"Substance, Recommended"
Data elements that meet criteria using this datatype should document a recommendation for the substance indicated by the QDM category and its corresponding value set.
Timing: The time the recommendation is authored (i.e., provided to the patient).
Notes:
- 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.
- Recommendations address the time that the recommendation occurs, a single point in time. Vendors have expressed concerns that recommendations are not necessarily captured or managed in a standard manner as part of structured data capture in clinical workflow; many are documented as part of assessments in narrative text. Measure developers should address the feasibility of clinical workflow to capture recommendations when evaluating measures.
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 FHIR realm:
Nutrition [Considerations for Future Use]
The nutrition mappings from QDM to FHIR resources require continued effort as of the publication of this QDM 5.6 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 5.6 reference, substance is modeled similarly to medications.
Blood Products [Considerations for Future Use]
The FHIR version 4.0 resource for blood products allows 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 5.6 reference, blood product administration can be managed using QDM datatypes "Procedure, Performed" or "Substance, Administered" based on measure developer findings during measure implementation testing.
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
frequency
- 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.
For updated guidance and implementer feedback regarding use of the QDM negation rationale attribute see Section 6.6.
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.