the preferred result (e.g., a higher score indicates better quality OR a lower score indicates better quality OR quality is within a range).

Measure consumers and implementers must be able to determine how to interpret a measure score.

Provides a description of an individual term used within the measure.

Measure developers must be able to provide precise definitions of terms used within measure descriptions and guidance to help communicate the intent of the measure.

A codeable representation of the defined term.

Provides a definition for the term as used within the measure.

Additional guidance for the measure including how it can be used in a clinical context, and the intent of the measure.

Measure developers must be able to provide additional guidance for implementers to understand the intent with greater specificity than that provided in the population criteria of the measure. This element provides detailed guidance, where the usage element provides a summary of the guidance.

NOTE: This element is deprecated in favor of the usage element

A group of population criteria for the measure.

An identifier that is unique within the Measure allowing linkage to the equivalent item in a MeasureReport resource.

MeasureReport does not require omitted groups to be included.

This ''can'' be a meaningful identifier (e.g. a LOINC code) but is not intended to have any meaning. GUIDs or sequential numbers are appropriate here.

LinkIds can have whitespaces and slashes by design. Tooling should not rely on linkIds being valid XHTML element IDs, and should not directly embed them as such

Indicates a meaning for the group. This can be as simple as a unique identifier, or it can establish meaning in a broader context by drawing from a terminology, allowing groups to be correlated across measures.

The human readable description of this population group.

Indicates whether the measure is used to examine a process, an outcome over time, a patient-reported outcome, or a structure measure such as utilization.

When specified at the group level, defines the measure type for this specific group. If not specified, the measureType of the group is determined by the root type element

The intended subjects for the measure. If this element is not provided, a Patient subject is assumed, but the subject of the measure can be anything.

The subject of the measure is critical in interpreting the criteria definitions, as the logic in the measures is evaluated with respect to a particular subject. This corresponds roughly to the notion of a Compartment in that it limits what content is available based on its relationship to the subject. In CQL, this corresponds to the context declaration.

The population basis specifies the type of elements in the population. For a subject-based measure, this is boolean (because the subject and the population basis are the same, and the population criteria define yes/no values for each individual in the population). For measures that have a population basis that is different than the subject, this element specifies the type of the population basis. For example, an encounter-based measure has a subject of Patient and a population basis of Encounter, and the population criteria all return lists of Encounters.

Allows non-subject-based measures to be specified

When specified at the group level, defines the population basis for this specific group. If not specified, the basis for the group is determined by the root basis element

Indicates how the calculation is performed for the measure, including proportion, ratio, continuous-variable, and cohort. The value set is extensible, allowing additional measure scoring types to be represented.

When specified at the group level, defines the scoring for this specific group. If not specified, scoring for this group is determined by the root scoring element

Defines the expected units of measure for the measure score. This element SHOULD be specified as a UCUM unit.

When the unit cannot be inferred directly from the calculation logic, this element allows the specification of the desired units of measure of the output.

When specified at the group level, this defines the scoringUnit for this specific group. If not specified, the scoringUnit for this group is determined by the root scoringUnit element. As with the root element, when this element is specified, implementations are expected to report measure scores in the specified units. Note that this may involve unit conversion if the expected units are different than the units of the resulting score calculation. In this case, unit conversions SHALL be performed according to the unit conversion semantics specified by UCUM.

Describes how to combine the information calculated, based on logic in each of several populations, into one summarized result.

The measure rate for an organization or clinician is based upon the entities’ aggregate data and summarizes the performance of the entity over a given time period (e.g., monthly, quarterly, yearly). The aggregated data are derived from the results of a specific measure algorithm and, if appropriate, the application of specific risk adjustment models. Can also be used to describe how to risk adjust the data based on supplemental data elements described in the eMeasure (e.g., pneumonia hospital measures antibiotic selection in the ICU versus non-ICU and then the roll-up of the two). This could be applied to aggregated cohort measure definitions (e.g., CDC's aggregate reporting for TB at the state level).

Information on whether an increase or decrease in score is the preferred result (e.g., a higher score indicates better quality OR a lower score indicates better quality OR quality is within a range).

Measure consumers and implementers must be able to determine how to interpret a measure score.

When specified at the group level, this element defines the improvementNotation for this specific group. If not specified, improvementNotation for this group is determined by the root improvementNotation element

A reference to a Library resource containing the formal logic used by the measure group.

A population criteria for the measure.

An identifier that is unique within the Measure allowing linkage to the equivalent population in a MeasureReport resource.

MeasureReport does not require omitted populations to be included.

This ''can'' be a meaningful identifier (e.g. a LOINC code) but is not intended to have any meaning. GUIDs or sequential numbers are appropriate here.

LinkIds can have whitespaces and slashes by design. Tooling should not rely on linkIds being valid XHTML element IDs, and should not directly embed them as such

The type of population criteria.

The human readable description of this population criteria.

An expression that specifies the criteria for the population, typically the name of an expression in a library.

