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  <title>Comprehensive Primary Care Plus (CPC+) Sample QRDA-III Report</title>
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        <state>OK</state>
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  <!--
********************************************************
CDA Body
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-->
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    <structuredBody>
      <!--
      ********************************************************
      Missing QRDA Category III Measure Section (CMS EP)
      ********************************************************
      -->


      <!--
      ********************************************************
      Promoting Interoperability Section
      ********************************************************
      -->
      <component>
        <section>
          <!-- Measure Section -->
          <templateId root="2.16.840.1.113883.10.20.24.2.2"/>
          <!-- Promoting Interoperability Section V2 templateId -->
          <templateId root="2.16.840.1.113883.10.20.27.2.5" extension="2017-06-01"/>
          <code code="55186-1" codeSystem="2.16.840.1.113883.6.1"
            displayName="Measure Section"/>
          <title>Measure Section</title>
          <text>
            <table border="1" width="100%">
              <thead>
                <tr>
                  <th>PI Measure Title</th>
                  <th>Measure Identifier</th>
                </tr>
              </thead>
              <tbody>
                <tr>
                  <td>Security Risk Analysis</td>
                  <td>PI_PPHI_1</td>
                </tr>
              </tbody>
            </table>
            <list>
              <item>
                <content styleCode="Bold">Measure Answer (Yes/No):
                </content>Yes</item>
            </list>

            <table border="1" width="100%">
              <thead>
                <tr>
                  <th>PI Measure Title</th>
                  <th>Measure Identifier</th>
                </tr>
              </thead>
              <tbody>
                <tr>
                  <td>ePrescribing</td>
                  <td>PI_EP_1</td>
                </tr>
              </tbody>
            </table>
            <list>
              <item>
                <content styleCode="Bold">Denominator: </content>800</item>
              <item>
                <content styleCode="Bold">Numerator: </content>750</item>
            </list>
            <table border="1" width="100%">
              <thead>
                <tr>
                  <th>PI Measure Title</th>
                  <th>Measure Identifier</th>
                </tr>
              </thead>
              <tbody>
                <tr>
                  <td>Provide Patient Access</td>
                  <td>PI_PEA_1</td>
                </tr>
              </tbody>
            </table>
            <list>
              <item>
                <content styleCode="Bold">Denominator: </content>800</item>
              <item>
                <content styleCode="Bold">Numerator: </content>600</item>
            </list>

            <table border="1" width="100%">
              <thead>
                <tr>
                  <th>PI Measure Title</th>
                  <th>Measure Identifier</th>
                </tr>
              </thead>
              <tbody>
                <tr>
                  <td>Patient-Specific Education</td>
                  <td>PI_PEA_2</td>
                </tr>
              </tbody>
            </table>
            <list>
              <item>
                <content styleCode="Bold">Denominator: </content>800</item>
              <item>
                <content styleCode="Bold">Numerator: </content>554</item>
            </list>
            <table border="1" width="100%">
              <thead>
                <tr>
                  <th>PI Measure Title</th>
                  <th>Measure Identifier</th>
                </tr>
              </thead>
              <tbody>
                <tr>
                  <td>View, Download or Transmit (VDT)</td>
                  <td>PI_CCTPE_1</td>
                </tr>
              </tbody>
            </table>
            <list>
              <item>
                <content styleCode="Bold">Denominator: </content>800</item>
              <item>
                <content styleCode="Bold">Numerator: </content>460</item>
            </list>
            <table border="1" width="100%">
              <thead>
                <tr>
                  <th>PI Measure Title</th>
                  <th>Measure Identifier</th>
                </tr>
              </thead>
              <tbody>
                <tr>
                  <td>Secure Messaging</td>
                  <td>PI_CCTPE_2</td>
                </tr>
              </tbody>
            </table>
            <list>
              <item>
                <content styleCode="Bold">Denominator: </content>800</item>
              <item>
                <content styleCode="Bold">Numerator: </content>750</item>
            </list>
            <table border="1" width="100%">
              <thead>
                <tr>
                  <th>PI Measure Title</th>
                  <th>Measure Identifier</th>
                </tr>
              </thead>
              <tbody>
                <tr>
                  <td>Patient-Generated Health Data</td>
                  <td>PI_CCTPE_3</td>
                </tr>
              </tbody>
            </table>
            <list>
              <item>
                <content styleCode="Bold">Denominator: </content>800</item>
              <item>
                <content styleCode="Bold">Numerator: </content>330</item>
            </list>
            <table border="1" width="100%">
              <thead>
                <tr>
                  <th>PI Measure Title</th>
                  <th>Measure Identifier</th>
                </tr>
              </thead>
              <tbody>
                <tr>
                  <td>Send a Summary of Care</td>
                  <td>PI_HIE_1</td>
                </tr>
              </tbody>
            </table>
            <list>
              <item>
                <content styleCode="Bold">Denominator: </content>800</item>
              <item>
                <content styleCode="Bold">Numerator: </content>530</item>
            </list>
            <table border="1" width="100%">
              <thead>
                <tr>
                  <th>PI Measure Title</th>
                  <th>Measure Identifier</th>
                </tr>
              </thead>
              <tbody>
                <tr>
                  <td>Request/Accept Summary of Care</td>
                  <td>PI_HIE_2</td>
                </tr>
              </tbody>
            </table>
            <list>
              <item>
                <content styleCode="Bold">Denominator: </content>800</item>
              <item>
                <content styleCode="Bold">Numerator: </content>730</item>
            </list>
            <table border="1" width="100%">
              <thead>
                <tr>
                  <th>PI Measure Title</th>
                  <th>Measure Identifier</th>
                </tr>
              </thead>
              <tbody>
                <tr>
                  <td>Clinical Information Reconciliation</td>
                  <td>PI_HIE_3</td>
                </tr>
              </tbody>
            </table>
            <list>
              <item>
                <content styleCode="Bold">Denominator: </content>800</item>
              <item>
                <content styleCode="Bold">Numerator: </content>612</item>
            </list>
            <table border="1" width="100%">
              <thead>
                <tr>
                  <th>PI Measure Title</th>
                  <th>Measure Identifier</th>
                </tr>
              </thead>
              <tbody>
                <tr>
                  <td>Immunization Registry Reporting</td>
                  <td>PI_PHCDRR_1</td>
                </tr>
              </tbody>
            </table>
            <list>
              <item>
                <content styleCode="Bold">Measure Answer (Yes/No):
                </content>Yes</item>
            </list>
            <table border="1" width="100%">
              <thead>
                <tr>
                  <th>PI Measure Title</th>
                  <th>Measure Identifier</th>
                </tr>
              </thead>
              <tbody>
                <tr>
                  <td>(Optional) Syndromic Surveillance Reporting</td>
                  <td>PI_PHCDRR_2</td>
                </tr>
              </tbody>
            </table>
            <list>
              <item>
                <content styleCode="Bold">Measure Answer (Yes/No):
                </content>Yes</item>
            </list>
            <table border="1" width="100%">
              <thead>
                <tr>
                  <th>PI Measure Title</th>
                  <th>Measure Identifier</th>
                </tr>
              </thead>
              <tbody>
                <tr>
                  <td>(Optional) Electronic Case Reporting</td>
                  <td>PI_PHCDRR_3</td>
                </tr>
              </tbody>
            </table>
            <list>
              <item>
                <content styleCode="Bold">Measure Answer (Yes/No):
                </content>Yes</item>
            </list>
            <table border="1" width="100%">
              <thead>
                <tr>
                  <th>PI Measure Title</th>
                  <th>Measure Identifier</th>
                </tr>
              </thead>
              <tbody>
                <tr>
                  <td>(Optional) Public Health Registry Reporting</td>
                  <td>PI_PHCDRR_4</td>
                </tr>
              </tbody>
            </table>
            <list>
              <item>
                <content styleCode="Bold">Measure Answer (Yes/No):
                </content>Yes</item>
            </list>
            <table border="1" width="100%">
              <thead>
                <tr>
                  <th>PI Measure Title</th>
                  <th>Measure Identifier</th>
                </tr>
              </thead>
              <tbody>
                <tr>
                  <td>(Optional) Clinical Data Registry Reporting</td>
                  <td>PI_PHCDRR_5</td>
                </tr>
              </tbody>
            </table>
            <list>
              <item>
                <content styleCode="Bold">Measure Answer (Yes/No):
                </content>Yes</item>
            </list>
            <table border="1" width="100%">
              <thead>
                <tr>
                  <th>PI Measure Title</th>
                  <th>Measure Identifier</th>
                </tr>
              </thead>
              <tbody>
                <tr>
                  <td>Security Risk Analysis</td>
                  <td>PI_TRANS_PPHI_1</td>
                </tr>
              </tbody>
            </table>
            <list>
              <item>
                <content styleCode="Bold">Measure Answer (Yes/No):
                </content>Yes</item>
            </list>
            <table border="1" width="100%">
              <thead>
                <tr>
                  <th>PI Measure Title</th>
                  <th>Measure Identifier</th>
                </tr>
              </thead>
              <tbody>
                <tr>
                  <td>e-Prescribing</td>
                  <td>PI_TRANS_EP_1</td>
                </tr>
              </tbody>
            </table>
            <list>
              <item>
                <content styleCode="Bold">Denominator: </content>800</item>
              <item>
                <content styleCode="Bold">Numerator: </content>752</item>
            </list>
            <table border="1" width="100%">
              <thead>
                <tr>
                  <th>PI Measure Title</th>
                  <th>Measure Identifier</th>
                </tr>
              </thead>
              <tbody>
                <tr>
                  <td>Provide Patient Access</td>
                  <td>PI_TRANS_PEA_1</td>
                </tr>
              </tbody>
            </table>
            <list>
              <item>
                <content styleCode="Bold">Denominator: </content>800</item>
              <item>
                <content styleCode="Bold">Numerator: </content>722</item>
            </list>
            <table border="1" width="100%">
              <thead>
                <tr>
                  <th>PI Measure Title</th>
                  <th>Measure Identifier</th>
                </tr>
              </thead>
              <tbody>
                <tr>
                  <td>View, Download, or Transmit (VDT)</td>
                  <td>PI_TRANS_PEA_2</td>
                </tr>
              </tbody>
            </table>
            <list>
              <item>
                <content styleCode="Bold">Denominator: </content>800</item>
              <item>
                <content styleCode="Bold">Numerator: </content>537</item>
            </list>
            <table border="1" width="100%">
              <thead>
                <tr>
                  <th>PI Measure Title</th>
                  <th>Measure Identifier</th>
                </tr>
              </thead>
              <tbody>
                <tr>
                  <td>Patient-Specific Education</td>
                  <td>PI_TRANS_PSE_1</td>
                </tr>
              </tbody>
            </table>
            <list>
              <item>
                <content styleCode="Bold">Denominator: </content>800</item>
              <item>
                <content styleCode="Bold">Numerator: </content>700</item>
            </list>
            <table border="1" width="100%">
              <thead>
                <tr>
                  <th>PI Measure Title</th>
                  <th>Measure Identifier</th>
                </tr>
              </thead>
              <tbody>
                <tr>
                  <td>Secure Messaging</td>
                  <td>PI_TRANS_SM_1</td>
                </tr>
              </tbody>
            </table>
            <list>
              <item>
                <content styleCode="Bold">Denominator: </content>800</item>
              <item>
                <content styleCode="Bold">Numerator: </content>762</item>
            </list>
            <table border="1" width="100%">
              <thead>
                <tr>
                  <th>PI Measure Title</th>
                  <th>Measure Identifier</th>
                </tr>
              </thead>
              <tbody>
                <tr>
                  <td>Health Information Exchange</td>
                  <td>PI_TRANS_HIE_1</td>
                </tr>
              </tbody>
            </table>
            <list>
              <item>
                <content styleCode="Bold">Denominator: </content>800</item>
              <item>
                <content styleCode="Bold">Numerator: </content>753</item>
            </list>
            <table border="1" width="100%">
              <thead>
                <tr>
                  <th>PI Measure Title</th>
                  <th>Measure Identifier</th>
                </tr>
              </thead>
              <tbody>
                <tr>
                  <td>Medication Reconciliation</td>
                  <td>PI_TRANS_MR_1</td>
                </tr>
              </tbody>
            </table>
            <list>
              <item>
                <content styleCode="Bold">Denominator: </content>800</item>
              <item>
                <content styleCode="Bold">Numerator: </content>553</item>
            </list>
            <table border="1" width="100%">
              <thead>
                <tr>
                  <th>PI Measure Title</th>
                  <th>Measure Identifier</th>
                </tr>
              </thead>
              <tbody>
                <tr>
                  <td>Immunization Registry Reporting</td>
