Metadata
Title | Hospital Harm - Pressure InjuryFHIR
Version | 1.0.000
Short Name | CMS826FHIR
GUID (Version Independent) | urn:uuid:75ae89cd-c418-4de1-98c3-0230c72402b6
GUID (Version Specific) | urn:uuid:c3d4ffe9-0d52-4255-92bf-aecbcf2beafc
CMS Identifier | 826FHIR
CMS Consensus Based Entity Identifier | 3498e
Effective Period | 2026-01-01 through 2026-12-31
Steward (Publisher) | Centers for Medicare & Medicaid Services (CMS)
Developer | Mathematica
Description | The measure assesses the number of inpatient hospitalizations for patients aged 18 and older who suffer the harm of developing a new stage 2, stage 3, stage 4, deep tissue, or unstageable pressure injury
Copyright | Limited proprietary coding is contained in the Measure specifications for user convenience. Users of proprietary code sets should obtain all necessary licenses from the owners of the code sets. Mathematica disclaims all liability for use or accuracy of any third-party codes contained in the specifications. LOINC(R) copyright 2004-2024 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2024 International Health Terminology Standards Development Organization. ICD-10 copyright 2024 World Health Organization. All Rights Reserved.
Disclaimer | This performance measure is not a clinical guideline, does not establish a standard of medical care, and has not been tested for all potential applications. THE MEASURES AND SPECIFICATIONS ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND. Due to technical limitations, registered trademarks are indicated by (R) or [R] and unregistered trademarks are indicated by (TM) or [TM].
Rationale | This safety dQM captures the number of patients who experience harm in the form of a pressure injury during their inpatient hospitalization. The incidence of pressure injuries in hospitalized patients has been estimated at 5.4 per 10,000 patient-days, and the rate of hospital-acquired pressure injuries (HAPIs) has been estimated at 8.4% (Li et al., 2020). Over 50% of reported pressure injuries in hospitals were stage 2 or higher (Li et al., 2020). HAPIs are serious events and one of the most common patient harms. Pressure injuries commonly cause local infection, osteomyelitis, anemia, and sepsis in addition to causing significant depression, pain, and discomfort to patients (Shui et al., 2021). Pressure injury is considered a serious reportable event by the National Quality Forum (NQF) (NQF, 2011). Studies have shown that age, severity of illness, comorbidity indexes, and Braden scores are predictors of HAPIs (Rondinelli et al., 2018). However, even after risk adjustment for patient risk factors, significant variation in rates of HAPI exist between hospitals (Rondinelli et al., 2018). It is widely accepted that the risk of developing a pressure injury can be reduced through best practices. Hospital controlled factors that have been found to be significantly associated with an increase in pressure ulcer risk include infrequent repositioning (p=0.005) and number of days to bed change (OR, 2.89 [95% CI, 1.26-6.63]) (Tayyib et al., 2016; Bly et al., 2016). Nurse staffing, measured as hours per patient day (HPPD), skill mix, and expertise are also significant predictors of HAPI development; patients who require more nursing activity have actually been found to have a lower risk for HAPIs (Tschannen & Anderson, 2020). Systematically measuring patients who develop new pressure injuries while in the hospital setting will provide hospitals with a reliable and timely measurement to more reliably assess harm reduction efforts and modify their improvement efforts in near real-time. This dQM fills a gap in measurement and provides incentives for hospitals' quality improvement. The intent of this measure is to incentivize greater achievements in reducing harms and enhance hospital performance on patient safety outcomes. Stage 2 pressure injuries, characterized by partial-thickness skin loss, carry a less serious burden in terms of patient harm than stage 3, stage 4, unstageable, and deep tissue pressure injuries (DTPI). Partial-thickness wounds heal primarily as a result of epidermal regeneration and often heal without untoward consequences, loss of skin function, or scar tissue formation. Based on the healing capabilities inherent in these partial-thickness wounds, it is the expert opinion of the National Pressure Ulcer Advisory Panel (NPUAP) that the presentation of stage 2 pressure injuries does not carry the same potential longstanding negative consequences to patients as do full thickness pressure injuries. Stage 2 pressure injuries constitute a very real patient harm that should be monitored and addressed; however, the relative level of harm is less than with stage 3, stage 4, unstageable pressure injuries and potentially DTPI (NPUAP, 2019). The accurate and timely identification of DTPI is important for several reasons. Early discovery of DTPI allows prompt identification of possible causes, initiation of treatment, and potential development of preventive strategies. In addition, 24 to 72 hours can lapse between the precipitating pressure event and the onset of purple or maroon skin. This delayed manifestation becomes particularly important when the precipitating event occurred before the patient's admission, yet the DTPI appears beyond the 24-hour window for present-on-admission status (Tescher et al., 2018).
