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CMS Measure ID: CMS153v10    Performance/Reporting Period: 2022    Version: 10    NQF Number: Not Applicable
Description:

Percentage of women 16-24 years of age who were identified as sexually active and who had at least one test for chlamydia during the measurement period

Data Elements and coded QDM Attributes contained within the eCQM

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Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to represent concepts for assessments to indicate vaginal intercourse.
Data Element Scope: This value set may use a model element related to Assessment.
Inclusion Criteria: Includes concepts that represent an assessment for intercourse.
Exclusion Criteria: No exclusions.

Constrained to codes in the Assessment, Performed: Sexually Active value set (2.16.840.1.113883.3.464.1003.121.12.1040)

QDM Datatype and Definition (QDM Version 5.5 Guidance Update)

"Assessment, Performed"

Data elements that meet criteria using this datatype should document completion of the assessment indicated by the QDM category and its corresponding value set.

Timing:

  • relevant dateTime references timing for an assessment that occurs at a single point in time.
  • relevant Period references a start and stop time for an assessment that occurs over a time interval
  • author dateTime references the time the action was recorded.
  • Refer to the eCQM expression to determine allowable timings to meet measure criterion.

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.

Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to represent concepts for a diagnosis of complications related to pregnancy or childbirth.
Data Element Scope: This value set may use a model element related to Diagnosis.
Inclusion Criteria: Includes concepts that represent a diagnosis for complications of pregnancy or childbirth.
Exclusion Criteria: No exclusions.

Constrained to codes in the Diagnosis: Complications of Pregnancy, Childbirth and the Puerperium value set (2.16.840.1.113883.3.464.1003.111.12.1012)

QDM Datatype and Definition (QDM Version 5.5 Guidance Update)

"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.

Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to represent diagnoses indicating history of sexual activity.
Data Element Scope: This value set may use a model element related to Diagnosis.
Inclusion Criteria: Includes concepts that represent a diagnosis of pregnancy, postpartum, sexually transmitted infection, conditions caused by sexually transmitted infections (e.g., inflammatory disease of ovary, fallopian tubes or uterus), symptoms following intercourse (e.g., bleeding), contraceptive use (e.g., adverse effect of contraceptive).
Exclusion Criteria: Excludes concepts that represent a diagnosis of congenital sexually transmitted infections; exposure to HIV virus; inconclusive serologic evidence of HIV.

Constrained to codes in the Diagnosis: Diagnoses Used to Indicate Sexual Activity value set (2.16.840.1.113883.3.464.1003.111.12.1018)

QDM Datatype and Definition (QDM Version 5.5 Guidance Update)

"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.

Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to represent concepts for a diagnosis of human immunodeficiency virus (HIV) disease.
Data Element Scope: This value set may use a model element related to Diagnosis.
Inclusion Criteria: Includes concepts that represent a diagnosis of HIV and acquired immunodeficiency syndrome.
Exclusion Criteria: No exclusions.

Constrained to codes in the Diagnosis: HIV value set (2.16.840.1.113883.3.464.1003.120.12.1003)

QDM Datatype and Definition (QDM Version 5.5 Guidance Update)

"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.

Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to represent concepts for diagnostic studies performed on a fetus during pregnancy.
Data Element Scope: This value set may use a model element related to Diagnostic Study.
Inclusion Criteria: Includes concepts that represent a diagnostic study conducted on a fetus.
Exclusion Criteria: Excludes order only codes.

Constrained to codes in the Diagnostic Study, Order: Diagnostic Studies During Pregnancy value set (2.16.840.1.113883.3.464.1003.111.12.1008)

QDM Datatype and Definition (QDM Version 5.5 Guidance Update)

"Diagnostic Study, Order"

Data elements that meet criteria using this datatype should document a request by a clinician or appropriately licensed care provider to an appropriate provider or organization to perform the diagnostic study indicated by the QDM category and its corresponding value set. The request may be in the form of a consultation or a direct order to the organization that performs the diagnostic study. Diagnostic studies are those that are not performed in the clinical laboratory. Such studies include, but are not limited to, imaging studies, cardiology studies (electrocardiogram, treadmill stress testing), pulmonary function testing, and vascular laboratory testing.

Timing: The time the order is signed; author dateTime.

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.

Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to represent concepts for a radiology study involving x-rays.
Data Element Scope: This value set may use a model element related to Diagnostic Study.
Inclusion Criteria: Includes concepts that describe a diagnostic study involving x-rays.
Exclusion Criteria: Excludes order only codes.