                  <td>PI_TRANS_PHCDRR_1</td>
                </tr>
              </tbody>
            </table>
            <list>
              <item>
                <content styleCode="Bold">Measure Answer (Yes/No):
                </content>Yes</item>
            </list>
            <table border="1" width="100%">
              <thead>
                <tr>
                  <th>PI Measure Title</th>
                  <th>Measure Identifier</th>
                </tr>
              </thead>
              <tbody>
                <tr>
                  <td>Syndromic Surveillance Reporting</td>
                  <td>PI_TRANS_PHCDRR_2</td>
                </tr>
              </tbody>
            </table>
            <list>
              <item>
                <content styleCode="Bold">Measure Answer (Yes/No):
                </content>Yes</item>
            </list>
            <table border="1" width="100%">
              <thead>
                <tr>
                  <th>PI Measure Title</th>
                  <th>Measure Identifier</th>
                </tr>
              </thead>
              <tbody>
                <tr>
                  <td>Specialized Registry Reporting</td>
                  <td>PI_TRANS_PHCDRR_3</td>
                </tr>
              </tbody>
            </table>
            <list>
              <item>
                <content styleCode="Bold">Measure Answer (Yes/No):
                </content>Yes</item>
            </list>
          </text>
          <!-- PI_PPHI_1 which is an example of PI measure with reporting metric of yes/no -->
          <entry>
            <organizer classCode="CLUSTER" moodCode="EVN">
              <!-- Implied template Measure Reference templateId -->
              <templateId root="2.16.840.1.113883.10.20.24.3.98"/>
              <!-- PI Measure Performed Measure Reference and Results templateId -->
              <templateId root="2.16.840.1.113883.10.20.27.3.29"
                extension="2016-09-01"/>
              <id root="ac575aef-7062-4ea2-b723-df517cfa470a"/>
              <statusCode code="completed"/>
              <reference typeCode="REFR">
                <!-- Reference to a particular PI measure's unique identifier. -->
                <externalDocument classCode="DOC" moodCode="EVN">
                  <!-- extension is the unique identifier for an PI measure. -->
                  <id root="2.16.840.1.113883.3.7031" extension="PI_PPHI_1"/>
                  <!-- PI measure title -->
                  <text>Security Risk Analysis</text>
                </externalDocument>
              </reference>
              <component>
                <observation classCode="OBS" moodCode="EVN">
                  <!-- Measure Performed templateId -->
                  <templateId root="2.16.840.1.113883.10.20.27.3.27"
                    extension="2016-09-01"/>
                  <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"
                    codeSystemName="ActCode" displayName="Assertion"/>
                  <statusCode code="completed"/>
                  <value xsi:type="CD" code="Y" codeSystem="2.16.840.1.113883.12.136"
                    codeSystemName="Yes/no indicator (HL7 Table 0136)" displayName="Yes"/>
                </observation>
              </component>
            </organizer>
          </entry>
          <!-- PI_EP_1 which is an example of PI measure with reporting metric of numerator/denominator -->
          <entry>
            <organizer classCode="CLUSTER" moodCode="EVN">
              <!-- Implied template Measure Reference templateId -->
              <templateId root="2.16.840.1.113883.10.20.24.3.98"/>
              <!-- PI Numerator Denominator Type Measure Reference and Results V2 templateId -->
              <templateId root="2.16.840.1.113883.10.20.27.3.28"
                extension="2017-06-01"/>
              <id root="ac575aef-7062-4ea2-b723-df517cfa470a"/>
              <statusCode code="completed"/>
              <reference typeCode="REFR">
                <!-- Reference to a particular PI measure's unique identifier. -->
                <externalDocument classCode="DOC" moodCode="EVN">
                  <!-- extension is the unique identifier for an PI measure. -->
                  <id root="2.16.840.1.113883.3.7031" extension="PI_EP_1"/>
                  <!-- PI measure title -->
                  <text>ePrescribing</text>
                </externalDocument>
              </reference>
              <component>
                <observation classCode="OBS" moodCode="EVN">
                  <!-- PI Numerator Denominator Type Measure Numerator Data templateId -->
                  <templateId root="2.16.840.1.113883.10.20.27.3.31"
                    extension="2016-09-01"/>
                  <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"
                    codeSystemName="ActCode" displayName="Assertion"/>
                  <statusCode code="completed"/>
                  <value xsi:type="CD" code="NUMER"
                    codeSystem="2.16.840.1.113883.5.4" codeSystemName="ActCode"/>
                  <!-- Numerator Count-->
                  <entryRelationship typeCode="SUBJ" inversionInd="true">
                    <observation classCode="OBS" moodCode="EVN">
                      <templateId root="2.16.840.1.113883.10.20.27.3.3"/>
                      <code code="MSRAGG" codeSystem="2.16.840.1.113883.5.4"
                        codeSystemName="ActCode"
                        displayName="rate aggregation"/>
                      <statusCode code="completed"/>
                      <value xsi:type="INT" value="750"/>
                      <methodCode code="COUNT"
                        codeSystem="2.16.840.1.113883.5.84"
                        codeSystemName="ObservationMethod"
                        displayName="Count"/>
                    </observation>
                  </entryRelationship>
                </observation>
              </component>
              <component>
                <observation classCode="OBS" moodCode="EVN">
                  <!-- PI Numerator Denominator Type Measure Denominator Data templateId -->
                  <templateId root="2.16.840.1.113883.10.20.27.3.32"
                    extension="2016-09-01"/>
                  <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"
                    codeSystemName="ActCode" displayName="Assertion"/>
                  <statusCode code="completed"/>
                  <value xsi:type="CD" code="DENOM"
                    codeSystem="2.16.840.1.113883.5.4" codeSystemName="ActCode"/>
                  <!-- Denominator Count-->
                  <entryRelationship typeCode="SUBJ" inversionInd="true">
                    <observation classCode="OBS" moodCode="EVN">
                      <templateId root="2.16.840.1.113883.10.20.27.3.3"/>
                      <code code="MSRAGG" codeSystem="2.16.840.1.113883.5.4"
                        codeSystemName="ActCode"
                        displayName="rate aggregation"/>
                      <statusCode code="completed"/>
                      <value xsi:type="INT" value="800"/>
                      <methodCode code="COUNT"
                        codeSystem="2.16.840.1.113883.5.84"
                        codeSystemName="ObservationMethod"
                        displayName="Count"/>
                    </observation>
                  </entryRelationship>
                </observation>
              </component>
            </organizer>
          </entry>
          <!-- PI_PEA_1 which is an example of a numerator/denominator PI measure -->
          <entry>
            <organizer classCode="CLUSTER" moodCode="EVN">
              <!-- Implied template Measure Reference templateId -->
              <templateId root="2.16.840.1.113883.10.20.24.3.98"/>
              <!-- PI Numerator Denominator Type Measure Reference and Results V2 templateId -->
              <templateId root="2.16.840.1.113883.10.20.27.3.28"
                extension="2017-06-01"/>
              <id root="ac575aef-7062-4ea2-b723-df517cfa470a"/>
              <statusCode code="completed"/>
              <reference typeCode="REFR">
                <!-- Reference to a particular PI measure's unique identifier. -->
                <externalDocument classCode="DOC" moodCode="EVN">
                  <!-- extension is the unique identifier for an PI measure. -->
                  <id root="2.16.840.1.113883.3.7031" extension="PI_PEA_1"/>
                  <!-- PI measure title -->
                  <text>Provide Patient Access</text>
                </externalDocument>
              </reference>
              <component>
                <observation classCode="OBS" moodCode="EVN">
                  <!-- PI Numerator Denominator Type Measure Numerator Data templateId -->
                  <templateId root="2.16.840.1.113883.10.20.27.3.31"
                    extension="2016-09-01"/>
                  <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"
                    codeSystemName="ActCode" displayName="Assertion"/>
                  <statusCode code="completed"/>
                  <value xsi:type="CD" code="NUMER"
                    codeSystem="2.16.840.1.113883.5.4" codeSystemName="ActCode"/>
                  <!-- Numerator Count-->
                  <entryRelationship typeCode="SUBJ" inversionInd="true">
                    <observation classCode="OBS" moodCode="EVN">
                      <templateId root="2.16.840.1.113883.10.20.27.3.3"/>
                      <code code="MSRAGG" codeSystem="2.16.840.1.113883.5.4"
                        codeSystemName="ActCode"
                        displayName="rate aggregation"/>
                      <statusCode code="completed"/>
                      <value xsi:type="INT" value="600"/>
                      <methodCode code="COUNT"
                        codeSystem="2.16.840.1.113883.5.84"
                        codeSystemName="ObservationMethod"
                        displayName="Count"/>
                    </observation>
                  </entryRelationship>
                </observation>
              </component>
              <component>
                <observation classCode="OBS" moodCode="EVN">
                  <!-- PI Numerator Denominator Type Measure Denominator Data templateId -->
                  <templateId root="2.16.840.1.113883.10.20.27.3.32"
                    extension="2016-09-01"/>
                  <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"
                    codeSystemName="ActCode" displayName="Assertion"/>
                  <statusCode code="completed"/>
                  <value xsi:type="CD" code="DENOM"
                    codeSystem="2.16.840.1.113883.5.4" codeSystemName="ActCode"/>
                  <!-- Denominator Count-->
                  <entryRelationship typeCode="SUBJ" inversionInd="true">
                    <observation classCode="OBS" moodCode="EVN">
                      <templateId root="2.16.840.1.113883.10.20.27.3.3"/>
                      <code code="MSRAGG" codeSystem="2.16.840.1.113883.5.4"
                        codeSystemName="ActCode"
                        displayName="rate aggregation"/>
                      <statusCode code="completed"/>
                      <value xsi:type="INT" value="800"/>
                      <methodCode code="COUNT"
                        codeSystem="2.16.840.1.113883.5.84"
                        codeSystemName="ObservationMethod"
                        displayName="Count"/>
                    </observation>
                  </entryRelationship>
                </observation>
              </component>
            </organizer>
          </entry>
          <!-- PI_PEA_2  -->
          <entry>
            <organizer classCode="CLUSTER" moodCode="EVN">
              <templateId root="2.16.840.1.113883.10.20.24.3.98"/>
              <templateId root="2.16.840.1.113883.10.20.27.3.28"
                extension="2017-06-01"/>
              <id root="ac575aef-7062-4ea2-b723-df517cfa470a"/>
              <statusCode code="completed"/>
              <reference typeCode="REFR">
                <externalDocument classCode="DOC" moodCode="EVN">
                  <id root="2.16.840.1.113883.3.7031" extension="PI_PEA_2"/>
                  <text>Patient-Specific Education</text>
                </externalDocument>
              </reference>
              <component>
                <observation classCode="OBS" moodCode="EVN">
                  <!-- PI Numerator Denominator Type Measure Numerator Data templateId -->
                  <templateId root="2.16.840.1.113883.10.20.27.3.31"
                    extension="2016-09-01"/>
                  <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"
                    codeSystemName="ActCode" displayName="Assertion"/>
                  <statusCode code="completed"/>
                  <value xsi:type="CD" code="NUMER"
                    codeSystem="2.16.840.1.113883.5.4" codeSystemName="ActCode"/>
                  <!-- Numerator Count-->
                  <entryRelationship typeCode="SUBJ" inversionInd="true">
                    <observation classCode="OBS" moodCode="EVN">
                      <templateId root="2.16.840.1.113883.10.20.27.3.3"/>
                      <code code="MSRAGG" codeSystem="2.16.840.1.113883.5.4"
                        codeSystemName="ActCode"
                        displayName="rate aggregation"/>
                      <statusCode code="completed"/>
                      <value xsi:type="INT" value="554"/>
                      <methodCode code="COUNT"
                        codeSystem="2.16.840.1.113883.5.84"
                        codeSystemName="ObservationMethod"
                        displayName="Count"/>
                    </observation>
                  </entryRelationship>
                </observation>
              </component>
              <component>
                <observation classCode="OBS" moodCode="EVN">
                  <!-- PI Numerator Denominator Type Measure Denominator Data templateId -->
                  <templateId root="2.16.840.1.113883.10.20.27.3.32"
                    extension="2016-09-01"/>
                  <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"
                    codeSystemName="ActCode" displayName="Assertion"/>
                  <statusCode code="completed"/>
                  <value xsi:type="CD" code="DENOM"
                    codeSystem="2.16.840.1.113883.5.4" codeSystemName="ActCode"/>
                  <!-- Denominator Count-->
                  <entryRelationship typeCode="SUBJ" inversionInd="true">
                    <observation classCode="OBS" moodCode="EVN">
                      <templateId root="2.16.840.1.113883.10.20.27.3.3"/>
                      <code code="MSRAGG" codeSystem="2.16.840.1.113883.5.4"
                        codeSystemName="ActCode"
                        displayName="rate aggregation"/>
                      <statusCode code="completed"/>
                      <value xsi:type="INT" value="800"/>
                      <methodCode code="COUNT"
                        codeSystem="2.16.840.1.113883.5.84"
                        codeSystemName="ObservationMethod"
                        displayName="Count"/>
                    </observation>
                  </entryRelationship>
                </observation>
              </component>
            </organizer>
          </entry>
          <!-- PI_CCTPE_1  -->
          <entry>
            <organizer classCode="CLUSTER" moodCode="EVN">
              <templateId root="2.16.840.1.113883.10.20.24.3.98"/>
              <templateId root="2.16.840.1.113883.10.20.27.3.28"
                extension="2017-06-01"/>
              <id root="ac575aef-7062-4ea2-b723-df517cfa470a"/>
              <statusCode code="completed"/>
              <reference typeCode="REFR">
                <externalDocument classCode="DOC" moodCode="EVN">
                  <id root="2.16.840.1.113883.3.7031" extension="PI_CCTPE_1"/>
                  <text>View, Download or Transmit (VDT)</text>
                </externalDocument>
              </reference>
              <component>