In the case of a continuous-variable or ratio measure, this may be the name of a function that calculates the value of the individual observation for each patient or event in the population. For these types of measures, individual observations are reported as observation resources included in the evaluatedResources bundle for each patient. See the MeasureReport resource or the Quality Reporting topic for more information.

A Group resource that defines this population as a set of characteristics.

Note that this approach can only be used for measures where the basis is of the same type as the populations (e.g. a Patient-based measure, rather than an Encounter-based measure). In addition, the referenced Group resource SHALL be a definitional (as opposed to an actual) group.

The id of a population element in this measure that provides the input for this population criteria. In most cases, the scoring structure of the measure implies specific relationships (e.g. the Numerator uses the Denominator as the source in a proportion scoring). In some cases, however, multiple possible choices exist and must be resolved explicitly. For example in a ratio measure with multiple initial populations, the denominator must specify which population should be used as the starting point.

For ratio and continuous variable measures, the source populations must be specified explicitly when they cannot be unambiguously determined from the scoring structure.

Specifies which method should be used to aggregate measure observation values. For most scoring types, this is implied by scoring (e.g. a proportion measure counts members of the populations). For continuous variables, however, this information must be specified to ensure correct calculation.

For continuous variable measures, specifications must be able to indicate the aggregation method to be used for tallying results from individual observations.

The stratifier criteria for the measure report, specified as either the name of a valid CQL expression defined within a referenced library or a valid FHIR Resource Path.

An identifier that is unique within the Measure allowing linkage to the equivalent item in a MeasureReport resource.

MeasureReport does not require omitted stratifiers to be included.

This ''can'' be a meaningful identifier (e.g. a LOINC code) but is not intended to have any meaning. GUIDs or sequential numbers are appropriate here.

LinkIds can have whitespaces and slashes by design. Tooling should not rely on linkIds being valid XHTML element IDs, and should not directly embed them as such

Indicates a meaning for the stratifier. This can be as simple as a unique identifier, or it can establish meaning in a broader context by drawing from a terminology, allowing stratifiers to be correlated across measures.

The human readable description of this stratifier criteria.

An expression that specifies the criteria for the stratifier. This is typically the name of an expression defined within a referenced library, but it may also be a path to a stratifier element.

A Group resource that defines this population as a set of characteristics.

Note that this approach can only be used for measures where the basis is of the same type as the populations (e.g. a Patient-based measure, rather than an Encounter-based measure). In addition, the referenced Group SHALL be a definitional (as opposed to an actual) group.

A component of the stratifier criteria for the measure report, specified as either the name of a valid CQL expression defined within a referenced library or a valid FHIR Resource Path.

Stratifiers are defined either as a single criteria, or as a set of component criteria.

An identifier that is unique within the Measure allowing linkage to the equivalent item in a MeasureReport resource.

MeasureReport does not require omitted stratifier components to be included.

This ''can'' be a meaningful identifier (e.g. a LOINC code) but is not intended to have any meaning. GUIDs or sequential numbers are appropriate here.

LinkIds can have whitespaces and slashes by design. Tooling should not rely on linkIds being valid XHTML element IDs, and should not directly embed them as such

Indicates a meaning for the stratifier component. This can be as simple as a unique identifier, or it can establish meaning in a broader context by drawing from a terminology, allowing stratifiers to be correlated across measures.

The human readable description of this stratifier criteria component.

An expression that specifies the criteria for this component of the stratifier. This is typically the name of an expression defined within a referenced library, but it may also be a path to a stratifier element.

A Group resource that defines this population as a set of characteristics.

Note that this approach can only be used for measures where the basis is of the same type as the populations (e.g. a Patient-based measure, rather than an Encounter-based measure). In addition, the referenced Group SHALL be a definitional (as opposed to an actual) group.

The supplemental data criteria for the measure report, specified as either the name of a valid CQL expression within a referenced library, or a valid FHIR Resource Path.

Note that supplemental data are reported as resources for each patient and referenced in the supplementalData element of the MeasureReport. If the supplementalData expression results in a value other than a resource, it is reported using an Observation resource, typically contained in the resulting MeasureReport. See the MeasureReport resource and the Quality Reporting topic for more information.

An identifier that is unique within the Measure allowing linkage to the equivalent item in a MeasureReport resource.

MeasureReport does not require omitted supplementalData to be included.

This ''can'' be a meaningful identifier (e.g. a LOINC code) but is not intended to have any meaning. GUIDs or sequential numbers are appropriate here.

LinkIds can have whitespaces and slashes by design. Tooling should not rely on linkIds being valid XHTML element IDs, and should not directly embed them as such

Indicates a meaning for the supplemental data. This can be as simple as a unique identifier, or it can establish meaning in a broader context by drawing from a terminology, allowing supplemental data to be correlated across measures.

An indicator of the intended usage for the supplemental data element. Supplemental data indicates the data is additional information requested to augment the measure information. Risk adjustment factor indicates the data is additional information used to calculate risk adjustment factors when applying a risk model to the measure calculation.

The human readable description of this supplemental data.

The criteria for the supplemental data. This is typically the name of a valid expression defined within a referenced library, but it may also be a path to a specific data element. The criteria defines the data to be returned for this element.