Smile CDR v2024.08.PRE
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23.3.1Table of Contents

 

23.3.2Measure Resource

 

The FHIR Clinical Reasoning Module defines the Measure resource and several associated operations. The Measure Resource represents a structured, computable definition of a health-related measure such as a clinical quality measure, public health indicator, or population analytics measure. These Measures can then be used for reporting, analytics, and data-exchange purposes.

Electronic Clinical Quality Measures (eCQMs) in FHIR are represented as a FHIR Measure resource containing metadata and terminology, a population criteria section, and at least one FHIR Library resource containing a data criteria section as well as the logic used to define the population criteria. The population criteria section typically contains initial population criteria, denominator criteria, and numerator criteria subcomponents, among others. This is elaborated upon in greater detail in the CQF Measures IG. An example of an eCQM as defined in FHIR looks like:

{
  "resourceType" : "Measure",
  "library" : [
    "http://hl7.org/fhir/us/cqfmeasures/Library/EXMLogic"
  ],
  "group" : [
    {
      "population" : [
        {
          "code" : {
            "coding" : [
              {
                "code" : "initial-population"
              }
            ]
          },
          "criteria" : {
            "language" : "text/cql-identifier",
            "expression" : "Initial Population"
          }
        },
        {
          "code" : {
            "coding" : [
              {
                "code" : "numerator"
              }
            ]
          },
          "criteria" : {
            "language" : "text/cql-identifier",
            "expression" : "Numerator"
          }
        },
        {
          "code" : {
            "coding" : [
              {
                "code" : "denominator"
              }
            ]
          },
          "criteria" : {
            "language" : "text/cql-identifier",
            "expression" : "Denominator"
          }
        }
      ]
    }
  ]
}

Measures are then scored according to whether a subjects (or subjects) are members of the various populations.

For example, a Measure for Breast Cancer screening might define an Initial Population (via CQL expressions) of "all women", a Denominator of "women over 35", and a Numerator of "women over 35 who have had breast cancer screenings in the past year". If the Measure is evaluated against a population of 100 women, 50 are over 35, and of those 25 have had breast cancer screenings in the past year, the final score would be 50%1 (total number in numerator / total number in the denominator).

  1. There are several methods for scoring Measures, this is meant only as an example.

23.3.3Measure Evaluating Options

 

The FHIR Measure specification defines several types of Measures and various parameters for controlling the Measure evaluation. This section describes the features supported by Smile CDR.

23.3.3.1Populations

Smile CDR uses the populations defined by the CQF Measures IG for each scoring type. A matrix of the supported populations is shown in the Criteria Names section of the CQF Measures IG.

23.3.3.2Population Criteria

The logical criteria used for determining each Measure population is defined by the Measure.group.population.criteria element. The Measure specification allows population criteria to be defined using FHIR Path, CQL, or other languages as appropriate. Smile CDR currently only supports using CQL. The relationship between a Measure Population and CQL is illustrated in the Population Criteria section of the CQF Measures IG.

An example Measure resource with a population criteria referencing a CQL identifier looks like:

{
  "resourceType": "Measure",
  "group": [ {
    "population": [ {
      "code": {
        "coding": [ {
          "system": "http://terminology.hl7.org/CodeSystem/measure-population",
          "code": "initial-population",
          "display": "Initial Population"
        } ]
      },
      "criteria": {
        "language": "text/cql-identifier",
        "expression": "Initial Population"
      }
    }]
  }]
}

23.3.3.3Population Basis

The population basis specifies the type of elements represented in the MeasureReport populations (example: "Numerator").

For measures that have a population basis that is different from a subject, this element specifies the type of the population basis.

This done with an extension element that can be added to a measure, see examples below.

Scoring BasisSupportedDescription
BooleanPopulation criteria define True/False values for each individual in the population
EncounterPopulation criteria return lists of encounters for a subject in the population
other resourcesPopulation criteria return lists of "resources" like an encounter for a subject in population

Example Population Basis of Encounter

{
	"extension": [ {
"url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-populationBasis",
"valueCode": "Encounter"
} ]
}

Example Population Basis of Boolean

{
  "extension": [
    {
      "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-populationBasis",
      "valueCode": "boolean"
    }
  ]
}

23.3.3.4Scoring Methods

The Measure scoring method determines how a Measure score is calculated. It is set with the scoring element on the Measure resource.

The Smile CDR implementation conforms to the requirements defined by the CQF Measures IG. A more detailed description of each scoring method is linked in the table below.

Scoring MethodSupportedDescription
proportionProportion Measures
ratioRatio Measures
continuous-variableContinuous Variable
cohort✓*Cohort
composite See below
  • The cohort Measure scoring support is partial. The Smile CDR implementation does not yet return the required Measure observations

An example Measure resource with scoring defined looks like:

{
  "resourceType": "Measure",
  "scoring": {
    "coding": [ {
      "system": "http://terminology.hl7.org/CodeSystem/measure-scoring",
      "code": "proportion",
      "display": "Proportion"
    } ]
  }
}

CDR also supports setting measure-scoring` on a Group level instead of just on the Measure level.

{
  "group": [
    {
      "id": "64f0daaf56d636294b157ea1",
      "extension": [
        {
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-scoring",
          "valueCodeableConcept": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/measure-scoring",
                "code": "proportion",
                "display": "Proportion"
              }
            ]
          }
        },
        {
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-populationBasis",
          "valueCode": "Encounter"
        },
        {
          "url": "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-type",
          "valueCodeableConcept": {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/measure-type",
                "code": "process",
                "display": "Process"
              }
            ]
          }
        }
      ]
    }
  ]
}

23.3.3.4.1Composite Scoring

A composite Measure is scored by combining and/or aggregating the results of other Measures. The compositeScoring element is used to control how composite Measures are scored. Smile CDR does not currently support any composite scoring method.

Composite Scoring MethodSupportedDescription
opportunity Combines Numerators and Denominators for each component Measure
all-or-nothing Includes individuals that are in the numerator for all component Measures
linear Gives an individual score based on the number of numerators in which they appear
weighted Gives an individual a cored based on a weighted factor for each numerator in which they appear

23.3.3.5Criteria Expression Type

Expression TypeSupported
CQL
FHIR Path

23.3.3.6Supplemental Data Elements

Supplemental Data Elements are used to report additional information about the subjects that may not be included in the Population criteria definitions. For example, it may be of interest to report the gender of all subjects for informational purposes. Supplemental data elements are defined by the Measure.supplementalData element, and are reported as Observations in the evaluatedResources of the MeasureReport.

Supplemental Data Elements can be specified as either CQL definitions or FHIR Path expressions.

Expression TypeSupported
CQL
FHIR Path

An example Measure resource with some supplemental data elements set looks like:

{
"resourceType": "Measure",
   "supplementalData": [ {
      "code": {
         "text": "sde-ethnicity"
      },
      "criteria": {
         "language": "text/cql-identifier",
         "expression": "SDE Ethnicity"
      }
   }]
}

23.3.3.7Stratifiers

  • Stratifiers are used divide Measure populations into segments of interest. For example, it may be of interest to compare the Measure score between different age groups or genders. Each stratum within a stratification is scored the same way as the overall population. Stratifiers are defined using the Measure.group.stratifier element.

  • An example Measure resource with a stratifier set looks like:

{
  "resourceType": "Measure",
  "group": [ {
      "stratifier": [ {
         "code": {
            "text": "Stratum 1"
         },
         "criteria": {
            "language": "text/cql-identifier",
            "expression": "Stratification 1"
         }
      }]
   }]
}

23.3.3.7.1Stratifier Expression Support

As with Populations and Supplemental Data Elements the criteria used for Stratification may be defined with CQL or FHIR Path.

Expression TypeSupported
CQL
FHIR Path

23.3.3.7.2Stratifier Component Support

The Measure specification also supports multidimensional stratification, for cases where more than one data element is needed.

Stratifier TypeSupported
Single Component
Multi Component

23.3.3.8Evaluated Resources

A FHIR MeasureReport permits referencing the Resources used when evaluating in the MeasureReport.evaluatedResource element. Smile CDR includes these resources when generating subject reports for a single Patient. Evaluated resources for population or subject-list reports are not included. For large populations this could quickly become an extremely large number of resources.

The evaluated resources will not include every resource on the Smile CDR server for a given subject. Rather, it includes only the resources that were retrieved from the server by the CQL logic that was evaluated. This corresponds to the data-requirements for a given Measure. As an example, consider the following CQL:

valueset "Example Value Set" : 'http://fhir.org/example-value-set'

define "Example Observations":
   [Observation : "Example Value Set"]

That CQL will only select Observation Resources that have a code in the "Example Value Set". Those Observations will be reported in the Evaluated Resources while any others will not.

23.3.3.9Extensions

A number of extensions to Measure evaluation defined by various IGs are supported. They are described briefly in the table below.

ExtensionDescription
http://hl7.org/fhir/us/cqframework/cqfmeasures/StructureDefinition/cqfm-productLineUsed to evaluate different product lines (e.g. Medicare, Private, etc.)
http://hl7.org/fhir/StructureDefinition/cqf-measureInfoUsed to denote a Measure Observation
http://hl7.org/fhir/us/davinci-deqm/StructureDefinition/extension-populationReferenceUsed to specify the population that triggered a particular evaluatedResource

There's not currently a way to configure which extensions are enabled. All supported extensions are always enabled.