Clinical Recommendation Statement | The Clinical Guidelines Committee for the American College of Physicians (ACP) presents the available evidence on the comparative effectiveness of various risk assessment instruments and benefits and harms of strategies to prevent pressure ulcers (Qaseem et al., 2015). Recommendation 1: ACP recommends that clinicians should perform a risk assessment to identify patients who are at risk of developing pressure ulcers. Recommendation 2: ACP recommends that clinicians should choose advanced static mattresses or advanced static overlays in patients who are at an increased risk of developing pressure ulcers. Recommendation 3: ACP recommends against using alternating-air mattresses or alternating-air overlays in patients who are at an increased risk of developing pressure ulcers. The European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel, and Pan Pacific Pressure Injury Alliance's Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline (The International Guideline) provides guidance for categorizing pressure injuries and recommendations for structured skin and risk assessment (European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel, and Pan Pacific Pressure Injury Alliance, 2019). Guidelines focused on risk factors and risk assessment: 1.1: Consider individuals with limited mobility, limited activity and a high potential for friction and shear to be at risk of pressure injuries. 1.2: Consider individuals with a category/stage I pressure injury to be at risk of developing a category/stage II or greater pressure injury. 1.7: Consider the impact of diabetes mellitus on the risk of pressure injuries. 1.8: Consider the impact of perfusion and circulation deficits on the risk of pressure injuries. 1.12: Consider the impact of increased body temperature on the risk of pressure injuries. 1.17: Consider the impact of time spent immobilized before surgery, the duration of surgery and the American Society of Anesthesiologists (ASA) Physical Status Classification on surgery-related pressure injury risk. Guidelines focused on skin and tissue assessment: 2.2: Inspect the skin of individuals at risk of pressure injuries to identify presence of erythema. 2.3: Differentiate blanchable from non-blanchable erythema using either finger pressure or the transparent disk method and evaluate the extent of erythema. Guidelines focused on preventative skin care: 3.1: Implement a skin care regimen that includes: - Keeping skin clean and appropriately hydrated - Cleansing the skin promptly after episodes of incontinence - Avoiding use of alkaline soaps and cleansers - Protecting the skin from moisture with a barrier product 3.3: Use high absorbency incontinence products to protect the skin in individuals with or at risk of pressure injuries who have urinary incontinence. 3.4: Consider using textiles with low friction coefficients for individuals with or at risk of pressure injuries. 3.5: Use a soft silicone multi-layered foam dressing to protect the skin for individuals at risk of pressure injuries. Guidelines focused on nutrition screening: 4.1: Conduct nutritional screening for individuals at risk of a pressure injury. 4.2: Conduct a comprehensive nutrition assessment for adults at risk of a pressure injury who are screened to be at risk of malnutrition and for all adults with a pressure injury. 4.3: Develop and implement an individualized nutrition care plan for individuals with or at risk of a pressure injury who are malnourished or who are at risk of malnutrition. 4.4: Optimize energy intake for individuals at risk of pressure injuries who are malnourished or at risk of malnutrition. 4.6: Provide 30 to 35 kcalories/kg body weight/day for adults with a pressure injury who are malnourished or at risk of malnutrition. 4.7: Provide 1.25 to 1.5 g protein/kg body weight/day for adults with a pressure injury who are malnourished or at risk of malnutrition. 4.9: Offer high calorie, high protein nutritional supplements in addition to the usual diet for adults with a pressure injury who are malnourished or at risk of malnutrition, if nutritional requirements cannot be achieved by normal dietary intake. 4.12: Discuss the benefits and harms of enteral or parenteral feeding to support pressure injury treatment in light of preferences and goals of care for individuals with pressure injuries who cannot meet their nutritional requirements through oral intake despite nutritional interventions. Guidelines focused on repositioning and early mobilization: 5.1: Reposition all individuals with or at risk of pressure injuries on an individualized schedule, unless contraindicated. 5.2: Determine repositioning frequency with consideration to the individual's level of activity and ability to independently reposition. Guidelines focused on heel pressure injury: 6.1: Assess the vascular/perfusion status of the lower limbs, heels and feet when performing a skin and tissue assessment, and as part of a risk assessment. 