                <observation classCode="OBS" moodCode="EVN">
                  <!-- PI Numerator Denominator Type Measure Numerator Data templateId -->
                  <templateId root="2.16.840.1.113883.10.20.27.3.31"
                    extension="2016-09-01"/>
                  <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"
                    codeSystemName="ActCode" displayName="Assertion"/>
                  <statusCode code="completed"/>
                  <value xsi:type="CD" code="NUMER"
                    codeSystem="2.16.840.1.113883.5.4" codeSystemName="ActCode"/>
                  <!-- Numerator Count-->
                  <entryRelationship typeCode="SUBJ" inversionInd="true">
                    <observation classCode="OBS" moodCode="EVN">
                      <templateId root="2.16.840.1.113883.10.20.27.3.3"/>
                      <code code="MSRAGG" codeSystem="2.16.840.1.113883.5.4"
                        codeSystemName="ActCode"
                        displayName="rate aggregation"/>
                      <statusCode code="completed"/>
                      <value xsi:type="INT" value="460"/>
                        <methodCode code="COUNT"
                          codeSystem="2.16.840.1.113883.5.84"
                          codeSystemName="ObservationMethod"
                          displayName="Count"/>
                    </observation>
                  </entryRelationship>
                </observation>
              </component>
              <component>
                <observation classCode="OBS" moodCode="EVN">
                  <!-- PI Numerator Denominator Type Measure Denominator Data templateId -->
                  <templateId root="2.16.840.1.113883.10.20.27.3.32"
                    extension="2016-09-01"/>
                  <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"
                    codeSystemName="ActCode" displayName="Assertion"/>
                  <statusCode code="completed"/>
                  <value xsi:type="CD" code="DENOM"
                    codeSystem="2.16.840.1.113883.5.4" codeSystemName="ActCode"/>
                  <!-- Denominator Count-->
                  <entryRelationship typeCode="SUBJ" inversionInd="true">
                    <observation classCode="OBS" moodCode="EVN">
                      <templateId root="2.16.840.1.113883.10.20.27.3.3"/>
                      <code code="MSRAGG" codeSystem="2.16.840.1.113883.5.4"
                        codeSystemName="ActCode"
                        displayName="rate aggregation"/>
                      <statusCode code="completed"/>
                      <value xsi:type="INT" value="800"/>
                      <methodCode code="COUNT"
                        codeSystem="2.16.840.1.113883.5.84"
                        codeSystemName="ObservationMethod"
                        displayName="Count"/>
                    </observation>
                  </entryRelationship>
                </observation>
              </component>
            </organizer>
          </entry>
          <!-- PI_CCTPE_2  -->
          <entry>
            <organizer classCode="CLUSTER" moodCode="EVN">
              <templateId root="2.16.840.1.113883.10.20.24.3.98"/>
              <templateId root="2.16.840.1.113883.10.20.27.3.28"
                extension="2017-06-01"/>
              <id root="ac575aef-7062-4ea2-b723-df517cfa470a"/>
              <statusCode code="completed"/>
              <reference typeCode="REFR">
                <externalDocument classCode="DOC" moodCode="EVN">
                  <id root="2.16.840.1.113883.3.7031" extension="PI_CCTPE_2"/>
                  <text>Secure Messaging</text>
                </externalDocument>
              </reference>
              <component>
                <observation classCode="OBS" moodCode="EVN">
                  <!-- PI Numerator Denominator Type Measure Numerator Data templateId -->
                  <templateId root="2.16.840.1.113883.10.20.27.3.31"
                    extension="2016-09-01"/>
                  <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"
                    codeSystemName="ActCode" displayName="Assertion"/>
                  <statusCode code="completed"/>
                  <value xsi:type="CD" code="NUMER"
                    codeSystem="2.16.840.1.113883.5.4" codeSystemName="ActCode"/>
                  <!-- Numerator Count-->
                  <entryRelationship typeCode="SUBJ" inversionInd="true">
                    <observation classCode="OBS" moodCode="EVN">
                      <templateId root="2.16.840.1.113883.10.20.27.3.3"/>
                      <code code="MSRAGG" codeSystem="2.16.840.1.113883.5.4"
                        codeSystemName="ActCode"
                        displayName="rate aggregation"/>
                      <statusCode code="completed"/>
                      <value xsi:type="INT" value="750"/>
                        <methodCode code="COUNT"
                          codeSystem="2.16.840.1.113883.5.84"
                          codeSystemName="ObservationMethod"
                          displayName="Count"/>
                    </observation>
                  </entryRelationship>
                </observation>
              </component>
              <component>
                <observation classCode="OBS" moodCode="EVN">
                  <!-- PI Numerator Denominator Type Measure Denominator Data templateId -->
                  <templateId root="2.16.840.1.113883.10.20.27.3.32"
                    extension="2016-09-01"/>
                  <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"
                    codeSystemName="ActCode" displayName="Assertion"/>
                  <statusCode code="completed"/>
                  <value xsi:type="CD" code="DENOM"
                    codeSystem="2.16.840.1.113883.5.4" codeSystemName="ActCode"/>
                  <!-- Denominator Count-->
                  <entryRelationship typeCode="SUBJ" inversionInd="true">
                    <observation classCode="OBS" moodCode="EVN">
                      <templateId root="2.16.840.1.113883.10.20.27.3.3"/>
                      <code code="MSRAGG" codeSystem="2.16.840.1.113883.5.4"
                        codeSystemName="ActCode"
                        displayName="rate aggregation"/>
                      <statusCode code="completed"/>
                      <value xsi:type="INT" value="800"/>
                      <methodCode code="COUNT"
                        codeSystem="2.16.840.1.113883.5.84"
                        codeSystemName="ObservationMethod"
                        displayName="Count"/>
                    </observation>
                  </entryRelationship>
                </observation>
              </component>
            </organizer>
          </entry>
          <!-- PI_CCTPE_3  -->
          <entry>
            <organizer classCode="CLUSTER" moodCode="EVN">
              <templateId root="2.16.840.1.113883.10.20.24.3.98"/>
              <templateId root="2.16.840.1.113883.10.20.27.3.28"
                extension="2017-06-01"/>
              <id root="ac575aef-7062-4ea2-b723-df517cfa470a"/>
              <statusCode code="completed"/>
              <reference typeCode="REFR">
                <externalDocument classCode="DOC" moodCode="EVN">
                  <id root="2.16.840.1.113883.3.7031" extension="PI_CCTPE_3"/>
                  <text>Patient-Generated Health Data</text>
                </externalDocument>
              </reference>
              <component>
                <observation classCode="OBS" moodCode="EVN">
                  <!-- PI Numerator Denominator Type Measure Numerator Data templateId -->
                  <templateId root="2.16.840.1.113883.10.20.27.3.31"
                    extension="2016-09-01"/>
                  <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"
                    codeSystemName="ActCode" displayName="Assertion"/>
                  <statusCode code="completed"/>
                  <value xsi:type="CD" code="NUMER"
                    codeSystem="2.16.840.1.113883.5.4" codeSystemName="ActCode"/>
                  <!-- Numerator Count-->
                  <entryRelationship typeCode="SUBJ" inversionInd="true">
                    <observation classCode="OBS" moodCode="EVN">
                      <templateId root="2.16.840.1.113883.10.20.27.3.3"/>
                      <code code="MSRAGG" codeSystem="2.16.840.1.113883.5.4"
                        codeSystemName="ActCode"
                        displayName="rate aggregation"/>
                      <statusCode code="completed"/>
                      <value xsi:type="INT" value="330"/>
                        <methodCode code="COUNT"
                          codeSystem="2.16.840.1.113883.5.84"
                          codeSystemName="ObservationMethod"
                          displayName="Count"/>
                    </observation>
                  </entryRelationship>
                </observation>
              </component>
              <component>
                <observation classCode="OBS" moodCode="EVN">
                  <!-- PI Numerator Denominator Type Measure Denominator Data templateId -->
                  <templateId root="2.16.840.1.113883.10.20.27.3.32"
                    extension="2016-09-01"/>
                  <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"
                    codeSystemName="ActCode" displayName="Assertion"/>
                  <statusCode code="completed"/>
                  <value xsi:type="CD" code="DENOM"
                    codeSystem="2.16.840.1.113883.5.4" codeSystemName="ActCode"/>
                  <!-- Denominator Count-->
                  <entryRelationship typeCode="SUBJ" inversionInd="true">
                    <observation classCode="OBS" moodCode="EVN">
                      <templateId root="2.16.840.1.113883.10.20.27.3.3"/>
                      <code code="MSRAGG" codeSystem="2.16.840.1.113883.5.4"
                        codeSystemName="ActCode"
                        displayName="rate aggregation"/>
                      <statusCode code="completed"/>
                      <value xsi:type="INT" value="800"/>
                      <methodCode code="COUNT"
                        codeSystem="2.16.840.1.113883.5.84"
                        codeSystemName="ObservationMethod"
                        displayName="Count"/>
                    </observation>
                  </entryRelationship>
                </observation>
              </component>
            </organizer>
          </entry>
          <!-- Health Information Exchange -->
          <!-- PI_HIE_1  -->
          <entry>
            <organizer classCode="CLUSTER" moodCode="EVN">
              <templateId root="2.16.840.1.113883.10.20.24.3.98"/>
              <templateId root="2.16.840.1.113883.10.20.27.3.28"
                extension="2017-06-01"/>
              <id root="ac575aef-7062-4ea2-b723-df517cfa470a"/>
              <statusCode code="completed"/>
              <reference typeCode="REFR">
                <externalDocument classCode="DOC" moodCode="EVN">
                  <id root="2.16.840.1.113883.3.7031" extension="PI_HIE_1"/>
                  <text>Send a Summary of Care</text>
                </externalDocument>
              </reference>
              <component>
                <observation classCode="OBS" moodCode="EVN">
                  <!-- PI Numerator Denominator Type Measure Numerator Data templateId -->
                  <templateId root="2.16.840.1.113883.10.20.27.3.31"
                    extension="2016-09-01"/>
                  <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"
                    codeSystemName="ActCode" displayName="Assertion"/>
                  <statusCode code="completed"/>
                  <value xsi:type="CD" code="NUMER"
                    codeSystem="2.16.840.1.113883.5.4" codeSystemName="ActCode"/>
                  <!-- Numerator Count-->
                  <entryRelationship typeCode="SUBJ" inversionInd="true">
                    <observation classCode="OBS" moodCode="EVN">
                      <templateId root="2.16.840.1.113883.10.20.27.3.3"/>
                      <code code="MSRAGG" codeSystem="2.16.840.1.113883.5.4"
                        codeSystemName="ActCode"
                        displayName="rate aggregation"/>
                      <statusCode code="completed"/>
                      <value xsi:type="INT" value="730"/>
                        <methodCode code="COUNT"
                          codeSystem="2.16.840.1.113883.5.84"
                          codeSystemName="ObservationMethod"
                          displayName="Count"/>
                    </observation>
                  </entryRelationship>
                </observation>
              </component>
              <component>
                <observation classCode="OBS" moodCode="EVN">
                  <!-- PI Numerator Denominator Type Measure Denominator Data templateId -->
                  <templateId root="2.16.840.1.113883.10.20.27.3.32"
                    extension="2016-09-01"/>
                  <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"
                    codeSystemName="ActCode" displayName="Assertion"/>
                  <statusCode code="completed"/>
                  <value xsi:type="CD" code="DENOM"
                    codeSystem="2.16.840.1.113883.5.4" codeSystemName="ActCode"/>
                  <!-- Denominator Count-->
                  <entryRelationship typeCode="SUBJ" inversionInd="true">
                    <observation classCode="OBS" moodCode="EVN">
                      <templateId root="2.16.840.1.113883.10.20.27.3.3"/>
                      <code code="MSRAGG" codeSystem="2.16.840.1.113883.5.4"
                        codeSystemName="ActCode"
                        displayName="rate aggregation"/>
                      <statusCode code="completed"/>
                      <value xsi:type="INT" value="800"/>
                      <methodCode code="COUNT"
                        codeSystem="2.16.840.1.113883.5.84"
                        codeSystemName="ObservationMethod"
                        displayName="Count"/>
                    </observation>
                  </entryRelationship>
                </observation>
              </component>
            </organizer>
          </entry>
          <!-- PI_HIE_2  -->
          <entry>
            <organizer classCode="CLUSTER" moodCode="EVN">
              <templateId root="2.16.840.1.113883.10.20.24.3.98"/>
              <templateId root="2.16.840.1.113883.10.20.27.3.28"
                extension="2017-06-01"/>
              <id root="ac575aef-7062-4ea2-b723-df517cfa470a"/>
              <statusCode code="completed"/>
              <reference typeCode="REFR">
                <externalDocument classCode="DOC" moodCode="EVN">
                  <id root="2.16.840.1.113883.3.7031" extension="PI_HIE_2"/>
                  <text>Request/Accept Summary of Care</text>
                </externalDocument>
              </reference>
              <component>
                <observation classCode="OBS" moodCode="EVN">
                  <!-- PI Numerator Denominator Type Measure Numerator Data templateId -->
                  <templateId root="2.16.840.1.113883.10.20.27.3.31"
                    extension="2016-09-01"/>
                  <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"
                    codeSystemName="ActCode" displayName="Assertion"/>
                  <statusCode code="completed"/>
                  <value xsi:type="CD" code="NUMER"
                    codeSystem="2.16.840.1.113883.5.4" codeSystemName="ActCode"/>
                  <!-- Numerator Count-->
                  <entryRelationship typeCode="SUBJ" inversionInd="true">
                    <observation classCode="OBS" moodCode="EVN">
                      <templateId root="2.16.840.1.113883.10.20.27.3.3"/>
                      <code code="MSRAGG" codeSystem="2.16.840.1.113883.5.4"
                        codeSystemName="ActCode"
                        displayName="rate aggregation"/>
                      <statusCode code="completed"/>
                      <value xsi:type="INT" value="530"/>