23.3.4Operation

 

Smile CDR implements the $evaluate-measure operation into three different implementations and use cases.

FeatureStandard Evaluate-MeasureDistributed Evaluate-MeasureSpark Evaluate-Measure
Processing TypeLow Latency ResponseBulk ProcessingBig Data Processing
Population Size<1,000>=1000 to 10's of Millions100's of Millions to Billions
Integrated into CDR
FHIR R5
FHIR R4
FHIR DSTU3
Available in open-source
Creates MeasureReport
Persists MeasureReport
Multi-Threaded Processing
Horizontally Scalable
Populates Reporter Field
Evaluation Type 'Subject-List'Coming Soon

23.3.5Operation Parameters

 
ParameterSupportedDescription
Idthe id of the Measure to evaluate
PeriodStartThe start of the reporting period
PeriodEndThe end of the reporting period
ReportTypeThe type of measure report: subject, subject-list, or population. If not specified, a default value of subject will be used if the subject parameter is supplied, otherwise, population will be used
SubjectSubject for which the measure will be calculated. If not specified, the measure will be calculated for all subjects that meet the requirements of the measure. If specified, the measure will only be calculated for the referenced subject(s)
PractitionerPractitioner for which the measure will be calculated. If specified, the measure will be calculated only for subjects that have a primary relationship to the identified practitioner
LastReceivedOnThe date the results of this measure were last received. This parameter is only valid for patient-level reports and is used to indicate when the last time a result for this patient was received. This information can be used to limit the set of resources returned for a patient-level report
ProductLinethe productLine (e.g. Medicare, Medicaid, etc) to use for the evaluation. This is a non-standard parameter
Additional Datathe data bundle containing additional data
Terminology Endpoint
ParametersAny input parameters for the evaluation. Parameters defined in this input will be made available by name to the CQL expression. Parameter types are mapped to CQL as specified in the Using CQL topic of the Clinical Reasoning Module. If a parameter appears more than once in the input Parameters resource, it is represented with a List in the input CQL. If a parameter has parts, it is represented as a Tuple in the input CQL.

23.3.5.0.1Reporting Period

The periodStart and periodEnd parameters are used to control the Reporting Period for which a report is generated. This corresponds to Measurement Period defined in the CQL logic, as defined by the conformance requirements in the CQF Measures IG. Both periodStart and periodEnd must be used or neither must be used.

If neither are used the default reporting period specified in the CQL logic is used, as shown here

parameter "Measurement Period" Interval<DateTime>
  default Interval[@2019-01-01T00:00:00.0, @2020-01-01T00:00:00.0)

If neither are used and there is no default reporting period in the CQL logic an error is thrown.

A request using periodStart and periodEnd looks like:

GET fhir/Measure/<MeasureId>/$evaluate-measure?periodStart=2019-01-01&periodEnd=2019-12-31

periodStart and periodEnd support Dates (YYYY, YYYY-MM, or YYYY-MM-DD) and DateTimes (YYYY-MM-DDThh:mm:ss+zz:zz)

23.3.5.0.2Report Types

Measure report types determine what data is returned from the evaluation. This is controlled with the reportType parameter on the $evaluate-measure Operation

Report TypeSupportedDescription
subjectMeasure report for a single subject (e.g. one patient). Includes additional detail, such as evaluatedResources
subject-listMeasure report including the list of subjects in each population (e.g. all the patients in the "numerator")
populationSummary measure report for a population

NOTE: There's an open issue on the FHIR specification to align these names to the MeasureReportType value set.

A request using reportType looks like:

GET fhir/Measure/<MeasureId>/$evaluate-measure?reportType=subject-list

23.3.5.0.3Subject Types

The subject of a measure evaluation is controlled with the subject (R4+) and patient (DSTU3) operation parameters. Currently, the only subject type supported by Smile CDR is Patient. This means that all Measure evaluation and reporting happens with respect to a Patient or set of Patient resources.

Subject TypeSupportedDescription
PatientA Patient
Practitioner A Practitioner
Organization An Organization
Location A Location
Device A Device
Group1A set of subjects
  1. See next section

A request using subject looks like:

GET fhir/Measure/<MeasureId>/$evaluate-measure?subject=Patient/123

23.3.5.0.3.1Selecting a set of Patients

The set of Patients used for Measure evaluation is controlled with the subject (R4+) or patient (DSTU3), and practitioner parameters. The two parameters are mutually exclusive.

ParameterSupportedDescription
Not specifiedAll Patients on the server
subject=XXX or subject=Patient/XXXA single Patient
practitioner=XXX or practitioner=Practitioner/XXX or practitioner=Group/XXXAll Patients whose generalPractitioner is the referenced Practitioner or practitioners in Group
subject=Group/XXX1Group containing subjects
subject=XXX AND practitioner=XXXNot a valid combination
  1. Currently only Groups containing Patient or Practitioner resources are supported.

A request using practitioner looks like:

GET fhir/Measure/<MeasureId>/$evaluate-measure?practitioner=Practitioner/XYZ

23.3.5.0.4ReportType, Subject, Practitioner Matrix

The following table shows the combinations of the subject (or patient), practitioner and reportType parameters that are valid

subject reportTypesubject-list reportTypepopulation reportType
subject parameter1,21,2
practitioner parameter3
  1. Including the subject parameter restricts the Measure evaluation to a single Patient. Omit the subject (or patient) parameter to get report for multiple Patients. The subject-list and population report types have less detail than a subject report.
  2. A Group subject with a subject-list or population reportType will be a valid combination once Group support is implemented.
  3. A practitioner have may zero, one, or many patients so a practitioner report always assumes a set.

23.3.5.0.5Last Received On

The lastReceivedOn parameter is the date the Measure was evaluated and reported. It is used to limit the number of resources reported in the Measure report for individual reports. It is currently not supported by Smile CDR.

23.3.5.0.6Parameters

Any input parameters for the evaluation. Parameters defined in this input will be made available by name to the CQL expression. Parameter types are mapped to CQL as specified in the Using CQL topic of the Clinical Reasoning Module. If a parameter appears more than once in the input Parameters resource, it is represented with a List in the input CQL. If a parameter has parts, it is represented as a Tuple in the input CQL.

23.3.6Measure Report Resource

 

The outcome of running $evaluate-measure returns a Measure Report resource with the results outputting in the structure defined in the Measure resource.

23.3.6.0.1Example Measure Report Individual

Example requests and outputs with parameter reportType=subject.

23.3.6.0.1.1Example Individual Request

GET http://your-server-base/fhir/Measure/ColorectalCancerScreeningsFHIR/$evaluate-measure?periodStart=2023-01-01&periodEnd=2023-12-31&reportType=subject&subject=Patient/numer-EXM130-Patient-1