6.2: For individuals at risk of heel pressure injuries and/or with category/stage I or II pressure injuries, elevate the heels using a specifically designed heel suspension device or a pillow/ foam cushion. Offload the heel completely in such a way as to distribute the weight of the leg along the calf without placing pressure on the Achilles tendon and the popliteal vein. 6.4: Use a prophylactic dressing as an adjunct to heel offloading and other strategies to prevent heel pressure injuries. Guidelines focused on support surfaces: 7.4: Use a high specification reactive single layer foam mattress or overlay in preference to a foam mattress without high specification qualities for individuals at risk of developing pressure injuries. 7.7: Assess the relative benefits of using an alternating pressure air mattress or overlay for individuals at risk of pressure injuries. 7.8: Use a pressure redistribution support surface on the operating table for all individuals with or at risk of pressure injuries who are undergoing surgery. 7.12: Use a pressure redistribution cushion for preventing pressure injuries in people at high risk who are seated in a chair/wheelchair for prolonged periods, particularly if the individual is unable to perform pressure relieving maneuvers. 7.13: Assess the relative benefits of using an alternating pressure air cushion for supporting pressure injury healing in individuals who are seated in a chair/wheelchair for prolonged periods, particularly if the individual is unable to perform pressure relieving maneuvers. Guidelines focused on device related pressure injury: 8.1: To reduce the risk of medical device related pressure injuries, review and select medical devices with consideration to: - The device's ability to minimize tissue damage - Correct sizing/shape of the device for the individual - Ability to correctly apply the device according to manufacturer's instructions - Ability to correctly secure the device 8.5: Use a prophylactic dressing beneath a medical device to reduce the risk of medical device related pressure injuries. Guidelines focused on implementing best practices: 20.2: At the organizational level, assess the knowledge health professionals have about pressure injuries to facilitate implementation of an education program and a quality improvement program. 20.4: At an organizational level, assess and maximize the availability and quality of equipment and standards for its use as part of a quality improvement plan to reduce the incidence of pressure injuries. 20.5: At an organizational level, develop and implement a structured, tailored and multi-faceted quality improvement program to reduce the incidence of pressure injuries. 20.6: At an organizational level, engage all key stakeholders in oversight and implementation of the quality improvement program to reduce the incidence of pressure injuries. 20.7: At an organizational level, include evidence-based policies, procedures and protocols and standardized documentation systems to reduce the incidence of pressure injuries. 20.8: At an organizational level, provide clinical decision support tools as part of a quality improvement plan to reduce the incidence of pressure injuries. 20.9: Provide clinical leadership in pressure injury prevention and treatment as part of a quality improvement plan to reduce pressure injuries. 20.10: At a professional level, provide education in pressure injury prevention and treatment as part of a quality improvement plan to reduce the incidence of pressure injuries. 20.11: At an organizational level, regularly monitor, analyze and evaluate performance against quality indicators for pressure injury prevention and treatment. 20.12: At an organizational level, use feedback and reminder systems to promote the quality improvement program and its outcomes to stakeholders. Guidelines focused on health professional education: 21.1: At the organizational level, assess the knowledge health professionals have about pressure injuries to facilitate implementation of an education program and a quality improvement program. 21.2: At an organizational level, develop and implement a multi-faceted education program for pressure injury prevention and treatment.
Citation | American College of Physicians (ACP). (2015). Risk assessment and prevention of pressure ulcers: a clinical practice guideline.
Citation | Bly, D., Schallom, M., Sona, C., & Klinkenberg, D. (2016). A model of pressure, oxygenation, and perfusion risk factors for pressure ulcers in the intensive care unit. American Journal of Critical Care, 25(2), 156-154
Citation | Brem, H., Maggi, J., Nierman, D., Rolnitzky, L., Bell, D., Rennert, R., Golinko, M., Yan, A., Lyder, C., Vladeck, B. High cost of stage IV pressure ulcers. Am J Surg. 2010 Oct;200(4):473-7. doi: 10.1016/j.amjsurg.2009.12.021. PMID: 20887840; PMCID: PMC2950802.
Citation | Centers for Medicare & Medicaid Services. (2015). Hospital-acquired conditions. Retrieved January 13, 2017, from https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Hospital-Acquired_Conditions.html
Citation | Cremasco, M. F., Wenzel, F., Zanei, S. S. V., & Whitaker, I. Y. (2013). Pressure ulcers in the intensive care unit: the relationship between nursing workload, illness severity and pressure ulcer risk. Journal of Clinical Nursing, 22(15-16), 2183-2191. https://doi.org/10.1111/j.1365-2702.2012.04216.x
Citation | European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance. (2019). Prevention and treatment of pressure ulcers/injuries: clinical practice guideline. The International Guideline: Haesler (Ed.). EPUAP/NPIAP/PPPIA.