                        <methodCode code="COUNT"
                          codeSystem="2.16.840.1.113883.5.84"
                          codeSystemName="ObservationMethod"
                          displayName="Count"/>
                    </observation>
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              <component>
                <observation classCode="OBS" moodCode="EVN">
                  <!-- PI Numerator Denominator Type Measure Denominator Data templateId -->
                  <templateId root="2.16.840.1.113883.10.20.27.3.32"
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                  <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"
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                  <statusCode code="completed"/>
                  <value xsi:type="CD" code="DENOM"
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                  <!-- Denominator Count-->
                  <entryRelationship typeCode="SUBJ" inversionInd="true">
                    <observation classCode="OBS" moodCode="EVN">
                      <templateId root="2.16.840.1.113883.10.20.27.3.3"/>
                      <code code="MSRAGG" codeSystem="2.16.840.1.113883.5.4"
                        codeSystemName="ActCode"
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                      <statusCode code="completed"/>
                      <value xsi:type="INT" value="800"/>
                      <methodCode code="COUNT"
                        codeSystem="2.16.840.1.113883.5.84"
                        codeSystemName="ObservationMethod"
                        displayName="Count"/>
                    </observation>
                  </entryRelationship>
                </observation>
              </component>
            </organizer>
          </entry>
          <!-- PI_HIE_3  -->
          <entry>
            <organizer classCode="CLUSTER" moodCode="EVN">
              <templateId root="2.16.840.1.113883.10.20.24.3.98"/>
              <templateId root="2.16.840.1.113883.10.20.27.3.28"
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              <id root="ac575aef-7062-4ea2-b723-df517cfa470a"/>
              <statusCode code="completed"/>
              <reference typeCode="REFR">
                <externalDocument classCode="DOC" moodCode="EVN">
                  <id root="2.16.840.1.113883.3.7031" extension="PI_HIE_3"/>
                  <text>Clinical Information Reconciliation</text>
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              </reference>
              <component>
                <observation classCode="OBS" moodCode="EVN">
                  <!-- PI Numerator Denominator Type Measure Numerator Data templateId -->
                  <templateId root="2.16.840.1.113883.10.20.27.3.31"
                    extension="2016-09-01"/>
                  <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"
                    codeSystemName="ActCode" displayName="Assertion"/>
                  <statusCode code="completed"/>
                  <value xsi:type="CD" code="NUMER"
                    codeSystem="2.16.840.1.113883.5.4" codeSystemName="ActCode"/>
                  <!-- Numerator Count-->
                  <entryRelationship typeCode="SUBJ" inversionInd="true">
                    <observation classCode="OBS" moodCode="EVN">
                      <templateId root="2.16.840.1.113883.10.20.27.3.3"/>
                      <code code="MSRAGG" codeSystem="2.16.840.1.113883.5.4"
                        codeSystemName="ActCode"
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                      <statusCode code="completed"/>
                      <value xsi:type="INT" value="612"/>
                        <methodCode code="COUNT"
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                          codeSystemName="ObservationMethod"
                          displayName="Count"/>
                    </observation>
                  </entryRelationship>
                </observation>
              </component>
              <component>
                <observation classCode="OBS" moodCode="EVN">
                  <!-- PI Numerator Denominator Type Measure Denominator Data templateId -->
                  <templateId root="2.16.840.1.113883.10.20.27.3.32"
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                  <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"
                    codeSystemName="ActCode" displayName="Assertion"/>
                  <statusCode code="completed"/>
                  <value xsi:type="CD" code="DENOM"
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                  <!-- Denominator Count-->
                  <entryRelationship typeCode="SUBJ" inversionInd="true">
                    <observation classCode="OBS" moodCode="EVN">
                      <templateId root="2.16.840.1.113883.10.20.27.3.3"/>
                      <code code="MSRAGG" codeSystem="2.16.840.1.113883.5.4"
                        codeSystemName="ActCode"
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                      <statusCode code="completed"/>
                      <value xsi:type="INT" value="800"/>
                      <methodCode code="COUNT"
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                        codeSystemName="ObservationMethod"
                        displayName="Count"/>
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                  </entryRelationship>
                </observation>
              </component>
            </organizer>
          </entry>
          <!-- Public Health and Clinical Data Registry Reporting -->
          <!-- PI_PHCDRR_1 -->
          <entry>
            <organizer classCode="CLUSTER" moodCode="EVN">
              <!-- Implied template Measure Reference templateId -->
              <templateId root="2.16.840.1.113883.10.20.24.3.98"/>
              <!-- PI Measure Performed Measure Reference and Results templateId -->
              <templateId root="2.16.840.1.113883.10.20.27.3.29"
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              <id root="ac575aef-7062-4ea2-b723-df517cfa470a"/>
              <statusCode code="completed"/>
              <reference typeCode="REFR">
                <externalDocument classCode="DOC" moodCode="EVN">
                  <id root="2.16.840.1.113883.3.7031" extension="PI_PHCDRR_1"/>
                  <text>Immunization Registry Reporting</text>
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              </reference>
              <component>
                <observation classCode="OBS" moodCode="EVN">
                  <templateId root="2.16.840.1.113883.10.20.27.3.27"
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                  <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"
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                  <statusCode code="completed"/>
                  <value xsi:type="CD" code="Y" codeSystem="2.16.840.1.113883.12.136"
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              </component>
            </organizer>
          </entry>
          <!-- PI_PHCDRR_2 -->
          <entry>
            <organizer classCode="CLUSTER" moodCode="EVN">
              <!-- Implied template Measure Reference templateId -->
              <templateId root="2.16.840.1.113883.10.20.24.3.98"/>
              <!-- PI Measure Performed Measure Reference and Results templateId -->
              <templateId root="2.16.840.1.113883.10.20.27.3.29"
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              <id root="ac575aef-7062-4ea2-b723-df517cfa470a"/>
              <statusCode code="completed"/>
              <reference typeCode="REFR">
                <externalDocument classCode="DOC" moodCode="EVN">
                  <id root="2.16.840.1.113883.3.7031" extension="PI_PHCDRR_2"/>
                  <text>(Optional) Syndromic Surveillance Reporting</text>
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              </reference>
              <component>
                <observation classCode="OBS" moodCode="EVN">
                  <templateId root="2.16.840.1.113883.10.20.27.3.27"
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                  <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"
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                  <statusCode code="completed"/>
                  <value xsi:type="CD" code="Y" codeSystem="2.16.840.1.113883.12.136"
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              </component>
            </organizer>
          </entry>
          <!-- PI_PHCDRR_3 -->
          <entry>
            <organizer classCode="CLUSTER" moodCode="EVN">
              <!-- Implied template Measure Reference templateId -->
              <templateId root="2.16.840.1.113883.10.20.24.3.98"/>
              <!-- PI Measure Performed Measure Reference and Results templateId -->
              <templateId root="2.16.840.1.113883.10.20.27.3.29"
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              <id root="ac575aef-7062-4ea2-b723-df517cfa470a"/>
              <statusCode code="completed"/>
              <reference typeCode="REFR">
                <externalDocument classCode="DOC" moodCode="EVN">
                  <id root="2.16.840.1.113883.3.7031" extension="PI_PHCDRR_3"/>
                  <text>(Optional) Electronic Case Reporting</text>
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              </reference>
              <component>
                <observation classCode="OBS" moodCode="EVN">
                  <templateId root="2.16.840.1.113883.10.20.27.3.27"
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                  <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"
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                  <statusCode code="completed"/>
                  <value xsi:type="CD" code="Y" codeSystem="2.16.840.1.113883.12.136"
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              </component>
            </organizer>
          </entry>
          <!-- PI_PHCDRR_4 -->
          <entry>
            <organizer classCode="CLUSTER" moodCode="EVN">
              <!-- Implied template Measure Reference templateId -->
              <templateId root="2.16.840.1.113883.10.20.24.3.98"/>
              <!-- PI Measure Performed Measure Reference and Results templateId -->
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              <statusCode code="completed"/>
              <reference typeCode="REFR">
                <externalDocument classCode="DOC" moodCode="EVN">
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                  <text>(Optional) Public Health Registry Reporting</text>
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              </reference>
              <component>
                <observation classCode="OBS" moodCode="EVN">
                  <templateId root="2.16.840.1.113883.10.20.27.3.27"
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                  <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"
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                  <value xsi:type="CD" code="Y" codeSystem="2.16.840.1.113883.12.136"
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              </component>
            </organizer>
          </entry>
          <!-- PI_PHCDRR_5 -->
          <entry>
            <organizer classCode="CLUSTER" moodCode="EVN">
              <!-- Implied template Measure Reference templateId -->
              <templateId root="2.16.840.1.113883.10.20.24.3.98"/>
              <!-- PI Numerator Measure Performed Measure Reference and Results templateId -->
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              <id root="ac575aef-7062-4ea2-b723-df517cfa470a"/>
              <statusCode code="completed"/>
              <reference typeCode="REFR">
                <externalDocument classCode="DOC" moodCode="EVN">
                  <id root="2.16.840.1.113883.3.7031" extension="PI_PHCDRR_5"/>
                  <text>(Optional) Clinical Data Registry Reporting</text>
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              </reference>
              <component>
                <observation classCode="OBS" moodCode="EVN">
                  <templateId root="2.16.840.1.113883.10.20.27.3.27"
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                  <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"
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                  <statusCode code="completed"/>
                  <value xsi:type="CD" code="Y" codeSystem="2.16.840.1.113883.12.136"
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              </component>
            </organizer>
          </entry>
          <!-- Transition measures -->
          <!-- PI_TRANS_PPHI_1 -->
          <entry>
            <organizer classCode="CLUSTER" moodCode="EVN">
              <!-- Implied template Measure Reference templateId -->
              <templateId root="2.16.840.1.113883.10.20.24.3.98"/>
              <!-- PI Numerator Measure Performed Measure Reference and Results templateId -->
              <templateId root="2.16.840.1.113883.10.20.27.3.29"
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              <statusCode code="completed"/>
              <reference typeCode="REFR">
                <externalDocument classCode="DOC" moodCode="EVN">
                  <id root="2.16.840.1.113883.3.7031" extension="PI_TRANS_PPHI_1"/>
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              <component>
                <observation classCode="OBS" moodCode="EVN">
                  <templateId root="2.16.840.1.113883.10.20.27.3.27"
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                  <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"
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          </entry>
          <!-- PI_TRANS_EP_1 -->
          <entry>
            <organizer classCode="CLUSTER" moodCode="EVN">
              <templateId root="2.16.840.1.113883.10.20.24.3.98"/>
              <templateId root="2.16.840.1.113883.10.20.27.3.28"
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              <statusCode code="completed"/>
              <reference typeCode="REFR">
                <externalDocument classCode="DOC" moodCode="EVN">
                  <id root="2.16.840.1.113883.3.7031" extension="PI_TRANS_EP_1"/>
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              </reference>
              <component>
                <observation classCode="OBS" moodCode="EVN">
                  <!-- PI Numerator Denominator Type Measure Numerator Data templateId -->
                  <templateId root="2.16.840.1.113883.10.20.27.3.31"
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                  <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"
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                  <!-- Numerator Count-->
                  <entryRelationship typeCode="SUBJ" inversionInd="true">
                    <observation classCode="OBS" moodCode="EVN">
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                      <methodCode code="COUNT"
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              </component>
              <component>
                <observation classCode="OBS" moodCode="EVN">
                  <!-- PI Numerator Denominator Type Measure Denominator Data templateId -->
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                  <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"
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                  <!-- Denominator Count-->
                  <entryRelationship typeCode="SUBJ" inversionInd="true">
                    <observation classCode="OBS" moodCode="EVN">
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                      <code code="MSRAGG" codeSystem="2.16.840.1.113883.5.4"
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                      <statusCode code="completed"/>
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                      <methodCode code="COUNT"