23.3.6.0.1.2Example Individual Response

{
    "resourceType": "MeasureReport",
    "language": "en",
    "contained": [
        {
            "resourceType": "Observation",
            "id": "70e1db58-acc7-4d06-b9d1-1139164bfb0d",
            "extension": [
                {
                    "url": "http://hl7.org/fhir/StructureDefinition/cqf-measureInfo",
                    "extension": [
                        {
                            "url": "measure",
                            "valueCanonical": "http://ecqi.healthit.gov/ecqms/Measure/ColorectalCancerScreeningsFHIR"
                        }
                    ]
                }
            ],
            "status": "final",
            "code": {
                "coding": [
                    {
                        "system": "http://terminology.hl7.org/CodeSystem/measure-data-usage",
                        "code": "supplemental-data"
                    }
                ]
            },
            "valueCodeableConcept": {
                "coding": [
                    {
                        "code": "M"
                    }
                ]
            }
        },
        {
            "resourceType": "Observation",
            "id": "3f773d33-d40f-4b76-9de9-dd5af88f8924",
            "extension": [
                {
                    "url": "http://hl7.org/fhir/StructureDefinition/cqf-measureInfo",
                    "extension": [
                        {
                            "url": "measure",
                            "valueCanonical": "http://ecqi.healthit.gov/ecqms/Measure/ColorectalCancerScreeningsFHIR"
                        }
                    ]
                }
            ],
            "status": "final",
            "code": {
                "coding": [
                    {
                        "system": "http://terminology.hl7.org/CodeSystem/measure-data-usage",
                        "code": "supplemental-data"
                    }
                ]
            },
            "valueCodeableConcept": {
                "coding": [
                    {
                        "code": "2135-2"
                    }
                ]
            }
        },
        {
            "resourceType": "Observation",
            "id": "cd1924a6-15e5-448f-9b90-3de1bd1f4efe",
            "extension": [
                {
                    "url": "http://hl7.org/fhir/StructureDefinition/cqf-measureInfo",
                    "extension": [
                        {
                            "url": "measure",
                            "valueCanonical": "http://ecqi.healthit.gov/ecqms/Measure/ColorectalCancerScreeningsFHIR"
                        }
                    ]
                }
            ],
            "status": "final",
            "code": {
                "coding": [
                    {
                        "system": "http://terminology.hl7.org/CodeSystem/measure-data-usage",
                        "code": "supplemental-data"
                    }
                ]
            },
            "valueCodeableConcept": {
                "coding": [
                    {
                        "code": "2028-9"
                    }
                ]
            }
        }
    ],
    "extension": [
        {
            "url": "http://hl7.org/fhir/5.0/StructureDefinition/extension-MeasureReport.population.description",
            "valueString": "Percentage of adults 50-75 years of age who had appropriate screening for colorectal cancer"
        },
        {
            "url": "http://hl7.org/fhir/5.0/StructureDefinition/extension-MeasureReport.supplementalDataElement.reference",
            "valueReference": {
                "extension": [
                    {
                        "url": "http://hl7.org/fhir/us/davinci-deqm/StructureDefinition/extension-criteriaReference",
                        "valueString": "5C3ACF2A-15D2-44A0-A83D-F4FCC3E2F27A"
                    }
                ],
                "reference": "#cd1924a6-15e5-448f-9b90-3de1bd1f4efe"
            }
        },
        {
            "url": "http://hl7.org/fhir/5.0/StructureDefinition/extension-MeasureReport.supplementalDataElement.reference",
            "valueReference": {
                "extension": [
                    {
                        "url": "http://hl7.org/fhir/us/davinci-deqm/StructureDefinition/extension-criteriaReference",
                        "valueString": "9CB0299E-74B0-4425-8758-52D6FC0F979C"
                    }
                ],
                "reference": "#3f773d33-d40f-4b76-9de9-dd5af88f8924"
            }
        },
        {
            "url": "http://hl7.org/fhir/5.0/StructureDefinition/extension-MeasureReport.supplementalDataElement.reference",
            "valueReference": {
                "extension": [
                    {
                        "url": "http://hl7.org/fhir/us/davinci-deqm/StructureDefinition/extension-criteriaReference",
                        "valueString": "8114BAD7-FAC8-4E22-91CB-33BC3DDB9986"
                    }
                ],
                "reference": "#70e1db58-acc7-4d06-b9d1-1139164bfb0d"
            }
        }
    ],
    "status": "complete",
    "type": "individual",
    "measure": "http://ecqi.healthit.gov/ecqms/Measure/ColorectalCancerScreeningsFHIR|0.0.003",
    "subject": {
        "reference": "Patient/numer-EXM130-Patient-1"
    },
    "date": "2024-03-05T19:30:24+00:00",
    "period": {
        "start": "2023-01-01T00:00:00+00:00",
        "end": "2023-12-31T23:59:59+00:00"
    },
    "improvementNotation": {
        "coding": [
            {
                "system": "http://terminology.hl7.org/CodeSystem/measure-improvement-notation",
                "code": "increase"
            }
        ]
    },
    "group": [
        {
            "extension": [
                {
                    "url": "http://hl7.org/fhir/us/davinci-deqm/StructureDefinition/extension-cqfm-denominator-membership",
                    "valueString": "1"
                },
                {
                    "url": "http://hl7.org/fhir/us/davinci-deqm/StructureDefinition/extension-cqfm-numerator-membership",
                    "valueString": "1"
                }
            ],
            "population": [
                {
                    "id": "178DA8D8-0694-4B88-8FFE-42CE671EEE35",
                    "code": {
                        "coding": [
                            {
                                "system": "http://terminology.hl7.org/CodeSystem/measure-population",
                                "code": "initial-population",
                                "display": "Initial Population"
                            }
                        ]
                    },
                    "count": 1
                },
                {
                    "id": "0AC3911A-2ADC-4DA4-BEBF-545FF8D6D819",
                    "code": {
                        "coding": [
                            {
                                "system": "http://terminology.hl7.org/CodeSystem/measure-population",
                                "code": "denominator",
                                "display": "Denominator"
                            }
                        ]
                    },
                    "count": 1
                },
                {
                    "id": "67EABB9C-ADCF-4593-A8DA-35FF25DA594C",
                    "code": {
                        "coding": [
                            {
                                "system": "http://terminology.hl7.org/CodeSystem/measure-population",
                                "code": "denominator-exclusion",
                                "display": "Denominator Exclusion"
                            }
                        ]
                    },
                    "count": 0
                },
                {
                    "id": "14B66980-07F4-4872-83AF-C425C379B971",
                    "code": {
                        "coding": [
                            {
                                "system": "http://terminology.hl7.org/CodeSystem/measure-population",
                                "code": "numerator",
                                "display": "Numerator"
                            }
                        ]
                    },
                    "count": 1
                }
            ],
            "measureScore": {
                "value": 1.0
            }
        }
    ],
    "evaluatedResource": [
        {
            "extension": [
                {
                    "url": "http://hl7.org/fhir/us/davinci-deqm/StructureDefinition/extension-criteriaReference",
                    "valueString": "178DA8D8-0694-4B88-8FFE-42CE671EEE35"
                },
                {
                    "url": "http://hl7.org/fhir/us/davinci-deqm/StructureDefinition/extension-criteriaReference",
                    "valueString": "0AC3911A-2ADC-4DA4-BEBF-545FF8D6D819"
                },
                {
                    "url": "http://hl7.org/fhir/us/davinci-deqm/StructureDefinition/extension-criteriaReference",
                    "valueString": "67EABB9C-ADCF-4593-A8DA-35FF25DA594C"
                },
                {
                    "url": "http://hl7.org/fhir/us/davinci-deqm/StructureDefinition/extension-criteriaReference",
                    "valueString": "9CB0299E-74B0-4425-8758-52D6FC0F979C"
                },
                {
                    "url": "http://hl7.org/fhir/us/davinci-deqm/StructureDefinition/extension-criteriaReference",
                    "valueString": "5C3ACF2A-15D2-44A0-A83D-F4FCC3E2F27A"
                },
                {
                    "url": "http://hl7.org/fhir/us/davinci-deqm/StructureDefinition/extension-criteriaReference",
                    "valueString": "8114BAD7-FAC8-4E22-91CB-33BC3DDB9986"
                }
            ],
            "reference": "Patient/numer-EXM130-Patient-1"
        },
        {
            "extension": [
                {
                    "url": "http://hl7.org/fhir/us/davinci-deqm/StructureDefinition/extension-criteriaReference",
                    "valueString": "178DA8D8-0694-4B88-8FFE-42CE671EEE35"
                },
                {
                    "url": "http://hl7.org/fhir/us/davinci-deqm/StructureDefinition/extension-criteriaReference",
                    "valueString": "0AC3911A-2ADC-4DA4-BEBF-545FF8D6D819"
                },
                {
                    "url": "http://hl7.org/fhir/us/davinci-deqm/StructureDefinition/extension-criteriaReference",
                    "valueString": "67EABB9C-ADCF-4593-A8DA-35FF25DA594C"
                }
            ],
            "reference": "Encounter/numer-EXM130-Encounter-1"
        },
        {
            "extension": [
                {
                    "url": "http://hl7.org/fhir/us/davinci-deqm/StructureDefinition/extension-criteriaReference",
                    "valueString": "14B66980-07F4-4872-83AF-C425C379B971"
                }
            ],
            "reference": "Procedure/numer-EXM130-1"
        }
    ]
}

23.3.6.0.2Example Measure Report Summary

Example requests and outputs with parameter reportType=population.

23.3.6.0.2.1Example Summary Request

GET http://your-server-base/fhir/Measure/BreastCancerScreeningFHIR/$evaluate-measure?periodStart=2019-01-01&periodEnd=2019-12-31&subject=numerator&reportType=population