Citation | Gunningberg, L., Donaldson, N., Aydin, C., Idvall, E. (2011). Exploring variation in pressure ulcer prevalence in Sweden and the USA: Benchmarking in action. 18. Journal of evaluation in clinical practice., 904-910
Citation | Li, Z., Lin, F., Thalib, L., & Chaboyer, W. (2020). Global prevalence and incidence of pressure injuries in hospitalised adult patients: A systematic review and meta-analysis. International Journal of Nursing Studies, Vol. 105. https://doi.org/10.1016/j.ijnurstu.103546
Citation | National Pressure Ulcer Advisory Panel (NPUAP), Submission of Open Comment August 23, 2019, retrieved May 12, 2020 from: https://cdn.ymaws.com/npiap.com/resource/resmgr/npuap_nqf_response_final_8.2.pdf
Citation | Rondinelli, J., Zuniga, S., Kipnis, P., Kawar, L. N., Liu, V., & Escobar, G. J. (2018). Hospital-acquired pressure injury: Risk-adjusted comparisons in an integrated healthcare delivery system. Nurs Res, 67(1), 16-25
Citation | Tayyib, N., Coyer, F., & Lewis, P. (2016). Saudi Arabian adult intensive care unit pressure ulcer incidence and risk factors: A prospective cohort study. International Wound Journal, 13(5), 912-919. https://doi.org/10.1111/iwj.12406
Citation | Wound Management & Prevention. (2018, November). Index: Ostomy wound management. 64(11):30-41. ISSN 1943-2720
Guidance (Usage) | This dQM is an episode-based measure. An episode is defined as each inpatient hospitalization or encounter that ends during the measurement period. This FHIR-based measure has been derived from the QDM-based measure: CMS826v3. Please refer to the HL7 QI-Core Implementation Guide (https://hl7.org/fhir/us/qicore/STU6/) for more information on QI-Core and mapping recommendations from QDM to QI-Core STU 6 (https://hl7.org/fhir/us/qicore/STU6/qdm-to-qicore.html).
Measure Group (Rate) (ID: Group_1)
Basis | Encounter
Scoring | [http://terminology.hl7.org/CodeSystem/measure-scoring#proportion: 'Proportion']
Type | [http://terminology.hl7.org/CodeSystem/measure-type#outcome: 'Outcome']
Rate Aggregation | None
Improvement Notation | [http://terminology.hl7.org/CodeSystem/measure-improvement-notation#decrease: 'Decreased score indicates improvement']
Initial Population | ID: InitialPopulation_1 Description: Inpatient hospitalizations that end during the measurement period for patients aged 18 and older Logic Definition: Initial Population
Denominator | ID: Denominator_1 Description: Equals Initial Population Logic Definition: Denominator
Denominator Exclusion | ID: DenominatorExclusion_1 Description: Inpatient hospitalizations for patients with a DTPI or stage 2, 3, 4 or unstageable pressure injury diagnosis present on admission as indicated by a present on admission indicator of Y or W Inpatient hospitalizations for patients with a DTPI found on exam within 72 hours after the start of the encounter Inpatient hospitalizations for patients with a stage 2, 3, 4, or unstageable pressure injury found on exam within 24 hours after the start of the encounter Logic Definition: Denominator Exclusions
Numerator | ID: Numerator_1 Description: Inpatient hospitalizations for patients with a new deep tissue pressure injury (DTPI) or stage 2, 3, 4, or unstageable pressure injury, as evidenced by any of the following: A DTPI or stage 2, 3, 4, or unstageable pressure injury diagnosis not present on admission as indicated by a present on admission indicator of N or U A DTPI found on exam greater than 72 hours after the start of the encounter A stage 2, 3, 4 or unstageable pressure injury found on exam greater than 24 hours after the start of the encounter Only one harm (new qualifying pressure injury) is counted per hospitalization Logic Definition: Numerator
Supplemental Data Guidance | For every patient evaluated by this measure, also identify payer, race, ethnicity and sex
Supplemental Data Elements
Supplemental Data Element | ID: sde-ethnicity Usage Code: [http://terminology.hl7.org/CodeSystem/measure-data-usage#supplemental-data] Description: SDE Ethnicity Logic Definition: SDE Ethnicity
Supplemental Data Element | ID: sde-payer Usage Code: [http://terminology.hl7.org/CodeSystem/measure-data-usage#supplemental-data] Description: SDE Payer Logic Definition: SDE Payer
Supplemental Data Element | ID: sde-race Usage Code: [http://terminology.hl7.org/CodeSystem/measure-data-usage#supplemental-data] Description: SDE Race Logic Definition: SDE Race
Supplemental Data Element | ID: sde-sex Usage Code: [http://terminology.hl7.org/CodeSystem/measure-data-usage#supplemental-data] Description: SDE Sex Logic Definition: SDE Sex
Measure Logic
Primary Library | https://madie.cms.gov/Library/CMS826FHIRHHPI
Contents | Population Criteria Logic Definitions Terminology Dependencies Data Requirements
Population Criteria
Measure Group (Rate) (ID: Group_1)
Initial Population
    define "Initial Population":
      "Encounter With Age 18 And Older"
Denominator
    define "Denominator":
      "Initial Population"
Denominator Exclusion
    define "Denominator Exclusions":
      "Encounter With Deep Tissue Pressure Injury POA By Indicator Or Skin Exam Within First 72 Hours"
        union "Encounter With Stage 2, 3, 4 Or Unstageable Pressure Injury POA"
Numerator
    define "Numerator":
      "Encounter With New Deep Tissue Pressure Injury"
        union "Encounter With New Stage 2, 3, 4 Or Unstageable Pressure Injury"
Logic Definitions
Logic Definition | Library Name: SupplementalDataElements
    define "SDE Sex":
      case
        when Patient.sex = '248153007' then "Male (finding)"
        when Patient.sex = '248152002' then "Female (finding)"
        else null
      end
Logic Definition | Library Name: SupplementalDataElements
    define "SDE Payer":
      [Coverage: type in "Payer Type"] Payer
        return {
          code: Payer.type,
          period: Payer.period
        }
Logic Definition | Library Name: SupplementalDataElements
    define "SDE Ethnicity":
      Patient.ethnicity E
        return Tuple {
          codes: { E.ombCategory } union E.detailed,
          display: E.text
        }
Logic Definition | Library Name: SupplementalDataElements
    define "SDE Race":
      Patient.race R
        return Tuple {
          codes: R.ombCategory union R.detailed,
          display: R.text
        }
Logic Definition | Library Name: QICoreCommon
    /*
    @description: Returns true if any of the given references are to the given resource
    @comment: Returns true if the `id` element of the given resource exactly equals the tail of any of the given references.