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                        codeSystemName="ObservationMethod"
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              </component>
            </organizer>
          </entry>
          <!-- Patient Electronic Access -->
          <!-- PI_TRANS_PEA_1  -->
          <entry>
            <organizer classCode="CLUSTER" moodCode="EVN">
              <templateId root="2.16.840.1.113883.10.20.24.3.98"/>
              <templateId root="2.16.840.1.113883.10.20.27.3.28"
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              <statusCode code="completed"/>
              <reference typeCode="REFR">
                <externalDocument classCode="DOC" moodCode="EVN">
                  <id root="2.16.840.1.113883.3.7031" extension="PI_TRANS_PEA_1"/>
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              </reference>
              <component>
                <observation classCode="OBS" moodCode="EVN">
                  <!-- PI Numerator Denominator Type Measure Numerator Data templateId -->
                  <templateId root="2.16.840.1.113883.10.20.27.3.31"
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                  <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"
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                  <statusCode code="completed"/>
                  <value xsi:type="CD" code="NUMER"
                    codeSystem="2.16.840.1.113883.5.4" codeSystemName="ActCode"/>
                  <!-- Numerator Count-->
                  <entryRelationship typeCode="SUBJ" inversionInd="true">
                    <observation classCode="OBS" moodCode="EVN">
                      <templateId root="2.16.840.1.113883.10.20.27.3.3"/>
                      <code code="MSRAGG" codeSystem="2.16.840.1.113883.5.4"
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                      <statusCode code="completed"/>
                      <value xsi:type="INT" value="722"/>
                      <methodCode code="COUNT"
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                        codeSystemName="ObservationMethod"
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                    </observation>
                  </entryRelationship>
                </observation>
              </component>
              <component>
                <observation classCode="OBS" moodCode="EVN">
                  <!-- PI Numerator Denominator Type Measure Denominator Data templateId -->
                  <templateId root="2.16.840.1.113883.10.20.27.3.32"
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                  <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"
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                  <!-- Denominator Count-->
                  <entryRelationship typeCode="SUBJ" inversionInd="true">
                    <observation classCode="OBS" moodCode="EVN">
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                      <code code="MSRAGG" codeSystem="2.16.840.1.113883.5.4"
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                      <methodCode code="COUNT"
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          </entry>
          <!-- PI_TRANS_PEA_2  -->
          <entry>
            <organizer classCode="CLUSTER" moodCode="EVN">
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              <templateId root="2.16.840.1.113883.10.20.27.3.28"
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              <id root="ac575aef-7062-4ea2-b723-df517cfa470a"/>
              <statusCode code="completed"/>
              <reference typeCode="REFR">
                <externalDocument classCode="DOC" moodCode="EVN">
                  <id root="2.16.840.1.113883.3.7031" extension="PI_TRANS_PEA_2"/>
                  <text>View, Download, or Transmit (VDT)</text>
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              </reference>
              <component>
                <observation classCode="OBS" moodCode="EVN">
                  <!-- PI Numerator Denominator Type Measure Numerator Data templateId -->
                  <templateId root="2.16.840.1.113883.10.20.27.3.31"
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                  <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"
                    codeSystemName="ActCode" displayName="Assertion"/>
                  <statusCode code="completed"/>
                  <value xsi:type="CD" code="NUMER"
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                  <!-- Numerator Count-->
                  <entryRelationship typeCode="SUBJ" inversionInd="true">
                    <observation classCode="OBS" moodCode="EVN">
                      <templateId root="2.16.840.1.113883.10.20.27.3.3"/>
                      <code code="MSRAGG" codeSystem="2.16.840.1.113883.5.4"
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                      <statusCode code="completed"/>
                      <value xsi:type="INT" value="537"/>
                      <methodCode code="COUNT"
                        codeSystem="2.16.840.1.113883.5.84"
                        codeSystemName="ObservationMethod"
                        displayName="Count"/>
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                  </entryRelationship>
                </observation>
              </component>
              <component>
                <observation classCode="OBS" moodCode="EVN">
                  <!-- PI Numerator Denominator Type Measure Denominator Data templateId -->
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                  <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"
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                  <!-- Denominator Count-->
                  <entryRelationship typeCode="SUBJ" inversionInd="true">
                    <observation classCode="OBS" moodCode="EVN">
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                      <methodCode code="COUNT"
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          </entry>
          <!-- PI_TRANS_PSE_1  -->
          <entry>
            <organizer classCode="CLUSTER" moodCode="EVN">
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              <reference typeCode="REFR">
                <externalDocument classCode="DOC" moodCode="EVN">
                  <id root="2.16.840.1.113883.3.7031" extension="PI_TRANS_PSE_1"/>
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              <component>
                <observation classCode="OBS" moodCode="EVN">
                  <!-- PI Numerator Denominator Type Measure Numerator Data templateId -->
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                  <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"
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                  <!-- Numerator Count-->
                  <entryRelationship typeCode="SUBJ" inversionInd="true">
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      <!--
      ********************************************************
      Improvement Activity Section
      ********************************************************
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          <title>Measure Section</title>
          <text>
            <table border="1" width="100%">
              <thead>
                <tr>
                  <th>Improvement Activity</th>
                  <th>Activity Identifier</th>
                  <th>Question Answer Code</th>
                </tr>
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                <tr>
                  <td>Provide 24/7 access to eligible clinicians or groups who have real-time access to patient's medical record</td>
                  <td>IA_EPA_1</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Use of telehealth services that expand practice access</td>
                  <td>IA_EPA_2</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Collection and use of patient experience and satisfaction data on access</td>
                  <td>IA_EPA_3</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Additional improvements in access as a result of QIN/QIO TA</td>
                  <td>IA_EPA_4</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Participation in systematic anticoagulation program</td>
                  <td>IA_PM_1</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Anticoagulant management improvements</td>
                  <td>IA_PM_2</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>RHC, IHS or FQHC quality improvement activities</td>
                  <td>IA_PM_3</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Glycemic management services</td>
                  <td>IA_PM_4</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Engagement of community for health status improvement</td>
                  <td>IA_PM_5</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Use of toolsets or other resources to close healthcare disparities across communities</td>
                  <td>IA_PM_6</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Use of QCDR for feedback reports that incorporate population health</td>
                  <td>IA_PM_7</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Participation in CMMI models such as Million Hearts Campaign</td>
                  <td>IA_PM_8</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Participation in population health research</td>
                  <td>IA_PM_9</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Use of QCDR data for quality improvement such as comparative analysis reports across patient populations</td>
                  <td>IA_PM_10</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Regular review practices in place on targeted patient population needs</td>
                  <td>IA_PM_11</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Population empanelment</td>
                  <td>IA_PM_12</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Chronic care and preventative care management for empanelled patients</td>
                  <td>IA_PM_13</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Implementation of methodologies for improvements in longitudinal care management for high risk patients</td>
                  <td>IA_PM_14</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Implementation of episodic care management practice improvements</td>
                  <td>IA_PM_15</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Implementation of medication management practice improvements</td>
                  <td>IA_PM_16</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Implementation of use of specialist reports back to referring clinician or group to close referral loop</td>
                  <td>IA_CC_1</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Implementation of improvements that contribute to more timely communication of test results</td>
                  <td>IA_CC_2</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Implementation of additional activity as a result of TA for improving care coordination</td>
                  <td>IA_CC_3</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>TCPI participation</td>
                  <td>IA_CC_4</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>CMS partner in Patients Hospital Engagement Network</td>
                  <td>IA_CC_5</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Use of QCDR to promote standard practices, tools and processes in practice for improvement in care coordination</td>
                  <td>IA_CC_6</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Regular training in care coordination</td>
                  <td>IA_CC_7</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Implementation of documentation improvements for practice/process improvements</td>
                  <td>IA_CC_8</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Implementation of practices/processes for developing regular individual care plans</td>
                  <td>IA_CC_9</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Care transition documentation practice improvements</td>
                  <td>IA_CC_10</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Care transition standard operational improvements</td>
                  <td>IA_CC_11</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Care coordination agreements that promote improvements in patient tracking across settings</td>
                  <td>IA_CC_12</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Practice improvements for bilateral exchange of patient information</td>
                  <td>IA_CC_13</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Practice improvements that engage community resources to support patient health goals</td>
                  <td>IA_CC_14</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Use of certified EHR to capture patient reported outcomes</td>
                  <td>IA_BE_1</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Use of QCDR to support clinical decision making</td>
                  <td>IA_BE_2</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Engagement with QIN-QIO to implement self-management training programs</td>
                  <td>IA_BE_3</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Engagement of patients through implementation of improvements in patient portal</td>
                  <td>IA_BE_4</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Enhancements/regular updates to practice websites/tools that also include considerations for patients with cognitive disabilities</td>
                  <td>IA_BE_5</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Collection and follow-up on patient experience and satisfaction data on beneficiary engagement</td>
                  <td>IA_BE_6</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Participation in a QCDR, that promotes use of patient engagement tools.</td>
                  <td>IA_BE_7</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Participation in a QCDR, that promotes collaborative learning network opportunities that are interactive.</td>
                  <td>IA_BE_8</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Use of QCDR patient experience data to inform and advance improvements in beneficiary engagement.</td>
                  <td>IA_BE_9</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Participation in a QCDR, that promotes implementation of patient self-action plans.</td>
                  <td>IA_BE_10</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Participation in a QCDR, that promotes use of processes and tools that engage patients for adherence to treatment plan.</td>
                  <td>IA_BE_11</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Use evidence-based decision aids to support shared decision-making.</td>
                  <td>IA_BE_12</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Regularly assess the patient experience of care through surveys, advisory councils and/or other mechanisms.</td>
                  <td>IA_BE_13</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Engage patients and families to guide improvement in the system of care.</td>
                  <td>IA_BE_14</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Engagement of patients, family and caregivers in developing a plan of care</td>
                  <td>IA_BE_15</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Evidenced-based techniques to promote self-management into usual care</td>
                  <td>IA_BE_16</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Use of tools to assist patient self-management</td>
                  <td>IA_BE_17</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Provide peer-led support for self-management.</td>
                  <td>IA_BE_18</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Use group visits for common chronic conditions (e.g., diabetes).</td>