23.3.6.0.2.2Example Summary Response

{
    "resourceType": "MeasureReport",
    "language": "en",
    "contained": [
        {
            "resourceType": "Observation",
            "id": "5203d419-bb0b-4fe5-b5a7-83f761b0f13e",
            "extension": [
                {
                    "url": "http://hl7.org/fhir/StructureDefinition/cqf-measureInfo",
                    "extension": [
                        {
                            "url": "measure",
                            "valueCanonical": "http://ecqi.healthit.gov/ecqms/Measure/ColorectalCancerScreeningsFHIR"
                        }
                    ]
                }
            ],
            "status": "final",
            "code": {
                "coding": [
                    {
                        "code": "F"
                    }
                ]
            },
            "valueInteger": 2
        },
        {
            "resourceType": "Observation",
            "id": "ccf81b4d-4440-44ef-91ff-101b0758eded",
            "extension": [
                {
                    "url": "http://hl7.org/fhir/StructureDefinition/cqf-measureInfo",
                    "extension": [
                        {
                            "url": "measure",
                            "valueCanonical": "http://ecqi.healthit.gov/ecqms/Measure/ColorectalCancerScreeningsFHIR"
                        }
                    ]
                }
            ],
            "status": "final",
            "code": {
                "coding": [
                    {
                        "code": "2135-2"
                    }
                ]
            },
            "valueInteger": 6
        },
        {
            "resourceType": "Observation",
            "id": "258b869e-b4da-441c-93d4-fc64c71bb49a",
            "extension": [
                {
                    "url": "http://hl7.org/fhir/StructureDefinition/cqf-measureInfo",
                    "extension": [
                        {
                            "url": "measure",
                            "valueCanonical": "http://ecqi.healthit.gov/ecqms/Measure/ColorectalCancerScreeningsFHIR"
                        }
                    ]
                }
            ],
            "status": "final",
            "code": {
                "coding": [
                    {
                        "code": "2028-9"
                    }
                ]
            },
            "valueInteger": 6
        },
        {
            "resourceType": "Observation",
            "id": "23995bb2-bc5e-4ff5-8509-17dacfe6b375",
            "extension": [
                {
                    "url": "http://hl7.org/fhir/StructureDefinition/cqf-measureInfo",
                    "extension": [
                        {
                            "url": "measure",
                            "valueCanonical": "http://ecqi.healthit.gov/ecqms/Measure/ColorectalCancerScreeningsFHIR"
                        }
                    ]
                }
            ],
            "status": "final",
            "code": {
                "coding": [
                    {
                        "code": "M"
                    }
                ]
            },
            "valueInteger": 4
        }
    ],
    "extension": [
        {
            "url": "http://hl7.org/fhir/5.0/StructureDefinition/extension-MeasureReport.population.description",
            "valueString": "Percentage of adults 50-75 years of age who had appropriate screening for colorectal cancer"
        },
        {
            "url": "http://hl7.org/fhir/5.0/StructureDefinition/extension-MeasureReport.supplementalDataElement.reference",
            "valueReference": {
                "extension": [
                    {
                        "url": "http://hl7.org/fhir/us/davinci-deqm/StructureDefinition/extension-criteriaReference",
                        "valueString": "5C3ACF2A-15D2-44A0-A83D-F4FCC3E2F27A"
                    }
                ],
                "reference": "#258b869e-b4da-441c-93d4-fc64c71bb49a"
            }
        },
        {
            "url": "http://hl7.org/fhir/5.0/StructureDefinition/extension-MeasureReport.supplementalDataElement.reference",
            "valueReference": {
                "extension": [
                    {
                        "url": "http://hl7.org/fhir/us/davinci-deqm/StructureDefinition/extension-criteriaReference",
                        "valueString": "8114BAD7-FAC8-4E22-91CB-33BC3DDB9986"
                    }
                ],
                "reference": "#23995bb2-bc5e-4ff5-8509-17dacfe6b375"
            }
        },
        {
            "url": "http://hl7.org/fhir/5.0/StructureDefinition/extension-MeasureReport.supplementalDataElement.reference",
            "valueReference": {
                "extension": [
                    {
                        "url": "http://hl7.org/fhir/us/davinci-deqm/StructureDefinition/extension-criteriaReference",
                        "valueString": "9CB0299E-74B0-4425-8758-52D6FC0F979C"
                    }
                ],
                "reference": "#ccf81b4d-4440-44ef-91ff-101b0758eded"
            }
        },
        {
            "url": "http://hl7.org/fhir/5.0/StructureDefinition/extension-MeasureReport.supplementalDataElement.reference",
            "valueReference": {
                "extension": [
                    {
                        "url": "http://hl7.org/fhir/us/davinci-deqm/StructureDefinition/extension-criteriaReference",
                        "valueString": "8114BAD7-FAC8-4E22-91CB-33BC3DDB9986"
                    }
                ],
                "reference": "#5203d419-bb0b-4fe5-b5a7-83f761b0f13e"
            }
        }
    ],
    "status": "complete",
    "type": "summary",
    "measure": "http://ecqi.healthit.gov/ecqms/Measure/ColorectalCancerScreeningsFHIR|0.0.003",
    "date": "2024-03-05T19:33:25+00:00",
    "period": {
        "start": "2023-01-01T00:00:00+00:00",
        "end": "2023-12-31T23:59:59+00:00"
    },
    "improvementNotation": {
        "coding": [
            {
                "system": "http://terminology.hl7.org/CodeSystem/measure-improvement-notation",
                "code": "increase"
            }
        ]
    },
    "group": [
        {
            "extension": [
                {
                    "url": "http://hl7.org/fhir/us/davinci-deqm/StructureDefinition/extension-cqfm-denominator-membership",
                    "valueString": "2"
                },
                {
                    "url": "http://hl7.org/fhir/us/davinci-deqm/StructureDefinition/extension-cqfm-numerator-membership",
                    "valueString": "1"
                }
            ],
            "population": [
                {
                    "id": "178DA8D8-0694-4B88-8FFE-42CE671EEE35",
                    "code": {
                        "coding": [
                            {
                                "system": "http://terminology.hl7.org/CodeSystem/measure-population",
                                "code": "initial-population",
                                "display": "Initial Population"
                            }
                        ]
                    },
                    "count": 2
                },
                {
                    "id": "0AC3911A-2ADC-4DA4-BEBF-545FF8D6D819",
                    "code": {
                        "coding": [
                            {
                                "system": "http://terminology.hl7.org/CodeSystem/measure-population",
                                "code": "denominator",
                                "display": "Denominator"
                            }
                        ]
                    },
                    "count": 2
                },
                {
                    "id": "67EABB9C-ADCF-4593-A8DA-35FF25DA594C",
                    "code": {
                        "coding": [
                            {
                                "system": "http://terminology.hl7.org/CodeSystem/measure-population",
                                "code": "denominator-exclusion",
                                "display": "Denominator Exclusion"
                            }
                        ]
                    },
                    "count": 0
                },
                {
                    "id": "14B66980-07F4-4872-83AF-C425C379B971",
                    "code": {
                        "coding": [
                            {
                                "system": "http://terminology.hl7.org/CodeSystem/measure-population",
                                "code": "numerator",
                                "display": "Numerator"
                            }
                        ]
                    },
                    "count": 1
                }
            ],
            "measureScore": {
                "value": 0.5
            }
        }
    ]
}

23.3.6.0.3Example Measure Report Subject-List

Example requests and outputs with parameter reportType=subject-list.

23.3.6.0.3.1Example Subject-List Request

GET http://your-server-base/fhir/Measure/ColorectalCancerScreeningsFHIR/$evaluate-measure?periodStart=2023-01-01&periodEnd=2023-12-31&reportType=subject-list&subject=Patient/numer-EXM130-Patient-1

23.3.6.0.3.2Example Subject-List Response

{
    "resourceType": "MeasureReport",
    "language": "en",
    "contained": [
        {
            "resourceType": "Observation",
            "id": "9ed35e34-9270-49e2-bf71-ca979fb2bcbf",
            "extension": [
                {
                    "url": "http://hl7.org/fhir/StructureDefinition/cqf-measureInfo",
                    "extension": [
                        {
                            "url": "measure",
                            "valueCanonical": "http://ecqi.healthit.gov/ecqms/Measure/ColorectalCancerScreeningsFHIR"
                        }
                    ]
                }
            ],
            "status": "final",
            "code": {
                "coding": [
                    {
                        "code": "2135-2"
                    }
                ]
            },
            "valueInteger": 1
        },
        {
            "resourceType": "List",
            "id": "d11fe780-66e2-4ab5-aff6-63028665114a",
            "entry": [
                {
                    "item": {
                        "reference": "numer-EXM130-Patient-1"
                    }
                }
            ]
        },
        {
            "resourceType": "Observation",
            "id": "428128d9-9e4f-4fe5-999f-b2748032c5dd",
            "extension": [
                {
                    "url": "http://hl7.org/fhir/StructureDefinition/cqf-measureInfo",
                    "extension": [
                        {
                            "url": "measure",
                            "valueCanonical": "http://ecqi.healthit.gov/ecqms/Measure/ColorectalCancerScreeningsFHIR"
                        }
                    ]
                }
            ],
            "status": "final",
            "code": {
                "coding": [
                    {
                        "code": "2028-9"
                    }
                ]
            },
            "valueInteger": 1
        },
        {
            "resourceType": "List",
            "id": "ca82c41b-e668-477d-80ae-b545986e013f",
            "entry": [
                {
                    "item": {
                        "reference": "numer-EXM130-Patient-1"
                    }
                }
            ]
        },
        {
            "resourceType": "List",
            "id": "80873504-6c9b-4d85-a0de-2b8c36962327",
            "entry": [
                {
                    "item": {
                        "reference": "numer-EXM130-Patient-1"
                    }
                }
            ]
        },
        {
            "resourceType": "Observation",
            "id": "56a28519-939e-41bd-99c9-1e6fddf600da",
            "extension": [
                {
                    "url": "http://hl7.org/fhir/StructureDefinition/cqf-measureInfo",
                    "extension": [
                        {
                            "url": "measure",
                            "valueCanonical": "http://ecqi.healthit.gov/ecqms/Measure/ColorectalCancerScreeningsFHIR"
                        }
                    ]
                }
            ],
            "status": "final",
            "code": {
                "coding": [
                    {
                        "code": "M"
                    }
                ]
            },
            "valueInteger": 1
        }
    ],
    "extension": [
        {
            "url": "http://hl7.org/fhir/5.0/StructureDefinition/extension-MeasureReport.population.description",
            "valueString": "Percentage of adults 50-75 years of age who had appropriate screening for colorectal cancer"
        },
        {
            "url": "http://hl7.org/fhir/5.0/StructureDefinition/extension-MeasureReport.supplementalDataElement.reference",
            "valueReference": {
                "extension": [
                    {
                        "url": "http://hl7.org/fhir/us/davinci-deqm/StructureDefinition/extension-criteriaReference",
                        "valueString": "8114BAD7-FAC8-4E22-91CB-33BC3DDB9986"
                    }
                ],
                "reference": "#56a28519-939e-41bd-99c9-1e6fddf600da"
            }
        },
        {
            "url": "http://hl7.org/fhir/5.0/StructureDefinition/extension-MeasureReport.supplementalDataElement.reference",
            "valueReference": {
                "extension": [
                    {
                        "url": "http://hl7.org/fhir/us/davinci-deqm/StructureDefinition/extension-criteriaReference",
                        "valueString": "9CB0299E-74B0-4425-8758-52D6FC0F979C"
                    }
                ],
                "reference": "#9ed35e34-9270-49e2-bf71-ca979fb2bcbf"
            }
        },
        {
            "url": "http://hl7.org/fhir/5.0/StructureDefinition/extension-MeasureReport.supplementalDataElement.reference",
            "valueReference": {
                "extension": [
                    {
                        "url": "http://hl7.org/fhir/us/davinci-deqm/StructureDefinition/extension-criteriaReference",
                        "valueString": "5C3ACF2A-15D2-44A0-A83D-F4FCC3E2F27A"
                    }
                ],
                "reference": "#428128d9-9e4f-4fe5-999f-b2748032c5dd"
            }
        }
    ],
    "status": "complete",
    "type": "subject-list",
    "measure": "http://ecqi.healthit.gov/ecqms/Measure/ColorectalCancerScreeningsFHIR|0.0.003",
    "date": "2024-03-05T19:31:47+00:00",
    "period": {
        "start": "2023-01-01T00:00:00+00:00",
        "end": "2023-12-31T23:59:59+00:00"
    },
    "improvementNotation": {
        "coding": [
            {
                "system": "http://terminology.hl7.org/CodeSystem/measure-improvement-notation",
                "code": "increase"
            }
        ]
    },
    "group": [
        {
            "extension": [
                {
                    "url": "http://hl7.org/fhir/us/davinci-deqm/StructureDefinition/extension-cqfm-denominator-membership",
                    "valueString": "1"
                },
                {
                    "url": "http://hl7.org/fhir/us/davinci-deqm/StructureDefinition/extension-cqfm-numerator-membership",
                    "valueString": "1"
                }
            ],
            "population": [
                {
                    "id": "178DA8D8-0694-4B88-8FFE-42CE671EEE35",
                    "code": {
                        "coding": [
                            {
                                "system": "http://terminology.hl7.org/CodeSystem/measure-population",
                                "code": "initial-population",
                                "display": "Initial Population"
                            }
                        ]
                    },
                    "count": 1,
                    "subjectResults": {
                        "reference": "#d11fe780-66e2-4ab5-aff6-63028665114a"
                    }
                },
                {
                    "id": "0AC3911A-2ADC-4DA4-BEBF-545FF8D6D819",
                    "code": {
                        "coding": [
                            {
                                "system": "http://terminology.hl7.org/CodeSystem/measure-population",
                                "code": "denominator",
                                "display": "Denominator"
                            }
                        ]
                    },
                    "count": 1,
                    "subjectResults": {
                        "reference": "#80873504-6c9b-4d85-a0de-2b8c36962327"
                    }
                },
                {
                    "id": "67EABB9C-ADCF-4593-A8DA-35FF25DA594C",
                    "code": {
                        "coding": [
                            {
                                "system": "http://terminology.hl7.org/CodeSystem/measure-population",
                                "code": "denominator-exclusion",
                                "display": "Denominator Exclusion"
                            }
                        ]
                    },
                    "count": 0
                },
                {
                    "id": "14B66980-07F4-4872-83AF-C425C379B971",
                    "code": {
                        "coding": [
                            {
                                "system": "http://terminology.hl7.org/CodeSystem/measure-population",
                                "code": "numerator",
                                "display": "Numerator"
                            }
                        ]
                    },
                    "count": 1,
                    "subjectResults": {
                        "reference": "#ca82c41b-e668-477d-80ae-b545986e013f"
                    }
                }
            ],
            "measureScore": {
                "value": 1.0
            }
        }
    ]
}