    NOTE: This function assumes resources from the same source server.
    */
    define fluent function references(references List<Reference>, resource Resource):
      exists (references R where R.references(resource))
Logic Definition | Library Name: QICoreCommon
    /*
    @description: Returns true if the given reference is to the given resource
    @comment: Returns true if the `id` element of the given resource exactly equals the tail of the given reference.
    NOTE: This function assumes resources from the same source server.
    */
    define fluent function references(reference Reference, resource Resource):
      resource.id = Last(Split(reference.reference, '/'))
Logic Definition | Library Name: QICoreCommon
    /*
    @description: Returns true if the given reference is to the given resourceId
    @comment: Returns true if the `resourceId` parameter exactly equals the tail of the given reference.
    NOTE: This function assumes resources from the same source server.
    */
    define fluent function references(reference Reference, resourceId String):
      resourceId = Last(Split(reference.reference, '/'))
Logic Definition | Library Name: CQMCommon
    /*
     @description: Returns true if the given diagnosis is present on admission, based on the given poaValueSet
     @comment: See the QICore 6 Authoring Patterns discussion on [Principal Diagnosis and Present on Admission](https://github.com/cqframework/CQL-Formatting-and-Usage-Wiki/wiki/Authoring-Patterns-QICore-v6.0.0#conditions-present-on-admission-and-principal-diagnoses) for more information
     */
     define fluent function isDiagnosisPresentOnAdmission(encounter Encounter, diagnosisValueSet ValueSet, poaValueSet ValueSet):
       exists (
         (encounter.claimDiagnosis()) CD
           where CD.onAdmission in poaValueSet
             and (
               CD.diagnosis in diagnosisValueSet
                 or CD.diagnosis.getCondition().code in diagnosisValueSet
             )
       )
Logic Definition | Library Name: CQMCommon
    /*
    @description: Returns the claim diagnosis elements for the given encounter
    @comment: See the QICore 6 Authoring Patterns discussion on [Principal Diagnosis and Present on Admission](https://github.com/cqframework/CQL-Formatting-and-Usage-Wiki/wiki/Authoring-Patterns-QICore-v6.0.0#conditions-present-on-admission-and-principal-diagnoses) for more information
    */
    define fluent function claimDiagnosis(encounter Encounter):
      encounter E
        let
          claim: ([Claim] C where C.status = 'active' and C.use = 'claim' and exists (C.item I where I.encounter.references(E))),
          claimItem: (claim.item I where I.encounter.references(E))
        return claim.diagnosis D where D.sequence in claimItem.diagnosisSequence
Logic Definition | Library Name: CQMCommon
    /*
    @description: Returns the Condition resource for the given reference
    */
    define fluent function getCondition(reference Reference):
      singleton from (([ConditionEncounterDiagnosis] union [ConditionProblemsHealthConcerns]) C where reference.references(C.id))
Logic Definition | Library Name: CQMCommon
    /*
    @description: Hospitalization with Observation returns the total interval from the start of any immediately prior emergency department visit through the observation visit to the discharge of the given encounter
    */
    define fluent function hospitalizationWithObservation(TheEncounter Encounter ):
      TheEncounter Visit
      		let ObsVisit: Last([Encounter: "Observation Services"] LastObs
      				where LastObs.status = 'finished'
                and LastObs.period ends 1 hour or less on or before start of Visit.period
      				sort by end of period
      			),
      			VisitStart: Coalesce(start of ObsVisit.period, start of Visit.period),
      			EDVisit: Last([Encounter: "Emergency Department Visit"] LastED
      				where LastED.status = 'finished'
                and LastED.period ends 1 hour or less on or before VisitStart
      				sort by end of period
      			)
      		return Interval[Coalesce(start of EDVisit.period, VisitStart), end of Visit.period]
Logic Definition | Library Name: CMS826FHIRHHPI
    define "SDE Sex":
      SDE."SDE Sex"
Logic Definition | Library Name: CMS826FHIRHHPI
    define "Encounter With Age 18 And Older":
      ["Encounter": "Encounter Inpatient"] InpatientEncounter
