The Measure resource provides the definition of a quality measure.

The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.

The only time that a resource does not have an id is when it is being submitted to the server using a create operation.

The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.

A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.

The base language in which the resource is written.

Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).

A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.

Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.

These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.

This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.

May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

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

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

The url for measures defined in The Situation Awareness for Novel Epidemic Response IG will follow IG URL naming conventions.

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

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

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

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

There may be different measure instances that have the same identifier but different versions. The version can be appended to the url in a reference to allow a reference to a particular business version of the measure with the format [url]|[version].

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

Support human navigation and code generation.

The name should be in PascalCase, and should represent the Author's title of the Measure. Identify the Author to clarify

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

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

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

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

draft - The Measure is still in development or ballot. active - The Measure is ready for piloting or normal use. retired - Measure has been deprecated or replaced.

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

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

true - development, testing or pilots, false - production use

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

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

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

Note that this is not the same as the resource last-modified-date, since the resource may be a secondary representation of the measure. Additional specific dates may be added as extensions or be found by consulting Provenances associated with past versions of the resource.

The name of the organization or individual that published the measure.

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

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

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

At least one contact shall be an email

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

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

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

Assist in searching for appropriate content.

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

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

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

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

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

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

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

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

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

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

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

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

If specified, this date follows the original approval date.

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

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

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

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

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

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

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

• value @ url

The name of an individual to contact.

If there is no named individual, the telecom information is for the organization as a whole.

The contact details for the individual (if a name was provided) or the organization.

At least on author contact should be an email address.

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

An individual or organization primarily responsible for review of some aspect of the content.

An individual or organization responsible for officially endorsing the content for use in some setting.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

A group of population criteria for the measure.

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

An Extension

• value @ url

Optional Extension Element - found in all resources.

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

An Extension

• value @ url

An Extension

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

An Extension

• value @ url

Source of the definition for the extension code - a logical name or a URL.

The definition may point directly to a computable or human-readable definition of the extensibility codes, or it may be a logical URI as declared in some other specification. The definition SHALL be a URI for the Structure Definition defining the extension.

Value of extension - must be one of a constrained set of the data types (see Extensibility for a list).

• type @ $this

Value of extension - must be one of a constrained set of the data types (see Extensibility for a list).

continuous-variable : Use continuous-variable when reporting a group of counts of the same type of resource, with different constraints on when to count it. Also use continuous variable to report measures with computations over measure-observation values (e.g., average length of stay).

proportion : Use proportion to report percentages, or ratios from the (generally) same initial population.

ratio : Use ratio to report ratios from different initial populations.

cohort: : Use cohort to report counts of unrelated or orthogonal categories (e.g., masks, gowns, gloves) within a group, where proportions aren't of significance. Also use cohort to count answers to categorical questions, where each question is one cohort, and is stratified by possible answers (e.g., Yes/No, 0 days/1-3 days/4-6 days/7-9 days/more than 9 days supply).

An Extension

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

An Extension

• value @ url

Source of the definition for the extension code - a logical name or a URL.

The definition may point directly to a computable or human-readable definition of the extensibility codes, or it may be a logical URI as declared in some other specification. The definition SHALL be a URI for the Structure Definition defining the extension.

Value of extension - must be one of a constrained set of the data types (see Extensibility for a list).

• type @ $this

Value of extension - must be one of a constrained set of the data types (see Extensibility for a list).

An Extension

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

An Extension

• value @ url

Source of the definition for the extension code - a logical name or a URL.

The definition may point directly to a computable or human-readable definition of the extensibility codes, or it may be a logical URI as declared in some other specification. The definition SHALL be a URI for the Structure Definition defining the extension.

Value of extension - must be one of a constrained set of the data types (see Extensibility for a list).

• type @ $this

Value of extension - must be one of a constrained set of the data types (see Extensibility for a list).

structure : Use when the measure is about capacity of a facility or organization to provide services, e.g., quantities of resources, staff, expendibles, et cetera.

process : Use when the measure is about the execution of a process, things that are done, in process, et cetera.

outcome : Use when the measure describes the outcome or result. If by the measure you know a patient is getting better or worse, it's an outcome measure.

patient-reported-outcome : Use when the outcome is reported by a patient or their authorized representative (usually used with "satisfaction scores", but could be used with other outcomes).

composite : Use when two or more of the above are appropriate. Consider subdividing the group further.

An Extension

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

An Extension

• value @ url

Source of the definition for the extension code - a logical name or a URL.