23.3.7Measure Report Populations And Scores

 

When looking at single-rate or Multi-rate (more than one group) measures that have been evaluated it is important to understand what you are looking at in the counts for each population.

We learned in population-basis that this could represent a patient resource or represent resources of a subject like an encounter, but each population is not simply a raw expression output of CQL, each scoring-method defines the structure of each Measure Report as well as how population membership is evaluated and scored.

These scoring algorithms are defined in the following IG.

The intent of the MeasureReport population counts is to display how each population was evaluated to the scoring algorithm for the specified scoring type. Allowing end users the ability to compute the measure "score" using the values from population counts.

If a user ever needed to understand the raw output of a population expression, as a means to audit the algorithm, they could use the available Library $evaluate operation.

The tables below express in set logic how each scoring method would evaluate from raw CQL expression output to eventual "score".

  • MeasureReport Populations - population names found in Measure Report
  • Criteria Expression Result Set - Set representation of criteria expression output, raw results
  • Evaluated Population Membership Set - Set representation of evaluator algorithm
  • Criteria Expression Result Count - Count representation of criteria expression output, raw results
  • Evaluated Population Membership Count representation of evaluator algorithm, the values shown on report

23.3.7.1Proportion & Ratio Measure

MeasureReport PopulationsCriteria Expression Result SetEvaluated Population Membership SetCriteria Expression Result CountEvaluated Population Membership Count
Initial PopulationA,B,C,D,EA,B,C,D,E55
DenominatorA,B,C,D,EB,E52
Denominator ExclusionAA11
Denominator Exception*B,CC21
Numerator ExclusionDD11
NumeratorB,D,EB,E32
TotalDenominator*B,EB,E 2
TotalNumerator*B,EB,E 2
MeasureScore 1.0
  • Denominator Exception does not apply to Ratio measures
  • TotalDenominator and TotalNumerator are also available extensions in CDR that show the final values used to calculate measureScore.

23.3.7.2Continuous Variable Measure

MeasureReport PopulationsCriteria Expression Result SetEvaluated Population Membership SetCriteria Expression Result CountEvaluated Population Membership Count
InitialPopulationA,B,C,D,EA,B,C,D,E55
MeasurePopulationA,B,C,D,EB,C,D,E54
MeasurePopulationExclusionAA11
Observation*NAB11
TotalMeasurePopulation 4

23.3.7.3Cohort Measure

MeasureReport PopulationsCriteria Expression Result SetEvaluated Population Membership SetCriteria Expression Result CountEvaluated Population Membership Count
InitialPopulationA,B,C,D,EA,B,C,D,E55
MeasureScore NA

23.3.8Multiple Measure Evaluation

 

The $evaluate-measures operation is used to execute more than one measure resource per selected subject population. This behaves similarly to the $evalaute-measure operation in that it has a "Distributed" and "Standard" mode for low latency and batch processing, but returns a Bundle resource instead of a MeasureReport resource.

This is designed to assist any users that will perform the measure evaluations for the same population against multiple measures.

  • One use case could be evaluating a provider's population against a specialty measurement-set. Instead of multiple requests of $evaluate-measure, one for each measure, you can now have a single request to $evaluate-measures that contains all run results in a contained bundle resource.

23.3.9Multiple Measure Operation Parameters

 
ParameterSupportedDescription
measureIdsthe IDs of the Measure to evaluate
periodStartThe start of the reporting period
periodEndThe end of the reporting period
reportTypeThe type of measure report: subject, subject-list, or population. If not specified, a default value of subject will be used if the subject parameter is supplied, otherwise, population will be used
subjectSubject for which the measure will be calculated. If not specified, the measure will be calculated for all subjects that meet the requirements of the measure. If specified, the measure will only be calculated for the referenced subject(s)
practitionerPractitioner for which the measure will be calculated. If specified, the measure will be calculated only for subjects that have a primary relationship to the identified practitioner
productLinethe productLine (e.g. Medicare, Medicaid, etc) to use for the evaluation. This is a non-standard parameter
additional Datathe data bundle containing additional data
terminology Endpoint
parametersAny input parameters for the evaluation. Parameters defined in this input will be made available by name to the CQL expression. Parameter types are mapped to CQL as specified in the Using CQL topic of the Clinical Reasoning Module. If a parameter appears more than once in the input Parameters resource, it is represented with a List in the input CQL. If a parameter has parts, it is represented as a Tuple in the input CQL.
reporteroptional parameter to pass in a reference to a resource that the user would like to have populated on Measure Report reporter field.

23.3.9.1Bundle of Measure Reports

For each measureIds parameter added to the operation request, a subsequent Measure Report resource will be added to the returned Bundle resource created by $evaluate-measures request.

For example, in order to evaluate six measure resources for a selected population (subject or practitioner parameters), then the operation will evaluate that same population against each of those measures and return a single Measure Report back for each passed in Measure.id.

23.3.9.2Measure Report Reporter Parameter

This feature also allows for an additional parameter to the standard $evaluate-measure, allowing callers to pass in a compliant resource for Measure Report reporter.

This can be used instead of dQM module configurations for default reporter and/or use Group Managing Entity.

  • The reporter parameter will override these configurations (if set), and persist the parameter value to each Measure Report created.