                  <td>IA_BE_19</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Implementation of condition-specific chronic disease self-management support programs</td>
                  <td>IA_BE_20</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Improved practices that disseminate appropriate self-management materials</td>
                  <td>IA_BE_21</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Improved practices that engage patients pre-visit</td>
                  <td>IA_BE_22</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Integration of patient coaching practices between visits</td>
                  <td>IA_BE_23</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Participation in an AHRQ-listed patient safety organization.</td>
                  <td>IA_PSPA_1</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Participation in MOC Part IV</td>
                  <td>IA_PSPA_2</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Participate in IHI Training/Forum Event; National Academy of Medicine, AHRQ Team STEPPS or other similar activity.</td>
                  <td>IA_PSPA_3</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Administration of the AHRQ Survey of Patient Safety Culture</td>
                  <td>IA_PSPA_4</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Annual registration in the Prescription Drug Monitoring Program</td>
                  <td>IA_PSPA_5</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Consultation of the Prescription Drug Monitoring program</td>
                  <td>IA_PSPA_6</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Use of QCDR data for ongoing practice assessment and improvements</td>
                  <td>IA_PSPA_7</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Use of patient safety tools</td>
                  <td>IA_PSPA_8</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Completion of the AMA STEPS Forward program</td>
                  <td>IA_PSPA_9</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Completion of training and receipt of approved waiver for provision opioid medication-assisted treatments</td>
                  <td>IA_PSPA_10</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Participation in CAHPS or other supplemental questionnaire</td>
                  <td>IA_PSPA_11</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Participation in private payer CPIA</td>
                  <td>IA_PSPA_12</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Participation in Joint Commission Evaluation Initiative</td>
                  <td>IA_PSPA_13</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Participation in Bridges to Excellence or other similar program</td>
                  <td>IA_PSPA_14</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Implementation of antibiotic stewardship program</td>
                  <td>IA_PSPA_15</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Use of decision support and standardized treatment protocols</td>
                  <td>IA_PSPA_16</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Implementation of analytic capabilities to manage total cost of care for practice population</td>
                  <td>IA_PSPA_17</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Measurement and improvement at the practice and panel level</td>
                  <td>IA_PSPA_18</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Implementation of formal quality improvement methods, practice changes or other practice improvement processes</td>
                  <td>IA_PSPA_19</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Leadership engagement in regular guidance and demonstrated commitment for implementing practice improvement changes</td>
                  <td>IA_PSPA_20</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Implementation of fall screening and assessment programs</td>
                  <td>IA_PSPA_21</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Engagement of new Medicaid patients and follow-up</td>
                  <td>IA_AHE_1</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Leveraging a QCDR to standardize processes for screening</td>
                  <td>IA_AHE_2</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Leveraging a QCDR to promote use of patient-reported outcome tools</td>
                  <td>IA_AHE_3</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Leveraging a QCDR for use of standard questionnaires</td>
                  <td>IA_AHE_4</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Participation on Disaster Medical Assistance Team, registered for 6 months.</td>
                  <td>IA_ERP_1</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Participation in a 60-day or greater effort to support domestic or international humanitarian needs.</td>
                  <td>IA_ERP_2</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Diabetes screening</td>
                  <td>IA_BMH_1</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Tobacco use</td>
                  <td>IA_BMH_2</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Unhealthy alcohol use</td>
                  <td>IA_BMH_3</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Depression screening</td>
                  <td>IA_BMH_4</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>MDD prevention and treatment interventions</td>
                  <td>IA_BMH_5</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Implementation of co-location PCP and MH services</td>
                  <td>IA_BMH_6</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Implementation of integrated PCBH model</td>
                  <td>IA_BMH_7</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Electronic Health Record Enhancements for BH data capture</td>
                  <td>IA_BMH_8</td>
                  <td>Y</td>
                </tr>
                <tr>
                  <td>Electronic submission of Patient Centered Medical Home accreditation</td>
                  <td>IA_PCMH</td>
                  <td>Y</td>
                </tr>
              </tbody>
            </table>
          </text>
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          <!-- improvement activity: IA_PM_10 -->
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          <!-- improvement activity: IA_PM_11 -->
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          <!-- improvement activity: IA_PM_12 -->
          <entry>
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          <!-- improvement activity: IA_PM_13 -->
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          <!-- improvement activity: IA_PM_14 -->
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          <!-- improvement activity: IA_CC_6 -->
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          <!-- improvement activity: IA_CC_9 -->
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          <!-- improvement activity: IA_CC_10 -->
          <entry>
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          <!-- improvement activity: IA_CC_11 -->
          <entry>
            <organizer classCode="CLUSTER" moodCode="EVN">
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          </entry>
          <!-- improvement activity: IA_CC_12 -->
          <entry>
            <organizer classCode="CLUSTER" moodCode="EVN">
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                  <text>Care coordination agreements that promote improvements in patient tracking across settings</text>
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                <observation classCode="OBS" moodCode="EVN">
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            </organizer>
          </entry>
          <!-- improvement activity: IA_CC_13 -->
          <entry>
            <organizer classCode="CLUSTER" moodCode="EVN">
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                  <text>Practice improvements for bilateral exchange of patient information</text>
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                <observation classCode="OBS" moodCode="EVN">
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            </organizer>
          </entry>
          <!-- improvement activity: IA_CC_14 -->
          <entry>
            <organizer classCode="CLUSTER" moodCode="EVN">
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                  <text>Practice improvements that engage community resources to support patient health goals</text>
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                <observation classCode="OBS" moodCode="EVN">
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          </entry>
          <!-- improvement activity: IA_BE_1 -->
          <entry>
            <organizer classCode="CLUSTER" moodCode="EVN">
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                <externalDocument classCode="DOC" moodCode="EVN">
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                  <text>Use of certified EHR to capture patient reported outcomes</text>
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                <observation classCode="OBS" moodCode="EVN">
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            </organizer>
          </entry>
          <!-- improvement activity: IA_BE_2 -->
          <entry>
            <organizer classCode="CLUSTER" moodCode="EVN">
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                <externalDocument classCode="DOC" moodCode="EVN">
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                  <text>Use of QCDR to support clinical decision making</text>
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                <observation classCode="OBS" moodCode="EVN">
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          </entry>
          <!-- improvement activity: IA_BE_3 -->
          <entry>
            <organizer classCode="CLUSTER" moodCode="EVN">
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                  <text>Engagement with QIN-QIO to implement self-management training programs</text>
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                <observation classCode="OBS" moodCode="EVN">
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          <!-- improvement activity: IA_BE_4 -->
          <entry>
            <organizer classCode="CLUSTER" moodCode="EVN">
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          <!-- improvement activity: IA_BE_5 -->
          <entry>
            <organizer classCode="CLUSTER" moodCode="EVN">
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          <!-- improvement activity: IA_BE_6 -->
          <entry>
            <organizer classCode="CLUSTER" moodCode="EVN">
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          <!-- improvement activity: IA_BE_7 -->
          <entry>
            <organizer classCode="CLUSTER" moodCode="EVN">
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                  <text>Participation in a QCDR, that promotes use of patient engagement tools.</text>
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          <!-- improvement activity: IA_BE_8 -->
          <entry>
            <organizer classCode="CLUSTER" moodCode="EVN">
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          <!-- improvement activity: IA_BE_9 -->
          <entry>
            <organizer classCode="CLUSTER" moodCode="EVN">
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                <externalDocument classCode="DOC" moodCode="EVN">
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          <!-- improvement activity: IA_BE_10 -->
          <entry>
            <organizer classCode="CLUSTER" moodCode="EVN">
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          <!-- improvement activity: IA_BE_11 -->
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            <organizer classCode="CLUSTER" moodCode="EVN">
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          <!-- improvement activity: IA_BE_12 -->
          <entry>
            <organizer classCode="CLUSTER" moodCode="EVN">
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                <observation classCode="OBS" moodCode="EVN">
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                    extension="2016-09-01"/>
                  <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"
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                  <statusCode code="completed"/>
                  <value xsi:type="CD" code="Y" displayName="Yes"
                    codeSystemName="Yes/no indicator (HL7 Table 0136)"
                    codeSystem="2.16.840.1.113883.12.136"/>
                </observation>
              </component>
            </organizer>
          </entry>
          <!-- improvement activity: IA_BE_13 -->
          <entry>
            <organizer classCode="CLUSTER" moodCode="EVN">
              <templateId root="2.16.840.1.113883.10.20.24.3.98"/>
              <templateId root="2.16.840.1.113883.10.20.27.3.33"
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              <id root="ae58d929-3574-47ae-87b8-438d2eac86d9"/>
              <statusCode code="completed"/>
              <reference typeCode="REFR">
                <externalDocument classCode="DOC" moodCode="EVN">
                  <id root="2.16.840.1.113883.3.7034" extension="IA_BE_13"/>
                  <text>Regularly assess the patient experience of care through surveys, advisory councils and/or other mechanisms.</text>
                </externalDocument>
              </reference>
              <component>
                <observation classCode="OBS" moodCode="EVN">
                  <templateId root="2.16.840.1.113883.10.20.27.3.27"
                    extension="2016-09-01"/>
                  <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"
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                  <statusCode code="completed"/>
                  <value xsi:type="CD" code="Y" displayName="Yes"
                    codeSystemName="Yes/no indicator (HL7 Table 0136)"
                    codeSystem="2.16.840.1.113883.12.136"/>
                </observation>
              </component>
            </organizer>
          </entry>
          <!-- improvement activity: IA_BE_14 -->
          <entry>
            <organizer classCode="CLUSTER" moodCode="EVN">
              <templateId root="2.16.840.1.113883.10.20.24.3.98"/>
              <templateId root="2.16.840.1.113883.10.20.27.3.33"
                extension="2016-09-01"/>
              <id root="ae58d929-3574-47ae-87b8-438d2eac86d9"/>
              <statusCode code="completed"/>
              <reference typeCode="REFR">
                <externalDocument classCode="DOC" moodCode="EVN">
                  <id root="2.16.840.1.113883.3.7034" extension="IA_BE_14"/>
                  <text>Engage patients and families to guide improvement in the system of care.</text>
                </externalDocument>
              </reference>
              <component>
                <observation classCode="OBS" moodCode="EVN">
                  <templateId root="2.16.840.1.113883.10.20.27.3.27"
                    extension="2016-09-01"/>
                  <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"
                    codeSystemName="ActCode" displayName="Assertion"/>
                  <statusCode code="completed"/>
                  <value xsi:type="CD" code="Y" displayName="Yes"
                    codeSystemName="Yes/no indicator (HL7 Table 0136)"
                    codeSystem="2.16.840.1.113883.12.136"/>
                </observation>
              </component>
            </organizer>
          </entry>
          <!-- improvement activity: IA_BE_15 -->
          <entry>
            <organizer classCode="CLUSTER" moodCode="EVN">
              <templateId root="2.16.840.1.113883.10.20.24.3.98"/>
              <templateId root="2.16.840.1.113883.10.20.27.3.33"
                extension="2016-09-01"/>
              <id root="ae58d929-3574-47ae-87b8-438d2eac86d9"/>