        where AgeInYearsAt(date from start of InpatientEncounter.period) >= 18
          and InpatientEncounter.period ends during day of "Measurement Period"
          and InpatientEncounter.status = 'finished'
Logic Definition | Library Name: CMS826FHIRHHPI
    define "Encounter With New Deep Tissue Pressure Injury Not POA By Indicator":
      "Encounter With Age 18 And Older" InpatientHospitalization
        where InpatientHospitalization.isDiagnosisPresentOnAdmission ( "Pressure Injury Deep Tissue Diagnoses", "Not Present On Admission or Documentation Insufficient to Determine" )
Logic Definition | Library Name: CMS826FHIRHHPI
    define "Clinical Skin Exams With Pressure Injury":
      ["ObservationClinicalResult": "Physical findings of Skin"] ClinicalSkinExam
        where ClinicalSkinExam.isIn ( "Pressure Injury Stage 2, 3, 4 or Unstageable" )
Logic Definition | Library Name: CMS826FHIRHHPI
    define "Simple Skin Exams With Pressure Injury":
      ["SimpleObservation": "Physical findings of Skin"] ObsSkinExam
        where ObsSkinExam.isIn ( "Pressure Injury Stage 2, 3, 4 or Unstageable" )
Logic Definition | Library Name: CMS826FHIRHHPI
    // @description Skin exams may be either a SimpleObservation or an ObservationClinicalResult in QI-Core. The definition below allows both QI-Core resource representations for more comprehensive data capture.

    define "Skin Exams With Pressure Injury":
      "Clinical Skin Exams With Pressure Injury"
        union "Simple Skin Exams With Pressure Injury"
Logic Definition | Library Name: CMS826FHIRHHPI
    define "Encounter With New Deep Tissue Pressure Injury By Skin Exam After First 72 Hours":
      "Encounter With Age 18 And Older" InpatientHospitalization
        let hospitalizationPeriod: InpatientHospitalization.hospitalizationWithObservation ( )
        with "Skin Exams With Pressure Injury" SkinExam
          such that SkinExam.effective.toInterval ( ) starts during Interval[start of hospitalizationPeriod + 72 hours, end of hospitalizationPeriod]
Logic Definition | Library Name: CMS826FHIRHHPI
    define "Encounter With New Deep Tissue Pressure Injury":
      "Encounter With New Deep Tissue Pressure Injury Not POA By Indicator"
        union "Encounter With New Deep Tissue Pressure Injury By Skin Exam After First 72 Hours"
Logic Definition | Library Name: CMS826FHIRHHPI
    define "Encounter With New Stage 2, 3, 4 Or Unstageable Pressure Injury Not POA By Indicator":
      "Encounter With Age 18 And Older" InpatientHospitalization
        where InpatientHospitalization.isDiagnosisPresentOnAdmission ( "Pressure Injury Stage 2, 3, 4, or Unstageable Diagnoses", "Not Present On Admission or Documentation Insufficient to Determine" )
Logic Definition | Library Name: CMS826FHIRHHPI
    define "Encounter With New Stage 2, 3, 4 Or Unstageable Pressure Injury By Skin Exam After First 24 Hours":
      "Encounter With Age 18 And Older" InpatientHospitalization
        let hospitalizationPeriod: InpatientHospitalization.hospitalizationWithObservation ( )
        with "Skin Exams With Pressure Injury" SkinExam
          such that SkinExam.effective.toInterval ( ) starts during Interval[start of hospitalizationPeriod + 24 hours, end of hospitalizationPeriod]
Logic Definition | Library Name: CMS826FHIRHHPI
    define "Encounter With New Stage 2, 3, 4 Or Unstageable Pressure Injury":
      "Encounter With New Stage 2, 3, 4 Or Unstageable Pressure Injury Not POA By Indicator"
        union "Encounter With New Stage 2, 3, 4 Or Unstageable Pressure Injury By Skin Exam After First 24 Hours"
Logic Definition | Library Name: CMS826FHIRHHPI
    define "Numerator":
      "Encounter With New Deep Tissue Pressure Injury"
        union "Encounter With New Stage 2, 3, 4 Or Unstageable Pressure Injury"
Logic Definition | Library Name: CMS826FHIRHHPI
    define "Initial Population":
      "Encounter With Age 18 And Older"
Logic Definition | Library Name: CMS826FHIRHHPI
    define "Denominator":
      "Initial Population"
Logic Definition | Library Name: CMS826FHIRHHPI
    define "SDE Payer":
      SDE."SDE Payer"
Logic Definition | Library Name: CMS826FHIRHHPI
    define "SDE Ethnicity":
      SDE."SDE Ethnicity"
Logic Definition | Library Name: CMS826FHIRHHPI
    define "Encounter With Deep Tissue Pressure Injury POA By Indicator":
      "Encounter With Age 18 And Older" InpatientHospitalization
