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"Substance, Administered"

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

Data elements that meet criteria using this datatype should document that the substance indicated by the QDM category and its corresponding value set was actually given to the patient.

Timing: The Relevant Period addresses:

  • startTime - when a single substance administration event starts (e.g., the initiation of an intravenous infusion, or administering the substance orally or topically to a patient);
  • stopTime - when a single substance administration event ends (e.g., the end time of the intravenous infusion, or the administration of a substance orally or topically is completed - for oral or topical administration, the start and stop times are the same)

 

QDM Category (QDM Version 5.4)

Substance

Substance represents a homogeneous material with definite composition that includes allergens, biological materials, chemicals, foods, drugs and materials. QDM distinguishes between medications from non-medication substances by separately listing medication datatypes. Substance may or may not have a code or be classified by a code system such RxNorm. Examples of a substance may include environmental agents (e.g., pollen, dust) and food (e.g., vitamins).

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.

dosage

Details of how medication is taken or is to be taken, i.e., the quantity (mg, cc, tablets) to be taken at a single administration.

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:
Details of how much medication is taken or is to be taken, i.e., the quantity (mg, cc, tablets) to be taken at a single administration.

frequency

Indicates how frequently the medication or substance: is administered to a patient for an active medication (Medication, Active), was administered to the patient (Medication, Administered and Substance, Administered), should be taken by the patient or administered to the patient (Medication, Discharge; Medication, Dispensed; Medication, Order; and Substance, Order), is recommended to be given to the patient (Substance, Recommended).

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.

route

Refers to the path by which the medication or substance should be taken into the body system, such as intradermally, intrathecally, intramuscularly, intranasally, intravenously, orally, rectally, subcutaneously, sublingually, topically, or vaginally.
Last Updated: Jul 08, 2021