Constrained to codes in the Diagnostic Study, Order: X-Ray Study (all inclusive) value set (2.16.840.1.113883.3.464.1003.198.12.1034)

QDM Datatype and Definition (QDM Version 5.5 Guidance Update)

"Diagnostic Study, Order"

Data elements that meet criteria using this datatype should document a request by a clinician or appropriately licensed care provider to an appropriate provider or organization to perform the diagnostic study indicated by the QDM category and its corresponding value set. The request may be in the form of a consultation or a direct order to the organization that performs the diagnostic study. Diagnostic studies are those that are not performed in the clinical laboratory. Such studies include, but are not limited to, imaging studies, cardiology studies (electrocardiogram, treadmill stress testing), pulmonary function testing, and vascular laboratory testing.

Timing: The time the order is signed; author dateTime.

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.

Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to represent concepts of inpatient hospitalization encounters.
Data Element Scope: This value set may use a model element related to Encounter.
Inclusion Criteria: Includes concepts that represent an encounter for inpatient hospitalizations.
Exclusion Criteria: No exclusions.

Constrained to codes in the Encounter, Performed: Encounter Inpatient value set (2.16.840.1.113883.3.666.5.307)

QDM Datatype and Definition (QDM Version 5.5 Guidance Update)

"Encounter, Performed"

Data elements that meet criteria using this datatype should document that the encounter indicated by the QDM category and its corresponding value set is in progress or has been completed.

The "Encounter, Performed" participant references the primary participant.

Previous versions of QDM included an attribute principal diagnosis, defined as the condition that, after study, was determined to be the principal cause of the admission. QDM version 5.5 addresses that concept using the diagnosis rank=1.

Timing:

  • The relevantPeriod addresses:
    • startTime - The time the encounter began (admission time).
    • stopTime - The time the encounter ended (discharge time).
  • author dateTime references the time the action was recorded.
  • Refer to the eCQM expression to determine allowable timings to meet measure criteria.

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.
  • The locationPeriod is an attribute of the attribute facility location that addresses:
    • startTime - the time the patient arrived at the location. The time the encounter began (admission time).
    • stopTime - the time the patient departed from the location.
Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to represent concepts for encounters for home health visits.
Data Element Scope: This value set may use a model element related to Encounter.
Inclusion Criteria: Includes concepts that represent an encounter for a home health visit for the evaluation and management of a new or established patient.
Exclusion Criteria: No exclusions.

Constrained to codes in the Encounter, Performed: Home Healthcare Services value set (2.16.840.1.113883.3.464.1003.101.12.1016)

QDM Datatype and Definition (QDM Version 5.5 Guidance Update)

"Encounter, Performed"

Data elements that meet criteria using this datatype should document that the encounter indicated by the QDM category and its corresponding value set is in progress or has been completed.

The "Encounter, Performed" participant references the primary participant.

Previous versions of QDM included an attribute principal diagnosis, defined as the condition that, after study, was determined to be the principal cause of the admission. QDM version 5.5 addresses that concept using the diagnosis rank=1.

Timing:

  • The relevantPeriod addresses:
    • startTime - The time the encounter began (admission time).
    • stopTime - The time the encounter ended (discharge time).
  • author dateTime references the time the action was recorded.
  • Refer to the eCQM expression to determine allowable timings to meet measure criteria.

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.
  • The locationPeriod is an attribute of the attribute facility location that addresses:
    • startTime - the time the patient arrived at the location. The time the encounter began (admission time).
    • stopTime - the time the patient departed from the location.
Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to represent concepts for encounters for an outpatient visit.
Data Element Scope: This value set may use a model element related to Encounter.
Inclusion Criteria: Includes concepts that represent an encounter for the comprehensive history, evaluation, and management of a patient presenting with minor to high severity problems.
Exclusion Criteria: No exclusions.

Constrained to codes in the Encounter, Performed: Office Visit value set (2.16.840.1.113883.3.464.1003.101.12.1001)

QDM Datatype and Definition (QDM Version 5.5 Guidance Update)

"Encounter, Performed"

Data elements that meet criteria using this datatype should document that the encounter indicated by the QDM category and its corresponding value set is in progress or has been completed.

The "Encounter, Performed" participant references the primary participant.

Previous versions of QDM included an attribute principal diagnosis, defined as the condition that, after study, was determined to be the principal cause of the admission. QDM version 5.5 addresses that concept using the diagnosis rank=1.

Timing:

  • The relevantPeriod addresses:
    • startTime - The time the encounter began (admission time).
    • stopTime - The time the encounter ended (discharge time).
  • author dateTime references the time the action was recorded.
  • Refer to the eCQM expression to determine allowable timings to meet measure criteria.