23.3.9.3Multiple Measure Evaluation Example Request

  • "Standard" Mode Request
GET fhir/Measure/$evaluate-measures?practitioner=Practitioner/XYZ?reporter=Organization/123?measureIds=<MeasureId-1>?measureIds=<MeasureId-2>?measureIds=<MeasureId-3>
  • "Distributed" Mode Request
GET fhir/Measure/$evaluate-measures?practitioner=Practitioner/XYZ?reporter=Organization/123?measureIds=<MeasureId-1>?measureIds=<MeasureId-2>?measureIds=<MeasureId-3>
Prefer: respond-async

23.3.9.4Multiple Measure Evaluation Example Response

  • "Distributed" Mode Response - pending
{
	"resourceType": "Bundle",
	"id": "bundle-id",
	"identifier": {
		"value": "measure-eval-job-id-<job-id>"
	},
	"type": "collection",
	"entry": [
		{
			"fullUrl": "http://localhost:8000/MeasureReport/<id>",
			"resource": {
				"resourceType": "MeasureReport",
				"id": "<id>",
				"extension": [
					{
						"url": "http://smilecdr.com/fhir/StructureDefinition/extension-MeasureReport.measureId",
						"valueString": "<MeasureId-1>"
					},
					{
						"url": "http://smilecdr.com/fhir/StructureDefinition/extension-MeasureReport.measureTitle",
						"valueString": "<MeasureId-1-Title>"
					}
				],
				"status": "pending",
				"measure": "url/Measure/<MeasureId-1>",
			}
		},
		{
			"fullUrl": "http://localhost:8000/MeasureReport/<id>",
			"resource": {
				"resourceType": "MeasureReport",
				"id": "<id>",
				"extension": [
					{
						"url": "http://smilecdr.com/fhir/StructureDefinition/extension-MeasureReport.measureId",
						"valueString": "<MeasureId-2>"
					},
					{
						"url": "http://smilecdr.com/fhir/StructureDefinition/extension-MeasureReport.measureTitle",
						"valueString": "<MeasureId-2-Title>"
					}
				],
				"status": "pending",
				"measure": "url/Measure/<MeasureId-2>"
			}
		},
		{
			"fullUrl": "http://localhost:8000/MeasureReport/<id>",
			"resource": {
				"resourceType": "MeasureReport",
				"id": "<id>",
				"extension": [
					{
						"url": "http://smilecdr.com/fhir/StructureDefinition/extension-MeasureReport.measureId",
						"valueString": "<MeasureId-3>"
					},
					{
						"url": "http://smilecdr.com/fhir/StructureDefinition/extension-MeasureReport.measureTitle",
						"valueString": "<MeasureId-3-Title>"
					}
				],
				"status": "pending",
				"measure": "url/Measure/<MeasureId-3>"
			}
		}
	]
}
  • "Distributed" Mode Response - complete
    • bundle and report(s) do persist
{
	"resourceType": "Bundle",
	"id": "bundle-id",
	"identifier": {
		"value": "measure-eval-job-id-<job-id>"
	},
	"type": "collection",
	"entry": [
		{
			"fullUrl": "http://localhost:8000/MeasureReport/<id>",
			"resource": {
				"resourceType": "MeasureReport",
				"id": "<id>",
				"extension": [
					{
						"url": "http://smilecdr.com/fhir/StructureDefinition/extension-MeasureReport.measureId",
						"valueString": "<MeasureId-1>"
					},
					{
						"url": "http://smilecdr.com/fhir/StructureDefinition/extension-MeasureReport.measureTitle",
						"valueString": "<MeasureId-1-Title>"
					}
				],
				"status": "complete",
				"measure": "url/Measure/<MeasureId-1>",
				"date": "2024-05-16T11:51:02-06:00",
				"reporter": {
					"reference": "Organization/123"
				},
				"subject": {
					"reference": "Practitioner/XYZ"
				},
				"period": {
					"start": "2023-01-01T00:00:00-07:00",
					"end": "2023-12-31T23:59:59-07:00"
				}
			}
		},
		{
			"fullUrl": "http://localhost:8000/MeasureReport/<id>",
			"resource": {
				"resourceType": "MeasureReport",
				"id": "<id>",
				"extension": [
					{
						"url": "http://smilecdr.com/fhir/StructureDefinition/extension-MeasureReport.measureId",
						"valueString": "<MeasureId-2>"
					},
					{
						"url": "http://smilecdr.com/fhir/StructureDefinition/extension-MeasureReport.measureTitle",
						"valueString": "<MeasureId-2-Title>"
					}
				],
				"status": "complete",
				"measure": "url/Measure/<MeasureId-2>",
				"date": "2024-05-16T11:51:02-06:00",
				"reporter": {
					"reference": "Organization/123"
				},
				"subject": {
					"reference": "Practitioner/XYZ"
				},
				"period": {
					"start": "2023-01-01T00:00:00-07:00",
					"end": "2023-12-31T23:59:59-07:00"
				}
			}
		},
		{
			"fullUrl": "http://localhost:8000/MeasureReport/<id>",
			"resource": {
				"resourceType": "MeasureReport",
				"id": "<id>",
				"extension": [
					{
						"url": "http://smilecdr.com/fhir/StructureDefinition/extension-MeasureReport.measureId",
						"valueString": "<MeasureId-3>"
					},
					{
						"url": "http://smilecdr.com/fhir/StructureDefinition/extension-MeasureReport.measureTitle",
						"valueString": "<MeasureId-3-Title>"
					}
				],

				"status": "complete",
				"measure": "url/Measure/<MeasureId-3>",
				"date": "2024-05-16T11:51:02-06:00",
				"reporter": {
					"reference": "Organization/123"
				},
				"subject": {
					"reference": "Practitioner/XYZ"
				},
				"period": {
					"start": "2023-01-01T00:00:00-07:00",
					"end": "2023-12-31T23:59:59-07:00"
				}
			}
		}
	]
}
  • "Standard" Mode Response - complete
    • bundle and report(s) do not persist, returns Bundle Type SearchSet instead of Collection
{
	"resourceType": "Bundle",
	"id": "bundle-id",
	"type": "searchset",
	"entry": [
		{
			"fullUrl": "http://localhost:8000/MeasureReport/<id>",
			"resource": {
				"resourceType": "MeasureReport",
				"id": "<id>",
				"extension": [
					{
						"url": "http://smilecdr.com/fhir/StructureDefinition/extension-MeasureReport.measureId",
						"valueString": "<MeasureId-1>"
					},
					{
						"url": "http://smilecdr.com/fhir/StructureDefinition/extension-MeasureReport.measureTitle",
						"valueString": "<MeasureId-1-Title>"
					}
				],
				"status": "complete",
				"measure": "url/Measure/<MeasureId-1>",
				"date": "2024-05-16T11:51:02-06:00",
				"reporter": {
					"reference": "Organization/123"
				},
				"subject": {
					"reference": "Practitioner/XYZ"
				},
				"period": {
					"start": "2023-01-01T00:00:00-07:00",
					"end": "2023-12-31T23:59:59-07:00"
				}
			}
		},
		{
			"fullUrl": "http://localhost:8000/MeasureReport/<id>",
			"resource": {
				"resourceType": "MeasureReport",
				"id": "<id>",
				"extension": [
					{
						"url": "http://smilecdr.com/fhir/StructureDefinition/extension-MeasureReport.measureId",
						"valueString": "<MeasureId-2>"
					},
					{
						"url": "http://smilecdr.com/fhir/StructureDefinition/extension-MeasureReport.measureTitle",
						"valueString": "<MeasureId-2-Title>"
					}
				],
				"status": "complete",
				"measure": "url/Measure/<MeasureId-2>",
				"date": "2024-05-16T11:51:02-06:00",
				"reporter": {
					"reference": "Organization/123"
				},
				"subject": {
					"reference": "Practitioner/XYZ"
				},
				"period": {
					"start": "2023-01-01T00:00:00-07:00",
					"end": "2023-12-31T23:59:59-07:00"
				}
			}
		},
		{
			"fullUrl": "http://localhost:8000/MeasureReport/<id>",
			"resource": {
				"resourceType": "MeasureReport",
				"id": "<id>",
				"extension": [
					{
						"url": "http://smilecdr.com/fhir/StructureDefinition/extension-MeasureReport.measureId",
						"valueString": "<MeasureId-3>"
					},
					{
						"url": "http://smilecdr.com/fhir/StructureDefinition/extension-MeasureReport.measureTitle",
						"valueString": "<MeasureId-3-Title>"
					}
				],

				"status": "complete",
				"measure": "url/Measure/<MeasureId-3>",
				"date": "2024-05-16T11:51:02-06:00",
				"reporter": {
					"reference": "Organization/123"
				},
				"subject": {
					"reference": "Practitioner/XYZ"
				},
				"period": {
					"start": "2023-01-01T00:00:00-07:00",
					"end": "2023-12-31T23:59:59-07:00"
				}
			}
		}
	]
}

23.3.10Standard Evaluate Measure

 

The $evaluate-measure operation is used to execute a Measure as specified by the relevant FHIR Resources against a subject or set of subjects. This implementation currently focuses primarily on supporting the narrower evaluation requirements defined by the CQF Measures IG. Some support for extensions defined by other IGs is included as well, and the implementation aims to support a wider range of functionality in the future.

23.3.10.0.1Standard Evaluate Measure Example Request

Several example Measures are available in the ecqm-content-r4 IG. Full Bundles with all the required supporting resources are available here. You can download a Bundle and load it on your server as a transaction:

POST http://your-server-base/fhir BreastCancerScreeningFHIR-bundle.json

These Bundles also include example Patient clinical data so once posted Measure evaluation can be invoked with:

GET http://your-server-base/fhir/Measure/BreastCancerScreeningFHIR/$evaluate-measure?periodStart=2019-01-01&periodEnd=2019-12-31&subject=numerator&reportType=subject

23.3.11Distributed Evaluate Measure

 

23.3.11.0.1Overview

CDR offers an exclusive enhancement to the evaluate-measure operation to allow it to work at scale with significantly larger patient populations. This enhanced version is called "Distributed" mode that leans on CDR's ability to perform parallel processing of larger workloads.

The open-source available "standard" mode allows for performant low-latency response on smaller populations.

To take advantage this functionality you need to have a clustered Smile CDR deployment (see Clustering for more information) and a premium license for the DQM module (see Licensing for more information).