The definition may point directly to a computable or human-readable definition of the extensibility codes, or it may be a logical URI as declared in some other specification. The definition SHALL be a URI for the Structure Definition defining the extension.

Value of extension - must be one of a constrained set of the data types (see Extensibility for a list).

An Extension

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

An Extension

• value @ url

Source of the definition for the extension code - a logical name or a URL.

The definition may point directly to a computable or human-readable definition of the extensibility codes, or it may be a logical URI as declared in some other specification. The definition SHALL be a URI for the Structure Definition defining the extension.

Value of extension - must be one of a constrained set of the data types (see Extensibility for a list).

aggregable-by-period : Use this when the value being reported can be aggregated (added to) values in other periods and retain meaning (e.g., adding admissions on day 1 and day 2 reporting period gives admissions for the combined reporting period)"

point-in-time : Use this when the value being reported is a point-in-time (e.g. instantanious value) that cannot be meaningfully combined with a value from another reporting period

cumulative : Use this when the value being reported is a point-in-time cumulative value over all reports

An Extension

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

An Extension

• value @ url

Source of the definition for the extension code - a logical name or a URL.

The definition may point directly to a computable or human-readable definition of the extensibility codes, or it may be a logical URI as declared in some other specification. The definition SHALL be a URI for the Structure Definition defining the extension.

Value of extension - must be one of a constrained set of the data types (see Extensibility for a list).

• type @ $this

Value of extension - must be one of a constrained set of the data types (see Extensibility for a list).

increase : Use when a higher score indicates more patients are having better outcomes, are being treated, or can be treated, et cetera.

decrease: : Use when a higher score indicates more patients are having worse outcomes, are not be treated, or cannot be treated, et cetera.

An Extension

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

An Extension

• value @ url

Source of the definition for the extension code - a logical name or a URL.

The definition may point directly to a computable or human-readable definition of the extensibility codes, or it may be a logical URI as declared in some other specification. The definition SHALL be a URI for the Structure Definition defining the extension.

A concept that may be defined by a formal reference to a terminology or ontology or may be provided by text.

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

• type @ $this

Value of extension - must be one of a constrained set of the data types (see Extensibility for a list).

Describe the subject being enumerated that is associated with the measure. The first code should identify the FHIR Resource type. The second should further describe it using SNOMED CT. Subsequent codes may describe it using other coding systems.

Source of the definition for the extension code - a logical name or a URL.

The definition may point directly to a computable or human-readable definition of the extensibility codes, or it may be a logical URI as declared in some other specification. The definition SHALL be a URI for the Structure Definition defining the extension.

Value of extension - must be one of a constrained set of the data types (see Extensibility for a list).

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

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

The human readable description of this population group.

A population criteria for the measure.

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

An Extension

• value @ url

Optional Extension Element - found in all resources.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

The type of population criteria.

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

• value @ url

A reference to a code defined by a terminology system.

Allows for alternative encodings within a code system, and translations to other code systems.

Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.

Very often the text is the same as a displayName of one of the codings.

The human readable description of this population criteria.

A expression that is evaluated in a specified context and returns a value. The context of use of the expression must specify the context in which the expression is evaluated, and how the result of the expression is used.

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

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

• value @ url

A brief, natural language description of the condition that effectively communicates the intended semantics.

A short name assigned to the expression to allow for multiple reuse of the expression in the context where it is defined.

The media type of the language for the expression.

An expression in the specified language that returns a value.

A URI that defines where the expression is found.

If both a reference and an expression is found, the reference SHALL point to the same expression.

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

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

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

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

• value @ url

A reference to a code defined by a terminology system.

Allows for alternative encodings within a code system, and translations to other code systems.

Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

• value @ url

The identification of the code system that defines the meaning of the symbol in the code.

Need to be unambiguous about the source of the definition of the symbol.

The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.

The version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged.

Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.

A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

Need to refer to a particular code in the system.

A representation of the meaning of the code in the system, following the rules of the system.

Need to be able to carry a human-readable meaning of the code for readers that do not know the system.

Indicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays).

This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing.

Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.

A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.

Very often the text is the same as a displayName of one of the codings.

The human readable description of this stratifier criteria.

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

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

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

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

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

The human readable description of this stratifier criteria component.

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

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

Note that supplemental data are reported as observations for each patient and included in the evaluatedResources bundle. See the MeasureReport resource or the Quality Reporting topic for more information.

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

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

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

The human readable description of this supplemental data.

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