Implementing Taiwan National Health Insurance Quality Indicators as Clinical Quality Language on Fast Healthcare...

Clinical Quality Language (CQL) and Fast Healthcare Interoperability Resources (FHIR) support executable electronic clinical quality measures. Translating national claims-based indicators into CQL remains challenging because terminology, exclusions, and data semantics require adaptation. To our knowledge, Taiwan National Health Insurance (NHI) medical-center indicators have not previously been represented as an executable CQL library.

This study aimed to develop CQL libraries derived from 39 Taiwan NHI medical-center quality indicator codes and evaluate technical executability and computational consistency using synthetic data and real-world cross-institution medication records.

We implemented 39 CQL libraries across 6 principal FHIR R4 clinical resources using 21 data elements, with documented adaptations where official requirements could not be represented. Compiled Expression Logical Model was executed against author-defined synthetic fixtures. In a retrospective 2-campus study, a separately coded Python implementation and the CQL pipeline computed aggregate numerators and denominators for 20 indicators from the same deidentified records, represented as a long table and FHIR resources, respectively.

All 39 CQL libraries compiled and executed against the predefined synthetic fixtures, and their outputs matched the author-defined expected results (39/39 libraries; 136/136 early-refill grace-period control groups). The real-world dataset included 88 patients (Taipei: n=65; Linkou: n=23), 1597 medication records, and 630 visits from January 1 to June 2, 2026. Across the 20 medication-based indicators, the 2 pipelines produced identical aggregate numerators and denominators (20/20), and 7 of the 8 cross-institution drug-class overlap indicators had nonzero numerators. All 2317 FHIR resources passed base FHIR R4 structural validation, and Anatomical Therapeutic Chemical mapping coverage was 98.3% (1570/1597 records).

The implemented NHI-derived indicator logic was executable and computationally consistent across synthetic testing and aggregate real-world comparisons. These findings do not establish complete fidelity to official NHI specifications. Further evaluation requires expert semantic review, patient-level testing, and execution across independent CQL/FHIR environments.