23.3.11.0.2Requirements

  • Distributed evaluate-measure has requirements to merge Measure Reports that get generated in parallel, and in order to perform this, there are different profile requirements to allow this to happen.
  • Multi-Rate Measures with >1 Groups or Stratifiers require an id be populated so merge logic can uniquely relate data elements together. If your resource does not have this, the operation will give you an error.

23.3.11.0.3Distributed Mode Configurations

  • Distributed mode breaks workloads into manageable pieces for parallel processing and exposes options to users to configure optimally to their deployment model.

23.3.11.0.4Distributed Workflow

diagram

23.3.11.0.4.1Work Chunk Size

  • Controls the size of the "subject chunks" created from the population that was queried.
  • If the configuration was set to 1000 and the total population of subjects retrieved was 10,000. Then 10 subject chunks would be created for processing.

See here for Dqm Module Configuration Categories

23.3.11.0.4.2Multi-Threading Options

  • On the evaluate work chunks step, a received work chunk can be additionally parallelized within each evaluation step. This can be optimally set when you have a parallel distribution of Smile CDR and can take advantage of available cores.

See here for Dqm Module Configuration Categories

23.3.11.0.4.2.1Enable Threading
  • This configuration controls whether or not to process multiple threads of a chunk or to process as is. If enabled, the work chunk will attempt to process in parallel.

See here for Dqm Module Configuration Categories

23.3.11.0.4.2.2Number of Threads
  • If Smile CDR is running on multiple cores, you can additionally saturate processing capacity to available computing.
  • If you want to saturate all available cores on a 4 core deployment of smile CDR, then set to 4 to use all available cores.

See here for Dqm Module Configuration Categories

23.3.11.0.4.2.3Threaded Batch Size
  • Similar to Work Chunk Size, users can set the chunk size for each thread to process.
  • Example, Work Chunk Size=1000, Thread Batch size=250, and Number of threads=4 with a total population of 10,000 subjects.
    • The process would create 10 work chunks
    • Then create 4 thread batches for each work chunk, totalling 40 thread batches

See here for Dqm Module Configuration Categories

23.3.11.0.5User Interface for Requested Jobs

  • Once a 'Distributed Evaluation' is requested from the server, it is viewable via CDR Admin Web Console, under the RunTime/Batch Jobs menu.
  • This will allow you to view progress, kill an ongoing request, and view metadata from the request.

23.3.11.0.6Example Distributed Request

  • The format follows the same parameter convention as Standard mode, but requires an additional header of prefer: respond-async. If done correctly, you will receive back a report in "Pending" status.
GET fhir/Measure/<MeasureId>/$evaluate-measure?practitioner=Practitioner/XYZ
Prefer: response-async

23.3.11.0.7Example In-Progress Response

  • Measure Report returned
{
    "resourceType": "MeasureReport",
    "id": "c365bc0a-7b76-4869-a99f-71c8c5a1ffb3",
    "meta": {
        "versionId": "1",
        "lastUpdated": "2024-03-04T09:35:08.802-07:00",
        "source": "#pvlOpkXdI88TcUUV"
    },
    "extension": [
        {
            "url": "http://smilecdr.com/fhir/StructureDefinition/extension-MeasureReport.jobId",
            "valueString": "2849ef30-66cb-4f75-add0-110479e2f365"
        },
        {
            "url": "http://smilecdr.com/fhir/StructureDefinition/extension-MeasureReport.measureId",
            "valueString": "Measure/ColorectalCancerScreeningsFHIR"
        },
        {
            "url": "http://smilecdr.com/fhir/StructureDefinition/extension-MeasureReport.measureTitle",
            "valueString": "Colorectal Cancer ScreeningFHIR"
        }
    ],
    "status": "pending",
    "date": "2024-03-04T09:35:08-07:00"
}

23.3.11.0.8Example Retrieve Completed Report

  • Once the report is completed, it will be available on the MeasureReport.id provided in the 'In-Progress' state. The id is also visible via CDR Admin Web Console Batch jobs screen.
    • Here is an example request with the MeasureReport.id populated.
GET fhir/MeasureReport/c365bc0a-7b76-4869-a99f-71c8c5a1ffb3
  • Generic Request
GET fhir/MeasureReport/<MeasureReport.id>

23.3.11.0.9Measure Report Reporter

  • Measure Report reporter field indicates who created the report. When using Standard mode it will not be populated, but in Distributed mode it can be populated from passed in operation resources or by defaulting it on module configuration.

23.3.11.0.9.1Defaulting Measure Report Reporter

Measure Report default reporter configuration in the DQM Module is meant to be set as a reference to an Organization Resource that you want to show on your Measure Reports.

To populate this, just add the Organization.id value to the configuration field in the Web Admin Console while in the DQM Module.

See here for Dqm Module Configuration Categories

23.3.11.0.9.2Use Group Managing Entity for Measure Report Reporter

If configuration is set to true, MeasureReport.reporter field will attempt to source MeasureReport.reporter from evaluate-measure subject or practitioner parameter.

If a Group resource is used for the parameter and has a populated managingEntity reference to an Organization. It will use this value instead of the value saved to Measure Report default reporter configuration.

See here for Dqm Module Configuration Categories

23.3.12Spark Evaluate-Measure

 

Spark Evaluate-Measure provides a premium Big Data processing solution for Quality Measure Evaluations that relies on scaled out parallel processing using a spark compute cluster. This solution is meant to compliment Distributed Measure-Evaluation by giving a larger ceiling of processing power for population scale Quality Measure queries with 100's of Millions to Billions of resources.

It also provides the ability to perform multi-measure processing where users have the option to process as many measures as needed with the same patient population.

23.3.13CMS Quality Reporting

 

In order to bridge capability between generating Quality Measure Reporting in FHIR and being able to submit Measure Reports to CMS, we have a built in operation that transforms FHIR into Quality Payment Program (QPP) JSON format.

For more information see QPP Reporting.

23.3.14Measure Data Requirements Operation

 

The data-requirements operation aggregates and returns the parameters and data requirements for the measure and all its dependencies as a single module definition.

23.3.14.1Data Requirements Parameters

ParameterSupportedDescription
Idthe id of the Measure to evaluate
PeriodStartThe start of the reporting period
PeriodEndThe end of the reporting period

23.3.14.2Example Data Requirements Request

GET fhir/Measure/<measureID>/$data-requirements?periodStart=2014&periodEnd=2014

23.3.14.3Example Data Requirements Response

{
  "resourceType": "Library",
  "type": {
    "coding": [
      {
        "code": "module-definition"
      }
    ]
  },
  "relatedArtifact": [
    {
      "type": "depends-on",
      "resource": "Library/library-quick-model-definition"
    }
  ],
  "dataRequirement": [
    {
      "type": "Condition",
      "codeFilter": [
        {
          "path": "code",
          "valueSetString": "Other Female Reproductive Conditions"
        }
      ]
    },
    {
      "type": "Patient"
    },
    {
      "type": "Condition",
      "codeFilter": [
        {
          "path": "category",
          "valueCode": [
            "diagnosis"
          ]
        },
        {
          "path": "clinicalStatus",
          "valueCode": [
            "confirmed"
          ]
        },
        {
          "path": "code",
          "valueSetString": "2.16.840.1.113883.3.464.1003.102.12.1011"
        }
      ]
    },
    {
      "type": "Condition",
      "codeFilter": [
        {
          "path": "category",
          "valueCode": [
            "diagnosis"
          ]
        },
        {
          "path": "clinicalStatus",
          "valueCode": [
            "confirmed"
          ]
        },
        {
          "path": "code",
          "valueSetString": "2.16.840.1.113883.3.464.1003.102.12.1012"
        }
      ]
    },
    {
      "type": "Encounter",
      "codeFilter": [
        {
          "path": "status",
          "valueCode": [
            "finished"
          ]
        },
        {
          "path": "class",
          "valueCode": [
            "ambulatory"
          ]
        },
        {
          "path": "type",
          "valueSetString": "2.16.840.1.113883.3.464.1003.101.12.1061"
        }
      ]
    },
    {
      "type": "DiagnosticReport",
      "codeFilter": [
        {
          "path": "diagnosis",
          "valueSetString": "2.16.840.1.113883.3.464.1003.198.12.1012"
        }
      ]
    },
    {
      "type": "Medication",
      "codeFilter": [
        {
          "path": "code",
          "valueSetString": "2.16.840.1.113883.3.464.1003.196.12.1001"
        }
      ]
    },
    {
      "type": "MedicationRequest",
      "codeFilter": [
        {
          "path": "status",
          "valueCode": [
            "active"
          ]
        },
        {
          "path": "medication.code",
          "valueSetString": "2.16.840.1.113883.3.464.1003.196.12.1001"
        }
      ]
    },
    {
      "type": "MedicationStatement",
      "codeFilter": [
        {
          "path": "status",
          "valueCode": [
            "completed"
          ]
        },
        {
          "path": "medication.code",
          "valueSetString": "2.16.840.1.113883.3.464.1003.196.12.1001"
        }
      ]
    }
  ]
}

23.3.15Measure Collect Data Operation

 

The collect-data operation is used to collect the data-of-interest for the given measure.

