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"Diagnostic Study, Performed"

Performance/Reporting Period
2020
QDM Datatype (QDM Version 5.4):

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 Category (QDM Version 5.4)

Diagnostic Study

Diagnostic Study represents any kind of medical test performed as a specific test or series of steps to aid in diagnosing or detecting disease (e.g., to establish a diagnosis, measure the progress or recovery from disease, confirm that a person is free from disease). The QDM defines diagnostic studies as those that are not performed in organizations that perform testing on samples of human blood, tissue, or other substance from the body. Diagnostic studies may make use of digital images and textual reports. Such studies include but are not limited to imaging studies, cardiology studies (electrocardiogram, treadmill stress testing), pulmonary-function testing, vascular laboratory testing, and others.

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.

components

Elements included or documented as part of evaluations or test panels. Examples include: specific questions included in assessments, tests included in a laboratory test panel, observations included in a cardiac exam during a physical examination. Each assessment, diagnostic study, laboratory test, physical exam or procedure may have one or more components.

facilityLocation

The particular locations in a facility in which the diagnostic study or encounter occurs or occurred. Examples include, but are not limited to, intensive care units (ICUs), non- ICUs, burn critical-care unit, neonatal ICU, and respiratory-care unit. Each Encounter, Performed may have 1 or more locations. For example, a patient treated in multiple locations during an individual encounter might be expressed as: Encounter, Performed: Inpatient Admission, ICU (location period), Non-ICU Admission (location period), Rehab (location period). Facility Location (singular) is used for Adverse Event; Diagnostic Study, Performed; Encounter, Order; Encounter, Recommended.

method

Indicates the procedure or technique used in its performance.

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

The thought process or justification for the datatype. In some measures, specific treatments are acceptable inclusion criteria only if a justified reason is present. Each of these measures uses a value set (often, but not exclusively, using SNOMED CT) to express acceptable justification reasons. Other measures specify reasons as justification for exclusions. Examples include patient, system, or medical-related reasons for declining to perform specific actions. Each of these measures also uses a value set to express acceptable justification reasons for declining to perform expected actions.

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.

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.

status

Indicates the particular stage of the action represented by the datatype.
Last Updated: Jul 08, 2021