              <statusCode code="completed"/>
              <reference typeCode="REFR">
                <externalDocument classCode="DOC" moodCode="EVN">
                  <id root="2.16.840.1.113883.3.7034" extension="IA_BE_15"/>
                  <text>Engagement of patients, family and caregivers in developing a plan of care.</text>
                </externalDocument>
              </reference>
              <component>
                <observation classCode="OBS" moodCode="EVN">
                  <templateId root="2.16.840.1.113883.10.20.27.3.27"
                    extension="2016-09-01"/>
                  <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"
                    codeSystemName="ActCode" displayName="Assertion"/>
                  <statusCode code="completed"/>
                  <value xsi:type="CD" code="Y" displayName="Yes"
                    codeSystemName="Yes/no indicator (HL7 Table 0136)"
                    codeSystem="2.16.840.1.113883.12.136"/>
                </observation>
              </component>
            </organizer>
          </entry>
          <!-- improvement activity: IA_BE_16 -->
          <entry>
            <organizer classCode="CLUSTER" moodCode="EVN">
              <templateId root="2.16.840.1.113883.10.20.24.3.98"/>
              <templateId root="2.16.840.1.113883.10.20.27.3.33"
                extension="2016-09-01"/>
              <id root="ae58d929-3574-47ae-87b8-438d2eac86d9"/>
              <statusCode code="completed"/>
              <reference typeCode="REFR">
                <externalDocument classCode="DOC" moodCode="EVN">
                  <id root="2.16.840.1.113883.3.7034" extension="IA_BE_16"/>
                  <text>Evidenced-based techniques to promote self-management into usual care.</text>
                </externalDocument>
              </reference>
              <component>
                <observation classCode="OBS" moodCode="EVN">
                  <templateId root="2.16.840.1.113883.10.20.27.3.27"
                    extension="2016-09-01"/>
                  <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"
                    codeSystemName="ActCode" displayName="Assertion"/>
                  <statusCode code="completed"/>
                  <value xsi:type="CD" code="Y" displayName="Yes"
                    codeSystemName="Yes/no indicator (HL7 Table 0136)"
                    codeSystem="2.16.840.1.113883.12.136"/>
                </observation>
              </component>
            </organizer>
          </entry>
          <!-- improvement activity: IA_BE_17 -->
          <entry>
            <organizer classCode="CLUSTER" moodCode="EVN">
              <templateId root="2.16.840.1.113883.10.20.24.3.98"/>
              <templateId root="2.16.840.1.113883.10.20.27.3.33"
                extension="2016-09-01"/>
              <id root="ae58d929-3574-47ae-87b8-438d2eac86d9"/>
              <statusCode code="completed"/>
              <reference typeCode="REFR">
                <externalDocument classCode="DOC" moodCode="EVN">
                  <id root="2.16.840.1.113883.3.7034" extension="IA_BE_17"/>
                  <text>Use of tools to assist patient self-management.</text>
                </externalDocument>
              </reference>
              <component>
                <observation classCode="OBS" moodCode="EVN">
                  <templateId root="2.16.840.1.113883.10.20.27.3.27"
                    extension="2016-09-01"/>
                  <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"
                    codeSystemName="ActCode" displayName="Assertion"/>
                  <statusCode code="completed"/>
                  <value xsi:type="CD" code="Y" displayName="Yes"
                    codeSystemName="Yes/no indicator (HL7 Table 0136)"
                    codeSystem="2.16.840.1.113883.12.136"/>
                </observation>
              </component>
            </organizer>
          </entry>
          <!-- improvement activity: IA_BE_18 -->
          <entry>
            <organizer classCode="CLUSTER" moodCode="EVN">
              <templateId root="2.16.840.1.113883.10.20.24.3.98"/>
              <templateId root="2.16.840.1.113883.10.20.27.3.33"
                extension="2016-09-01"/>
              <id root="ae58d929-3574-47ae-87b8-438d2eac86d9"/>
              <statusCode code="completed"/>
              <reference typeCode="REFR">
                <externalDocument classCode="DOC" moodCode="EVN">
                  <id root="2.16.840.1.113883.3.7034" extension="IA_BE_18"/>
                  <text>Provide peer-led support for self-management.</text>
                </externalDocument>
              </reference>
              <component>
                <observation classCode="OBS" moodCode="EVN">
                  <templateId root="2.16.840.1.113883.10.20.27.3.27"
                    extension="2016-09-01"/>
                  <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"
                    codeSystemName="ActCode" displayName="Assertion"/>
                  <statusCode code="completed"/>
                  <value xsi:type="CD" code="Y" displayName="Yes"
                    codeSystemName="Yes/no indicator (HL7 Table 0136)"
                    codeSystem="2.16.840.1.113883.12.136"/>
                </observation>
              </component>
            </organizer>
          </entry>
          <!-- improvement activity: IA_BE_19 -->
          <entry>
            <organizer classCode="CLUSTER" moodCode="EVN">
              <templateId root="2.16.840.1.113883.10.20.24.3.98"/>
              <templateId root="2.16.840.1.113883.10.20.27.3.33"
                extension="2016-09-01"/>
              <id root="ae58d929-3574-47ae-87b8-438d2eac86d9"/>
              <statusCode code="completed"/>
              <reference typeCode="REFR">
                <externalDocument classCode="DOC" moodCode="EVN">
                  <id root="2.16.840.1.113883.3.7034" extension="IA_BE_19"/>
                  <text>Use group visits for common chronic conditions (e.g., diabetes).</text>
                </externalDocument>
              </reference>
              <component>
                <observation classCode="OBS" moodCode="EVN">
                  <templateId root="2.16.840.1.113883.10.20.27.3.27"
                    extension="2016-09-01"/>
                  <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"
                    codeSystemName="ActCode" displayName="Assertion"/>
                  <statusCode code="completed"/>
                  <value xsi:type="CD" code="Y" displayName="Yes"
                    codeSystemName="Yes/no indicator (HL7 Table 0136)"
                    codeSystem="2.16.840.1.113883.12.136"/>
                </observation>
              </component>
            </organizer>
          </entry>
          <!-- improvement activity: IA_BE_20 -->
          <entry>
            <organizer classCode="CLUSTER" moodCode="EVN">
              <templateId root="2.16.840.1.113883.10.20.24.3.98"/>
              <templateId root="2.16.840.1.113883.10.20.27.3.33"
                extension="2016-09-01"/>
              <id root="ae58d929-3574-47ae-87b8-438d2eac86d9"/>
              <statusCode code="completed"/>
              <reference typeCode="REFR">
                <externalDocument classCode="DOC" moodCode="EVN">
                  <id root="2.16.840.1.113883.3.7034" extension="IA_BE_20"/>
                  <text>Implementation of condition-specific chronic disease self-management support programs</text>
                </externalDocument>
              </reference>
              <component>
                <observation classCode="OBS" moodCode="EVN">
                  <templateId root="2.16.840.1.113883.10.20.27.3.27"
                    extension="2016-09-01"/>
                  <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"
                    codeSystemName="ActCode" displayName="Assertion"/>
                  <statusCode code="completed"/>
                  <value xsi:type="CD" code="Y" displayName="Yes"
                    codeSystemName="Yes/no indicator (HL7 Table 0136)"
                    codeSystem="2.16.840.1.113883.12.136"/>
                </observation>
              </component>
            </organizer>
          </entry>
          <!-- improvement activity: IA_BE_21 -->
          <entry>
            <organizer classCode="CLUSTER" moodCode="EVN">
              <templateId root="2.16.840.1.113883.10.20.24.3.98"/>
              <templateId root="2.16.840.1.113883.10.20.27.3.33"
                extension="2016-09-01"/>
              <id root="ae58d929-3574-47ae-87b8-438d2eac86d9"/>
              <statusCode code="completed"/>
              <reference typeCode="REFR">
                <externalDocument classCode="DOC" moodCode="EVN">
                  <id root="2.16.840.1.113883.3.7034" extension="IA_BE_21"/>
                  <text>Improved practices that disseminate appropriate self-management materials</text>
                </externalDocument>
              </reference>
              <component>
                <observation classCode="OBS" moodCode="EVN">
                  <templateId root="2.16.840.1.113883.10.20.27.3.27"
                    extension="2016-09-01"/>
                  <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"
                    codeSystemName="ActCode" displayName="Assertion"/>
                  <statusCode code="completed"/>
                  <value xsi:type="CD" code="Y" displayName="Yes"
                    codeSystemName="Yes/no indicator (HL7 Table 0136)"
                    codeSystem="2.16.840.1.113883.12.136"/>
                </observation>
              </component>
            </organizer>
          </entry>
          <!-- improvement activity: IA_BE_22 -->
          <entry>
            <organizer classCode="CLUSTER" moodCode="EVN">
              <templateId root="2.16.840.1.113883.10.20.24.3.98"/>
              <templateId root="2.16.840.1.113883.10.20.27.3.33"
                extension="2016-09-01"/>
              <id root="ae58d929-3574-47ae-87b8-438d2eac86d9"/>
              <statusCode code="completed"/>
              <reference typeCode="REFR">
                <externalDocument classCode="DOC" moodCode="EVN">
                  <id root="2.16.840.1.113883.3.7034" extension="IA_BE_22"/>
                  <text>Improved practices that engage patients pre-visit</text>
                </externalDocument>
              </reference>
              <component>
                <observation classCode="OBS" moodCode="EVN">
                  <templateId root="2.16.840.1.113883.10.20.27.3.27"
                    extension="2016-09-01"/>
                  <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"
                    codeSystemName="ActCode" displayName="Assertion"/>
                  <statusCode code="completed"/>
                  <value xsi:type="CD" code="Y" displayName="Yes"
                    codeSystemName="Yes/no indicator (HL7 Table 0136)"
                    codeSystem="2.16.840.1.113883.12.136"/>
                </observation>
              </component>
            </organizer>
          </entry>
          <!-- improvement activity: IA_BE_23 -->
          <entry>
            <organizer classCode="CLUSTER" moodCode="EVN">
              <templateId root="2.16.840.1.113883.10.20.24.3.98"/>
              <templateId root="2.16.840.1.113883.10.20.27.3.33"
                extension="2016-09-01"/>
              <id root="ae58d929-3574-47ae-87b8-438d2eac86d9"/>
              <statusCode code="completed"/>
              <reference typeCode="REFR">
                <externalDocument classCode="DOC" moodCode="EVN">
                  <id root="2.16.840.1.113883.3.7034" extension="IA_BE_23"/>
                  <text>Integration of patient coaching practices between visits</text>
                </externalDocument>
              </reference>
              <component>
                <observation classCode="OBS" moodCode="EVN">
                  <templateId root="2.16.840.1.113883.10.20.27.3.27"
                    extension="2016-09-01"/>
                  <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"
                    codeSystemName="ActCode" displayName="Assertion"/>
                  <statusCode code="completed"/>
                  <value xsi:type="CD" code="Y" displayName="Yes"
                    codeSystemName="Yes/no indicator (HL7 Table 0136)"
                    codeSystem="2.16.840.1.113883.12.136"/>
                </observation>
              </component>
            </organizer>
          </entry>
          <!-- improvement activity: IA_PSPA_1 -->
          <entry>
            <organizer classCode="CLUSTER" moodCode="EVN">
              <templateId root="2.16.840.1.113883.10.20.24.3.98"/>
              <templateId root="2.16.840.1.113883.10.20.27.3.33"
                extension="2016-09-01"/>
              <id root="ae58d929-3574-47ae-87b8-438d2eac86d9"/>
              <statusCode code="completed"/>
              <reference typeCode="REFR">
                <externalDocument classCode="DOC" moodCode="EVN">
                  <id root="2.16.840.1.113883.3.7034" extension="IA_PSPA_1"/>
                  <text>Participation in an AHRQ-listed patient safety organization.</text>
                </externalDocument>
              </reference>
              <component>
                <observation classCode="OBS" moodCode="EVN">
                  <templateId root="2.16.840.1.113883.10.20.27.3.27"
                    extension="2016-09-01"/>
                  <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"
                    codeSystemName="ActCode" displayName="Assertion"/>
                  <statusCode code="completed"/>
                  <value xsi:type="CD" code="Y" displayName="Yes"
                    codeSystemName="Yes/no indicator (HL7 Table 0136)"
                    codeSystem="2.16.840.1.113883.12.136"/>
                </observation>
              </component>
            </organizer>
          </entry>
          <!-- improvement activity: IA_PSPA_2 -->
          <entry>
            <organizer classCode="CLUSTER" moodCode="EVN">
              <templateId root="2.16.840.1.113883.10.20.24.3.98"/>
              <templateId root="2.16.840.1.113883.10.20.27.3.33"
                extension="2016-09-01"/>
              <id root="ae58d929-3574-47ae-87b8-438d2eac86d9"/>
              <statusCode code="completed"/>
              <reference typeCode="REFR">
                <externalDocument classCode="DOC" moodCode="EVN">
                  <id root="2.16.840.1.113883.3.7034" extension="IA_PSPA_2"/>
                  <text>Participation in MOC Part IV</text>
                </externalDocument>
              </reference>
              <component>
                <observation classCode="OBS" moodCode="EVN">
                  <templateId root="2.16.840.1.113883.10.20.27.3.27"
                    extension="2016-09-01"/>
                  <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"
                    codeSystemName="ActCode" displayName="Assertion"/>
                  <statusCode code="completed"/>
                  <value xsi:type="CD" code="Y" displayName="Yes"
                    codeSystemName="Yes/no indicator (HL7 Table 0136)"
                    codeSystem="2.16.840.1.113883.12.136"/>
                </observation>
              </component>
            </organizer>
          </entry>
          <!-- improvement activity: IA_PSPA_3 -->
          <entry>
            <organizer classCode="CLUSTER" moodCode="EVN">
              <templateId root="2.16.840.1.113883.10.20.24.3.98"/>
              <templateId root="2.16.840.1.113883.10.20.27.3.33"
                extension="2016-09-01"/>
              <id root="ae58d929-3574-47ae-87b8-438d2eac86d9"/>
              <statusCode code="completed"/>
              <reference typeCode="REFR">
                <externalDocument classCode="DOC" moodCode="EVN">
                  <id root="2.16.840.1.113883.3.7034" extension="IA_PSPA_3"/>
                  <text>Participate in IHI Training/Forum Event; National Academy of Medicine, AHRQ Team STEPPS or other similar activity.</text>
                </externalDocument>