        where InpatientHospitalization.isDiagnosisPresentOnAdmission ( "Pressure Injury Deep Tissue Diagnoses", "Present on Admission or Clinically Undetermined" )
Logic Definition | Library Name: CMS826FHIRHHPI
    define "Encounter With Deep Tissue Pressure Injury POA By Skin Exam Within First 72 Hours":
      "Encounter With Age 18 And Older" InpatientHospitalization
        let hospitalizationPeriod: InpatientHospitalization.hospitalizationWithObservation ( )
        with "Skin Exams With Pressure Injury" SkinExam
          such that SkinExam.effective.toInterval ( ) starts during Interval[start of hospitalizationPeriod, start of hospitalizationPeriod + 72 hours]
Logic Definition | Library Name: CMS826FHIRHHPI
    define "Encounter With Deep Tissue Pressure Injury POA By Indicator Or Skin Exam Within First 72 Hours":
      "Encounter With Deep Tissue Pressure Injury POA By Indicator"
        union "Encounter With Deep Tissue Pressure Injury POA By Skin Exam Within First 72 Hours"
Logic Definition | Library Name: CMS826FHIRHHPI
    define "Encounter With Stage 2, 3, 4, Or Unstageable Pressure Injury Present On Admission By POA Indicator":
      "Encounter With Age 18 And Older" InpatientHospitalization
        where InpatientHospitalization.isDiagnosisPresentOnAdmission ( "Pressure Injury Stage 2, 3, 4, or Unstageable Diagnoses", "Present on Admission or Clinically Undetermined" )
Logic Definition | Library Name: CMS826FHIRHHPI
    define "Encounter With Stage 2, 3, 4 Or Unstageable Pressure Injury POA By Skin Exam Within 24 Hours":
      "Encounter With Age 18 And Older" InpatientHospitalization
        let hospitalizationPeriod: InpatientHospitalization.hospitalizationWithObservation ( )
        with "Skin Exams With Pressure Injury" SkinExam
          such that SkinExam.effective.toInterval ( ) starts during Interval[start of hospitalizationPeriod, start of hospitalizationPeriod + 24 hours]
Logic Definition | Library Name: CMS826FHIRHHPI
    define "Encounter With Stage 2, 3, 4 Or Unstageable Pressure Injury POA":
      "Encounter With Stage 2, 3, 4, Or Unstageable Pressure Injury Present On Admission By POA Indicator"
        union "Encounter With Stage 2, 3, 4 Or Unstageable Pressure Injury POA By Skin Exam Within 24 Hours"
Logic Definition | Library Name: CMS826FHIRHHPI
    define "Denominator Exclusions":
      "Encounter With Deep Tissue Pressure Injury POA By Indicator Or Skin Exam Within First 72 Hours"
        union "Encounter With Stage 2, 3, 4 Or Unstageable Pressure Injury POA"
Logic Definition | Library Name: CMS826FHIRHHPI
    define "SDE Race":
      SDE."SDE Race"
Logic Definition | Library Name: CMS826FHIRHHPI
    // @description This function, attached to either a SimpleObseration or an ObservationClinicalResult, is used to determine if the observation is completed and its value is in the given value set
    // @example  ExampleObservation.isIn("Pressure Injury Stage 2, 3, 4 or Unstageable")

    define fluent function isIn(observation Choice<"SimpleObservation", "ObservationClinicalResult">, vset ValueSet):
      observation.status in { 'final', 'amended', 'corrected' }
        and observation.effective.toInterval ( ) during "Measurement Period"
        and case
          when observation is SimpleObservation then ( observation as SimpleObservation ).value as Concept in vset
          when observation is ObservationClinicalResult then ( observation as ObservationClinicalResult ).value as Concept in vset
          else null end
Logic Definition | Library Name: FHIRHelpers
    define function ToString(value uri): value.value
Logic Definition | Library Name: FHIRHelpers
    /*
    @description: Converts the given [Period](https://hl7.org/fhir/datatypes.html#Period)
    value to a CQL DateTime Interval
    @comment: If the start value of the given period is unspecified, the starting
    boundary of the resulting interval will be open (meaning the start of the interval
    is unknown, as opposed to interpreted as the beginning of time).
    */
    define function ToInterval(period FHIR.Period):
        if period is null then
            null
        else
            if period."start" is null then
                Interval(period."start".value, period."end".value]
            else
                Interval[period."start".value, period."end".value]
Logic Definition | Library Name: FHIRHelpers
    /*
    @description: Converts the given FHIR [Coding](https://hl7.org/fhir/datatypes.html#Coding) value to a CQL Code.
