"Laboratory Test, Performed"
Data elements that meet criteria using this datatype should document the laboratory test indicated by the QDM category and its corresponding value set was performed.
A QDM Known Issue has been identified related to this datatype. To see this QDM known Issue, please click here.
Timing: The Relevant Period addresses:
- startTime – when the laboratory test is initiated (i.e., the time the specimen collection begins)
- stopTime – when the laboratory test is completed (i.e., the time the specimen collection ends)
Examples:
- Initiation of a venipuncture for a fasting blood glucose to the time venipuncture for the fasting blood glucose is completed – basically a single point in time for many specimen collections
- Initiation of a 24-hour urine collection for measured creatinine clearance until completion of the 24-hour urine collection
Note – the time that the result report is available is a separate attribute than the time of the study (specimen collection).
"Laboratory Test"
Laboratory Test represents a medical procedure that involves testing a sample of blood, urine, or other substance from the body. Tests can help determine a diagnosis, plan treatment, check to see if treatment is working, or monitor the disease over time. This QDM data category for Laboratory Test is only used for information about the subject of record.
authorDateTime
components
method
negationRationale
The QDM attribute, negation rationale indicates the reason that an action was not performed. Only QDM datatypes that represent actions (e.g., performed, recommended, communication, order, dispensed) allow the 'negation rationale' attribute. The intent is to indicate a justification that such action did not happen as expected. This attribute specifically does not address the presence or absence of information in a clinical record (e.g., documented absence of allergies versus lack of documentation about allergies). QDM assumes that any information expected will be in a clinical record. The situation is different when something that normally would be expected to be done is specifically not done because of a valid clinical reason (such as the patient is allergic, they are suffering from a complication, or some other rationale. In this case, the 'thing not done' is rarely documented, especially as a code, in the patient record. To express such lack of evidence, an eCQM author should use a CQL 'not exists' expression noted in the examples, and they must also capture the Negation rationale to capture a reason for the absence, i.e., the reason must be included to qualify as a negation rationale type expression. The syntax in the human readable HQMF is described in CQL examples and in the MAT User Guide. Prior versions of QDM used the syntax, 'Procedure, Performed not done.' QDM 5.5 uses the syntax, 'Procedure, not Performed' and this is then associated with either a DRC or a value set used to identify 'the expected thing,' that in this case was not done. Negation Rationale attribute value indicates a one-time documentation of a reason an activity is not performed. Negation of QDM datatype-related actions for a reason always use the author dateTime attribute to reference timing.
A QDM Known Issue has been identified related to this attribute. To see this QDM known Issue, please click here.
reason
referenceRange
relevantPeriod
result
resultDateTime
The time the result report is generated and saved in the database.
NOTE: Although 2020 eCQMs use QDM Version 5.4, the QDM Version 5.5 Guidance Update provides clarification to the definition of this attribute which may be helpful when implementing eCQMs for 2020 Reporting/Performance periods.
QDM Version 5.5 Guidance Update:
The date and time this version of the observation was made available to providers, typically after the results have been reviewed and verified.