              </reference>
              <component>
                <observation classCode="OBS" moodCode="EVN">
                  <templateId root="2.16.840.1.113883.10.20.27.3.27"
                    extension="2016-09-01"/>
                  <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"
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                  <statusCode code="completed"/>
                  <value xsi:type="CD" code="Y" displayName="Yes"
                    codeSystemName="Yes/no indicator (HL7 Table 0136)"
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              </component>
            </organizer>
          </entry>
          <!-- improvement activity: IA_PSPA_4 -->
          <entry>
            <organizer classCode="CLUSTER" moodCode="EVN">
              <templateId root="2.16.840.1.113883.10.20.24.3.98"/>
              <templateId root="2.16.840.1.113883.10.20.27.3.33"
                extension="2016-09-01"/>
              <id root="ae58d929-3574-47ae-87b8-438d2eac86d9"/>
              <statusCode code="completed"/>
              <reference typeCode="REFR">
                <externalDocument classCode="DOC" moodCode="EVN">
                  <id root="2.16.840.1.113883.3.7034" extension="IA_PSPA_4"/>
                  <text>Administration of the AHRQ Survey of Patient Safety Culture</text>
                </externalDocument>
              </reference>
              <component>
                <observation classCode="OBS" moodCode="EVN">
                  <templateId root="2.16.840.1.113883.10.20.27.3.27"
                    extension="2016-09-01"/>
                  <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"
                    codeSystemName="ActCode" displayName="Assertion"/>
                  <statusCode code="completed"/>
                  <value xsi:type="CD" code="Y" displayName="Yes"
                    codeSystemName="Yes/no indicator (HL7 Table 0136)"
                    codeSystem="2.16.840.1.113883.12.136"/>
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              </component>
            </organizer>
          </entry>
          <!-- improvement activity: IA_PSPA_5 -->
          <entry>
            <organizer classCode="CLUSTER" moodCode="EVN">
              <templateId root="2.16.840.1.113883.10.20.24.3.98"/>
              <templateId root="2.16.840.1.113883.10.20.27.3.33"
                extension="2016-09-01"/>
              <id root="ae58d929-3574-47ae-87b8-438d2eac86d9"/>
              <statusCode code="completed"/>
              <reference typeCode="REFR">
                <externalDocument classCode="DOC" moodCode="EVN">
                  <id root="2.16.840.1.113883.3.7034" extension="IA_PSPA_5"/>
                  <text>Annual registration in the Prescription Drug Monitoring Program</text>
                </externalDocument>
              </reference>
              <component>
                <observation classCode="OBS" moodCode="EVN">
                  <templateId root="2.16.840.1.113883.10.20.27.3.27"
                    extension="2016-09-01"/>
                  <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"
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                  <statusCode code="completed"/>
                  <value xsi:type="CD" code="Y" displayName="Yes"
                    codeSystemName="Yes/no indicator (HL7 Table 0136)"
                    codeSystem="2.16.840.1.113883.12.136"/>
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              </component>
            </organizer>
          </entry>
          <!-- improvement activity: IA_PSPA_6 -->
          <entry>
            <organizer classCode="CLUSTER" moodCode="EVN">
              <templateId root="2.16.840.1.113883.10.20.24.3.98"/>
              <templateId root="2.16.840.1.113883.10.20.27.3.33"
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              <id root="ae58d929-3574-47ae-87b8-438d2eac86d9"/>
              <statusCode code="completed"/>
              <reference typeCode="REFR">
                <externalDocument classCode="DOC" moodCode="EVN">
                  <id root="2.16.840.1.113883.3.7034" extension="IA_PSPA_6"/>
                  <text>Consultation of the Prescription Drug Monitoring program</text>
                </externalDocument>
              </reference>
              <component>
                <observation classCode="OBS" moodCode="EVN">
                  <templateId root="2.16.840.1.113883.10.20.27.3.27"
                    extension="2016-09-01"/>
                  <code code="ASSERTION" codeSystem="2.16.840.1.113883.5.4"
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                  <statusCode code="completed"/>
                  <value xsi:type="CD" code="Y" displayName="Yes"
                    codeSystemName="Yes/no indicator (HL7 Table 0136)"
                    codeSystem="2.16.840.1.113883.12.136"/>
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              </component>
            </organizer>
          </entry>
          <!-- improvement activity: IA_PSPA_7 -->
          <entry>
            <organizer classCode="CLUSTER" moodCode="EVN">
              <templateId root="2.16.840.1.113883.10.20.24.3.98"/>
              <templateId root="2.16.840.1.113883.10.20.27.3.33"
                extension="2016-09-01"/>
              <id root="ae58d929-3574-47ae-87b8-438d2eac86d9"/>
              <statusCode code="completed"/>
              <reference typeCode="REFR">
                <externalDocument classCode="DOC" moodCode="EVN">
                  <id root="2.16.840.1.113883.3.7034" extension="IA_PSPA_7"/>
                  <text>Use of QCDR data for ongoing practice assessment and improvements</text>
                </externalDocument>
              </reference>
              <component>
                <observation classCode="OBS" moodCode="EVN">
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            </organizer>
          </entry>
          <!-- improvement activity: IA_PSPA_8 -->
          <entry>
            <organizer classCode="CLUSTER" moodCode="EVN">
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                  <text>Use of patient safety tools</text>
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            </organizer>
          </entry>
          <!-- improvement activity: IA_PSPA_9 -->
          <entry>
            <organizer classCode="CLUSTER" moodCode="EVN">
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                  <text>Completion of the AMA STEPS Forward program</text>
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            </organizer>
          </entry>
          <!-- improvement activity: IA_PSPA_10 -->
          <entry>
            <organizer classCode="CLUSTER" moodCode="EVN">
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              <reference typeCode="REFR">
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                  <text>Completion of training and receipt of approved waiver for provision opioid medication-assisted treatments</text>
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                <observation classCode="OBS" moodCode="EVN">
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              </component>
            </organizer>
          </entry>
          <!-- improvement activity: IA_PSPA_11 -->
          <entry>
            <organizer classCode="CLUSTER" moodCode="EVN">
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              <templateId root="2.16.840.1.113883.10.20.27.3.33"
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              <statusCode code="completed"/>
              <reference typeCode="REFR">
                <externalDocument classCode="DOC" moodCode="EVN">
                  <id root="2.16.840.1.113883.3.7034" extension="IA_PSPA_11"/>
                  <text>Participation in CAHPS or other supplemental questionnaire</text>
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              </reference>
              <component>
                <observation classCode="OBS" moodCode="EVN">
                  <templateId root="2.16.840.1.113883.10.20.27.3.27"
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                    codeSystemName="Yes/no indicator (HL7 Table 0136)"
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              </component>
            </organizer>
          </entry>
          <!-- improvement activity: IA_PSPA_12 -->
          <entry>
            <organizer classCode="CLUSTER" moodCode="EVN">
              <templateId root="2.16.840.1.113883.10.20.24.3.98"/>
              <templateId root="2.16.840.1.113883.10.20.27.3.33"
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              <id root="ae58d929-3574-47ae-87b8-438d2eac86d9"/>
              <statusCode code="completed"/>
              <reference typeCode="REFR">
                <externalDocument classCode="DOC" moodCode="EVN">
                  <id root="2.16.840.1.113883.3.7034" extension="IA_PSPA_12"/>
                  <text>Participation in private payer CPIA</text>
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              </reference>
              <component>
                <observation classCode="OBS" moodCode="EVN">
                  <templateId root="2.16.840.1.113883.10.20.27.3.27"
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                    codeSystemName="Yes/no indicator (HL7 Table 0136)"
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              </component>
            </organizer>
          </entry>
          <!-- improvement activity: IA_PSPA_13 -->
          <entry>
            <organizer classCode="CLUSTER" moodCode="EVN">
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              <statusCode code="completed"/>
              <reference typeCode="REFR">
                <externalDocument classCode="DOC" moodCode="EVN">
                  <id root="2.16.840.1.113883.3.7034" extension="IA_PSPA_13"/>
                  <text>Participation in Joint Commission Evaluation Initiative</text>
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              </reference>
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                <observation classCode="OBS" moodCode="EVN">
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            </organizer>
          </entry>
          <!-- improvement activity: IA_PSPA_14 -->
          <entry>
            <organizer classCode="CLUSTER" moodCode="EVN">
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              <reference typeCode="REFR">
                <externalDocument classCode="DOC" moodCode="EVN">
                  <id root="2.16.840.1.113883.3.7034" extension="IA_PSPA_14"/>
                  <text>Participation in Bridges to Excellence or other similar program</text>
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              </reference>
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                <observation classCode="OBS" moodCode="EVN">
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              </component>
            </organizer>
          </entry>
          <!-- improvement activity: IA_PSPA_15 -->
          <entry>
            <organizer classCode="CLUSTER" moodCode="EVN">
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              <reference typeCode="REFR">
                <externalDocument classCode="DOC" moodCode="EVN">
                  <id root="2.16.840.1.113883.3.7034" extension="IA_PSPA_15"/>
                  <text>Implementation of antibiotic stewardship program</text>
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              </reference>
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                <observation classCode="OBS" moodCode="EVN">
                  <templateId root="2.16.840.1.113883.10.20.27.3.27"
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            </organizer>
          </entry>
          <!-- improvement activity: IA_PSPA_16 -->
          <entry>
            <organizer classCode="CLUSTER" moodCode="EVN">
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                <externalDocument classCode="DOC" moodCode="EVN">
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                  <text>Use of decision support and standardized treatment protocols</text>
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          </entry>
          <!-- improvement activity: IA_PSPA_17 -->
          <entry>
            <organizer classCode="CLUSTER" moodCode="EVN">
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          </entry>
          <!-- improvement activity: IA_PSPA_18 -->
          <entry>
            <organizer classCode="CLUSTER" moodCode="EVN">
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          </entry>
          <!-- improvement activity: IA_PSPA_19 -->
          <entry>
            <organizer classCode="CLUSTER" moodCode="EVN">
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                <observation classCode="OBS" moodCode="EVN">
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          </entry>
          <!-- improvement activity: IA_PSPA_20 -->
          <entry>
            <organizer classCode="CLUSTER" moodCode="EVN">
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                  <text>Leadership engagement in regular guidance and demonstrated commitment for implementing practice improvement changes</text>
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          </entry>
          <!-- improvement activity: IA_PSPA_21 -->
          <entry>
            <organizer classCode="CLUSTER" moodCode="EVN">
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            </organizer>
          </entry>
          <!-- improvement activity: IA_AHE_1 -->
          <entry>
            <organizer classCode="CLUSTER" moodCode="EVN">
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                <externalDocument classCode="DOC" moodCode="EVN">
                  <id root="2.16.840.1.113883.3.7034" extension="IA_AHE_1"/>
                  <text>Engagement of new Medicaid patients and follow-up</text>
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                <observation classCode="OBS" moodCode="EVN">
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            </organizer>
          </entry>
          <!-- improvement activity: IA_AHE_2 -->
          <entry>
            <organizer classCode="CLUSTER" moodCode="EVN">
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              <statusCode code="completed"/>
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                <externalDocument classCode="DOC" moodCode="EVN">
                  <id root="2.16.840.1.113883.3.7034" extension="IA_AHE_2"/>
                  <text>Leveraging a QCDR to standardize processes for screening</text>
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                <observation classCode="OBS" moodCode="EVN">
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          </entry>
          <!-- improvement activity: IA_AHE_3 -->
          <entry>
            <organizer classCode="CLUSTER" moodCode="EVN">
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              <reference typeCode="REFR">
                <externalDocument classCode="DOC" moodCode="EVN">
                  <id root="2.16.840.1.113883.3.7034" extension="IA_AHE_3"/>
                  <text>Leveraging a QCDR to promote use of patient-reported outcome tools</text>
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                <observation classCode="OBS" moodCode="EVN">
                  <templateId root="2.16.840.1.113883.10.20.27.3.27"
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          </entry>
          <!-- improvement activity: IA_AHE_4 -->
          <entry>
            <organizer classCode="CLUSTER" moodCode="EVN">
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                <externalDocument classCode="DOC" moodCode="EVN">
                  <id root="2.16.840.1.113883.3.7034" extension="IA_AHE_4"/>
                  <text>Leveraging a QCDR for use of standard questionnaires</text>
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