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["Diagnostic Study, Performed": "Optic Disc Exam for Structural Abnormalities"]

eCQM Data Element

Performance/Reporting Period
2020
Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent studies specific to looking for structural abnormalities of the optic disc by ophthalmoscopy.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Diagnostic Study.
Inclusion Criteria: Includes only relevant concepts associated with studies using ophthalmoscopy.
Exclusion Criteria: No exclusions.

Constrained to codes in the Diagnostic Study, Performed: Optic Disc Exam for Structural Abnormalities value set (2.16.840.1.113883.3.526.3.1334)

QDM Datatype and Definition (QDM Version 5.4)

"Diagnostic Study, Performed"

Data elements that meet criteria using this datatype should document the completion of the diagnostic study indicated by the QDM category and its corresponding value set.

Timing: The Relevant Period addresses:

  • startTime – when the diagnostic study is initiated
  • stopTime – when the diagnostic study is completed

Examples:

  • Initiation of a treadmill stress test to the time the treadmill stress test has completed
  • Initiation of the ultrasound study until completion of the ultrasound study
QDM Attributes

authorDateTime

The time the data element was entered into the clinical software. Note, some datatypes include both Relevant Time and Author dateTime attributes. The purpose is to accommodate Author dateTime if the actual start and stop times are not available when evaluating for feasibility, and also to allow specification of a time for Negation Rationale.

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.

relevantPeriod

Relevant Period addresses the time between the start of an action to the end of an action. Each datatype using relevant period defines specific definitions for the start and stop time for the action listed.

result

The final consequences or data collected from the datatype. Results can be used in four ways, to express: (1) That a result is present in the electronic record but any entry is acceptable. (2) A numerical result is reported directly as a value. Values may be integers or decimal numbers without units, or as a quantity with a value and units. Examples: 100 mg/dL for a lab test, 140 mmHg for blood pressure, as a percentage (actually a quantity with % as units), as a ratio (e.g., 1:4, 1:80). (3) A result that matches one of a specific set of coded concepts in a value set or a code that matches a direct reference code. (4) A result as a dateTime (Assessment, Performed and components). Note: Measures use Clinical Quality Language (CQL) logic to express the mathematical operators to constrain desired results to those above or below a certain threshold.
Last Updated: Jul 08, 2021