"Diagnosis"
Data elements that meet criteria using this datatype should document the Condition/Diagnosis/Problem and its corresponding value set. The onset dateTime corresponds to the implicit start dateTime of the datatype and the abatement dateTime corresponds to the implicit stop dateTime of the datatype. If the abatement dateTime is not present, then the diagnosis is considered to still be active. When this datatype is used with timing relationships, the criterion is looking for an active diagnosis for the time frame indicated by the timing relationships.
Timing: The prevalencePeriod references the time from the onset date to the abatement date.
Condition/Diagnosis/Problem
Condition/Diagnosis/Problem represents a practitioner’s identification of a patient’s disease, illness, injury, or condition. This category contains a single datatype to represent all these concepts: Diagnosis. A practitioner determines the diagnosis by means of examination, diagnostic test results, patient history, and/or family history. Diagnoses are usually considered unfavorable, but may also represent neutral or favorable conditions that affect a patient’s plan of care (e.g., pregnancy).
The QDM does not prescribe the source of diagnosis data in the EHR. Diagnoses may be found in a patient’s problem list, encounter diagnosis list, claims data, or other sources within the EHR. The preferred terminology for diagnoses is SNOMED CT, but diagnoses may also be encoded using ICD-9-CM (for historical data) and/or ICD-10-CM.
The Diagnosis datatype should not be used for differential diagnoses or rule-out diagnoses (neither of which are currently supported by the QDM).
anatomicalLocationSite
- Where the diagnosis/problem manifests itself (a).
- That is the focus of the action represented by the datatype (b).
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.
prevalencePeriod
recorder
The recorder indicates who recorded (or documented) the information (e.g., the individual or organization documenting the information). Note that FHIR modeling includes reference to asserter for concepts such as diagnosis and allergy/intolerance. Feedback from implementers and EHR vendors suggest that asserter fields default to the individual entering the information without clear evidence about how often clinicians change the default to the person who reported the information. Therefore, QDM retains a recorder attribute for the referenced QDM datatypes.
The prescriber 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 recorded a diagnosis is the same person who was the primary participant in an "Encounter, Performed" and to assure the physician’s specialty meets the measure’s 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.
[See Section 2.6 for description of QDM entities]