23.3.15.1Collect Data Parameters

ParameterSupportedDescription
Idthe id of the Measure
PeriodStartThe start of the reporting period
PeriodEndThe end of the reporting period
SubjectSubject for which the measure will be calculated. If not specified, the measure will be calculated for all subjects that meet the requirements of the measure. If specified, the measure will only be calculated for the referenced subject(s)
PractitionerPractitioner for which the measure will be calculated. If specified, the measure will be calculated only for subjects that have a primary relationship to the identified practitioner
LastReceivedOn The date the results of this measure were last received. This parameter is only valid for patient-level reports and is used to indicate when the last time a result for this patient was received. This information can be used to limit the set of resources returned for a patient-level report

23.3.15.2Example Collect Data Request

  • Practitioner example
GET fhir/Measure/<MeasureId>/$collect-data?practitioner=Practitioner/XYZ&periodStart=2023-01-01&periodEnd=2023-12-31
  • Patient Subject example
GET fhir/Measure/<MeasureId>/$collect-data?subject=Patient/XYZ&periodStart=2023-01-01&periodEnd=2023-12-31
  • Group Subject example
GET fhir/Measure/<MeasureId>/$collect-data?subject=Group/XYZ&periodStart=2023-01-01&periodEnd=2023-12-31

23.3.15.3Example Collect Data Response

  • example response
  {
  "resourceType": "Parameters",
  "parameter": [
    {
      "name": "measureReport",
      "resource": {
		  "resourceType": "MeasureReport",
		  "status": "complete",
		  "type": "data-collection",
		  "measure": "Measure/measure-mrp",
		  "patient": {
			"reference": "Patient/Practitioner-2178"
		  },
		  "period": {
			"start": "2017-01-01T00:00:00+00:00",
			"end": "2017-12-31T00:00:00+00:00"
		  },
		  "evaluatedResource": [
			  {
				"reference": "Patient/Practitioner-2178"
			  },
			  {
				"reference": "Encounter/Encounter-62912"
			  },
			  {
				"reference": "Procedure/Procedure-89972"
			  }
		  ]
		}
	},
	{
      "name": "resource",
      "resource": {
        "resourceType": "Patient",
        "id": "Practitioner-2178",
        "meta": {
          "versionId": "8",
          "lastUpdated": "2018-05-31T07:15:08.000+00:00",
          "profile": [
            "http://hl7.org/fhir/us/hedis/StructureDefinition/hedis-patient"
          ]
        },
        "text": {
          "status": "generated",
          "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><div class=\"hapiHeaderText\">Natalie Huff <b>WALTER </b></div><table class=\"hapiPropertyTable\"><tbody><tr><td>Identifier</td><td>000002418</td></tr><tr><td>Address</td><td><span>623 SW French Place </span><br/><span>Westland </span><span>MI </span></td></tr><tr><td>Date of birth</td><td><span>26 July 1974</span></td></tr></tbody></table></div>"
        },
        "extension": [
          {
            "url": "http://mihin.org/extension/copyright",
            "valueString": "Copyright 2014-2017 Michigan Health Information Network Shared Services. Licensed under the Apache License, Version 2.0 (the 'License'); you can not use this file except in compliance with the License. You can obtain a copy of the License at  http://www.apache.org/licenses/LICENSE-2.0.  Unless required by applicable law or agreed to in writing, software distributed under the License is distributed on an 'AS IS' BASIS, WITHOUT WARRANTIES OR CONDITIONS OF ANY KIND, either express or implied. See the License for the specific language governing permissions and limitations under the License."
          },
          {
            "url": "http://hl7.org/fhir/us/core/StructureDefinition/us-core-race",
            "valueCodeableConcept": {
              "coding": [
                {
                  "system": "http://hl7.org/fhir/v3/Race",
                  "code": "2106-3",
                  "display": "White"
                }
              ]
            }
          },
          {
            "url": "http://hl7.org/fhir/us/core/StructureDefinition/us-core-ethnicity",
            "valueCodeableConcept": {
              "coding": [
                {
                  "system": "http://hl7.org/fhir/v3/Ethnicity",
                  "code": "2186-5",
                  "display": "Not Hispanic or Latino"
                }
              ]
            }
          },
          {
            "url": "http://hl7.org/fhir/us/core/StructureDefinition/us-core-religion",
            "valueCodeableConcept": {
              "coding": [
                {
                  "system": "http://hl7.org/fhir/v3/ReligiousAffiliation",
                  "code": "1020",
                  "display": "Hinduism"
                }
              ]
            }
          }
        ],
        "identifier": [
          {
            "use": "official",
            "type": {
              "coding": [
                {
                  "system": "http://terminology.hl7.org/CodeSystem/v2-0203",
                  "code": "SB",
                  "display": "Social Beneficiary Identifier"
                }
              ],
              "text": "US Social Security Number"
            },
            "system": "http://hl7.org/fhir/sid/us-ssn",
            "value": "000002418"
          }
        ],
        "active": true,
        "name": [
          {
            "family": "Walter",
            "given": [
              "Natalie",
              "Huff"
            ]
          }
        ],
        "telecom": [
          {
            "system": "phone",
            "value": "248-555-3608",
            "use": "home"
          },
          {
            "system": "phone",
            "value": "248-555-4649",
            "use": "mobile"
          }
        ],
        "gender": "female",
        "birthDate": "1974-07-26",
        "address": [
          {
            "use": "home",
            "type": "postal",
            "line": [
              "623 SW French Place"
            ],
            "city": "Westland",
            "district": "Wayne County",
            "state": "MI",
            "postalCode": "48185"
          }
        ]
      }
    },
    {
      "name": "resource",
      "resource": {
        "resourceType": "Encounter",
        "id": "Encounter-62912",
        "meta": {
          "versionId": "1",
          "lastUpdated": "2018-05-31T08:21:50.000+00:00",
          "profile": [
            "http://hl7.org/fhir/us/hedis/StructureDefinition/hedis-encounter"
          ]
        },
        "extension": [
          {
            "url": "http://mihin.org/extension/copyright",
            "valueString": "Copyright 2014-2017 Michigan Health Information Network Shared Services. Licensed under the Apache License, Version 2.0 (the 'License'); you can not use this file except in compliance with the License. You can obtain a copy of the License at  http://www.apache.org/licenses/LICENSE-2.0.  Unless required by applicable law or agreed to in writing, software distributed under the License is distributed on an 'AS IS' BASIS, WITHOUT WARRANTIES OR CONDITIONS OF ANY KIND, either express or implied. See the License for the specific language governing permissions and limitations under the License."
          }
        ],
        "status": "finished",
        "class": {
          "system": "http://hl7.org/fhir/encounter-class",
          "code": "inpatient",
          "display": "Inpatient"
        },
        "type": [
          {
            "coding": [
              {
                "system": "http://snomed.info/sct",
                "code": "56876005",
                "display": "Drug rehabilitation and detoxification"
              }
            ]
          }
        ],
        "subject": {
          "reference": "Patient/Practitioner-2178",
          "display": "Natalie Huff Walter"
        },
        "period": {
          "start": "2018-05-29T11:00:00-04:00",
          "end": "2018-05-29T11:00:00-04:00"
        },
        "hospitalization": {
          "dischargeDisposition": {
            "coding": [
              {
                "system": "http://hl7.org/fhir/discharge-disposition",
                "code": "home",
                "display": "Home"
              }
            ]
          }
        }
      }
    },
    {
      "name": "resource",
      "resource": {
        "resourceType": "Procedure",
        "id": "Procedure-89972",
        "meta": {
          "versionId": "1",
          "lastUpdated": "2018-05-30T23:56:19.000+00:00",
          "profile": [
            "http://hl7.org/fhir/us/hedis/StructureDefinition/hedis-procedure"
          ]
        },
        "extension": [
          {
            "url": "http://mihin.org/extension/copyright",
            "valueString": "Copyright 2014-2017 Michigan Health Information Network Shared Services. Licensed under the Apache License, Version 2.0 (the 'License'); you can not use this file except in compliance with the License. You can obtain a copy of the License at  http://www.apache.org/licenses/LICENSE-2.0.  Unless required by applicable law or agreed to in writing, software distributed under the License is distributed on an 'AS IS' BASIS, WITHOUT WARRANTIES OR CONDITIONS OF ANY KIND, either express or implied. See the License for the specific language governing permissions and limitations under the License."
          }
        ],
        "identifier": [
          {
            "system": "mihin.org/fhir/sid/elementId",
            "value": "ca097928-b18c-406c-a01b-6ad4a321fc28"
          }
        ],
        "status": "completed",
        "code": {
          "coding": [
            {
              "system": "http://www.ama-assn.org/go/cpt",
              "code": "1111F",
              "display": "Medication reconciliation postdischarge"
            }
          ]
        },
        "subject": {
          "reference": "Patient/Practitioner-2178",
          "display": "Natalie Huff Walter"
        },
        "performedPeriod": {
          "start": "2018-06-02T14:00:00-05:00",
          "end": "2018-06-02T14:00:00-05:00"
        }
      }
    }
  ]
}

23.3.16DQM Module

 

To enable both 'Standard' and 'Distributed' evaluate-measure, you will need to turn on the DQM Module on CDR.

See DQM for more details.

23.3.17FAQs

 

Q: I get an error saying Smile CDR can't locate my library, and I've verified it's on the server.

A: Smile CDR follows the Library conformance requirements defined by the CQF Measures IG, meaning the Library must have a logic-library type, the name and versions of the FHIR Library and CQL Library must match, and the url of the Library must end in the name of the Library.

FHIR Libraries generated from CQL via the IG Publisher follow these requirements automatically.

Q: Does Smile CDR support partitions for evaluation?

A: Yes, though the Measure and associated Resources must be in the same partition as the clinical data being used.