    */
    define function ToCode(coding FHIR.Coding):
        if coding is null then
            null
        else
            System.Code {
              code: coding.code.value,
              system: coding.system.value,
              version: coding.version.value,
              display: coding.display.value
            }
Terminology
Code System | Description: Code system SNOMEDCT Resource: http://snomed.info/sct Canonical URL: `http://snomed.info/sct`
Code System | Description: Code system LOINC Resource: http://loinc.org Canonical URL: `http://loinc.org`
Value Set | Description: Value set Encounter Inpatient Resource: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.666.5.307 Canonical URL: `http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.666.5.307`
Value Set | Description: Value set Pressure Injury Deep Tissue Diagnoses Resource: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1147.194 Canonical URL: `http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1147.194`
Value Set | Description: Value set Not Present On Admission or Documentation Insufficient to Determine Resource: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1147.198 Canonical URL: `http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1147.198`
Value Set | Description: Value set Observation Services Resource: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1111.143 Canonical URL: `http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1111.143`
Value Set | Description: Value set Emergency Department Visit Resource: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.292 Canonical URL: `http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.292`
Value Set | Description: Value set Pressure Injury Stage 2, 3, 4 or Unstageable Resource: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1147.113 Canonical URL: `http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1147.113`
Value Set | Description: Value set Pressure Injury Stage 2, 3, 4, or Unstageable Diagnoses Resource: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1147.196 Canonical URL: `http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1147.196`
Value Set | Description: Value set Payer Type Resource: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591 Canonical URL: `http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591`
Value Set | Description: Value set Present on Admission or Clinically Undetermined Resource: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1147.197 Canonical URL: `http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1147.197`
Direct Reference Code | Display: Male (finding) Code: 248153007 System: `http://snomed.info/sct`
Direct Reference Code | Display: Female (finding) Code: 248152002 System: `http://snomed.info/sct`
Direct Reference Code | Display: Physical findings of Skin Code: 8709-8 System: `http://loinc.org`
Dependencies
Dependency | Description: QICore model information Resource: http://hl7.org/fhir/Library/QICore-ModelInfo Canonical URL: `http://hl7.org/fhir/Library/QICore-ModelInfo`
Dependency | Description: Library SDE Resource: https://madie.cms.gov/Library/SupplementalDataElements|5.1.000 Canonical URL: `https://madie.cms.gov/Library/SupplementalDataElements|5.1.000`
Dependency | Description: Library FHIRHelpers Resource: https://madie.cms.gov/Library/FHIRHelpers|4.4.000 Canonical URL: `https://madie.cms.gov/Library/FHIRHelpers|4.4.000`
Dependency | Description: Library CQMCommon Resource: https://madie.cms.gov/Library/CQMCommon|4.1.000 Canonical URL: `https://madie.cms.gov/Library/CQMCommon|4.1.000`
Dependency | Description: Library QICoreCommon Resource: https://madie.cms.gov/Library/QICoreCommon|4.0.000 Canonical URL: `https://madie.cms.gov/Library/QICoreCommon|4.0.000`
Data Requirements
Data Requirement | Type: Patient Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-patient Must Support Elements: extension, url
Data Requirement | Type: Encounter Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-encounter Must Support Elements: type, status, status.value, period, onAdmission, diagnosis, diagnosis.code Code Filter(s): Path: type ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1111.143
Data Requirement | Type: Encounter Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-encounter Must Support Elements: type, status, status.value, period, onAdmission, diagnosis, diagnosis.code Code Filter(s): Path: type ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.292
Data Requirement | Type: Encounter Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-encounter Must Support Elements: type, period, status, status.value, onAdmission, diagnosis, diagnosis.code Code Filter(s): Path: type ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.666.5.307
Data Requirement | Type: Resource Profile(s): http://hl7.org/fhir/StructureDefinition/Resource Must Support Elements: id, id.value
Data Requirement | Type: Claim Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-claim Must Support Elements: status, status.value, use, use.value, item
Data Requirement | Type: Condition Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-condition-encounter-diagnosis
Data Requirement | Type: Condition Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-condition-problems-health-concerns
Data Requirement | Type: Observation Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-simple-observation Must Support Elements: value
Data Requirement | Type: Observation Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-simple-observation Must Support Elements: code Code Filter(s): Path: code Code(s): http://loinc.org#8709-8: 'Physical findings of Skin'
Data Requirement | Type: Observation Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-observation-clinical-result Must Support Elements: value
Data Requirement | Type: Observation Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-observation-clinical-result Must Support Elements: code Code Filter(s): Path: code Code(s): http://loinc.org#8709-8: 'Physical findings of Skin'
Data Requirement | Type: Coverage Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-coverage Must Support Elements: type, period Code Filter(s): Path: type ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591
Generated using version 0.4.8 of the sample-content-ig Liquid templates