"Substance, Order"

Performance/Reporting Period

2022

QDM Datatype (QDM Version 5.5 Guidance Update):

Data elements that meet criteria using this datatype should document a request for the substance indicated by the QDM category and its corresponding value set.

Timing:

relevantPeriod addresses the time referenced in the dosage instruction indicating when the medication administration should start and end.
In the initial publication of QDM 5.5, relevantPeriod referenced the validity period, i.e., the time period for which the ordered supply is authorized by the prescription authorizing the dispensing event.
For clarification, see Appendix 6.4 with additional guidance for referencing relevantPeriod updating the definition for "Medication, Order", "Medication Dispensed", and "Substance, Order".
author dateTime references the date and time the substance order is authored.

Note: negation rationale 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 and must not use relevantPeriod.

QDM Datatype and Definition

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).

Measure developers have considered the use of the QDM substance category in light of alignment with existing interoperability data standards. Two use cases require further investigation and effort in the HL7 FHIR realm:

Nutrition [Considerations for Future Use]
The nutrition mappings from QDM to FHIR resources require continued effort as of the printing of this QDM 5.5 version. The FHIR NutritionOrder Resource is a record of the request for the supply of a diet, oral supplement or enteral formulas for a patient, and thus allow specification of a complete diet order, but not an order for an individual nutrient. The NutritionOrder resource is currently at a low maturity level (i.e., it has had limited testing). Therefore, for the current QDM 5.5 reference, substance is modeled similarly to medications.

Blood Products [Considerations for Future Use]
The HL7 FHIR version 4.0 resource for blood products allow specification of the blood product as a biologically derived product, but specification for how such products are administered remains in development. Therefore, for the current QDM 5.5 reference, blood product administration can be managed using QDM datatypes “Procedure, Performed” or “Substance, Administered” based on measure developer findings during measure implementation testing.

QDM Attributes

authorDateTime

The time the data element was entered into the clinical software. Note, some datatypes include both relevant dateTime and author dateTime attributes. When both are present, author dateTime is included to accommodate negation rationale.

The author dateTime addresses when an activity is documented. Documentation can occur at the beginning, during, at the end, or subsequent to the end of the activity. The author dateTime should be used only if the relevantPeriod cannot be obtained or to represent the time negation rationale is documented.

Note: negation rationale 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 and must not use relevantPeriod.

dosage

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 (a).
Was administered to the patient (b).
Should be taken by the patient or administered to the patient (c).
Is recommended to be given to the patient (d).

negationRationale

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 a world view that absence of evidence indicates information does not exist or an action did not happen. To express such lack of evidence, an eCQM author should use the CQL expression not exists with reference to the data element rather than the QDM data model. negation rationale in QDM signifies only a reason for such absence, i.e., the reason must be present to qualify for negation rationale. The syntax in the human readable HQMF is addressed in CQL examples and in the MAT User Guide. Prior versions of QDM used the syntax, "Procedure, Performed not done." QDM versions starting with 5.3 use the syntax, "Procedure, not Performed." Section A-5 provides examples for expressing negation rationale in CQL.

Note: negation rationale 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 and must not use relevantPeriod.

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.

refills

The number of refills allowed by the prescription.

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.

Note: negation rationale indicates a one-time documentation of a reason an activity is not performed. Negation of QDM datatyperelated actions for a reason always use the author dateTime attribute to reference timing and must not use relevantPeriod

requester

The requester is who or what is requesting service (e.g., the individual or organization asking for the service to be carried out). The requester attribute references the new QDM entities (Patient, Care Partner, Practitioner, or Organization) and any or all of the attributes of the respective QDM entity. For example, to reference that a physician who requested a procedure is the same person who was the primary participant in an "Encounter, Performed" and assure the physician's specialty meets the measures requirements, the eCQM can use the Practitioner Entity and its attributes. Should the eCQM choose to reference a physician practice or a hospital, the performer can reference the Organization Entity and indicate the identifier and/or the organization type.

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.

supply

The quantity (amount) of therapeutic agent that was provided to a patient (i.e., number of doses, number of tablets or pills, volume of medication) indicated to be given during a procedure, diagnostic test, or medication, or substance administration.

Note: Prior versions of the QDM (4.3 and earlier) addressed dose with two potential interpretations - (1) the quantity to be taken or administered with each administration and (2) the quantity of medication supplied (i.e., number of doses). QDM 5.0 and subsequent versions clarify the difference by defining dosage and supply, respectively.

"Medication, Discharge" includes medications the provider has indicated the patient should take after dischange from the hospital. This medication list is part of the discharge instructions provided to a patient. The list may include medication supply if it incorporates medication orders written at discharge even though the supply will not be present for medications the patient already has at home or purchases over-the-counter (without a prescription).

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