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.
  • The locationPeriod is an attribute of the attribute facility location that addresses:
    • startTime - the time the patient arrived at the location. The time the encounter began (admission time).
    • stopTime - the time the patient departed from the location.
Value Set Description from VSAC
Clinical Focus: Includes concepts that represent an encounter using online modalities.
Data Element Scope: This value set may use a model element related to Encounter.
Inclusion Criteria: Includes concepts that represent an encounter using online modalities.
Exclusion Criteria: Excludes concepts that represent encounters other than online.

Constrained to codes in the Encounter, Performed: Online Assessments value set (2.16.840.1.113883.3.464.1003.101.12.1089)

QDM Datatype and Definition (QDM Version 5.5 Guidance Update)

"Encounter, Performed"

Data elements that meet criteria using this datatype should document that the encounter indicated by the QDM category and its corresponding value set is in progress or has been completed.

The "Encounter, Performed" participant references the primary participant.

Previous versions of QDM included an attribute principal diagnosis, defined as the condition that, after study, was determined to be the principal cause of the admission. QDM version 5.5 addresses that concept using the diagnosis rank=1.

Timing:

  • The relevantPeriod addresses:
    • startTime - The time the encounter began (admission time).
    • stopTime - The time the encounter ended (discharge time).
  • author dateTime references the time the action was recorded.
  • Refer to the eCQM expression to determine allowable timings to meet measure criteria.

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.
  • The locationPeriod is an attribute of the attribute facility location that addresses:
    • startTime - the time the patient arrived at the location. The time the encounter began (admission time).
    • stopTime - the time the patient departed from the location.
Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to represent concepts for encounters for preventive care.
Data Element Scope: This value set may use a model element related to Encounter.
Inclusion Criteria: Includes concepts that represent an encounter for comprehensive preventive medicine reevaluation and management of an individual 18 years of age or over.
Exclusion Criteria: No exclusions.

Constrained to codes in the Encounter, Performed: Preventive Care Services - Established Office Visit, 18 and Up value set (2.16.840.1.113883.3.464.1003.101.12.1025)

QDM Datatype and Definition (QDM Version 5.5 Guidance Update)

"Encounter, Performed"

Data elements that meet criteria using this datatype should document that the encounter indicated by the QDM category and its corresponding value set is in progress or has been completed.

The "Encounter, Performed" participant references the primary participant.

Previous versions of QDM included an attribute principal diagnosis, defined as the condition that, after study, was determined to be the principal cause of the admission. QDM version 5.5 addresses that concept using the diagnosis rank=1.

Timing:

  • The relevantPeriod addresses:
    • startTime - The time the encounter began (admission time).
    • stopTime - The time the encounter ended (discharge time).
  • author dateTime references the time the action was recorded.
  • Refer to the eCQM expression to determine allowable timings to meet measure criteria.

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.
  • The locationPeriod is an attribute of the attribute facility location that addresses:
    • startTime - the time the patient arrived at the location. The time the encounter began (admission time).
    • stopTime - the time the patient departed from the location.
Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to represent concepts for encounters for preventive care.
Data Element Scope: This value set may use a model element related to Encounter.
Inclusion Criteria: Includes concepts that represent an encounter for comprehensive preventive medicine reevaluation and management of a patient 0 to 17 years of age.
Exclusion Criteria: No exclusions.

Constrained to codes in the Encounter, Performed: Preventive Care Services, Initial Office Visit, 0 to 17 value set (2.16.840.1.113883.3.464.1003.101.12.1022)

QDM Datatype and Definition (QDM Version 5.5 Guidance Update)

"Encounter, Performed"

Data elements that meet criteria using this datatype should document that the encounter indicated by the QDM category and its corresponding value set is in progress or has been completed.

The "Encounter, Performed" participant references the primary participant.

Previous versions of QDM included an attribute principal diagnosis, defined as the condition that, after study, was determined to be the principal cause of the admission. QDM version 5.5 addresses that concept using the diagnosis rank=1.

Timing:

  • The relevantPeriod addresses:
    • startTime - The time the encounter began (admission time).
    • stopTime - The time the encounter ended (discharge time).
  • author dateTime references the time the action was recorded.
  • Refer to the eCQM expression to determine allowable timings to meet measure criteria.

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.
  • The locationPeriod is an attribute of the attribute facility location that addresses:
    • startTime - the time the patient arrived at the location. The time the encounter began (admission time).
    • stopTime - the time the patient departed from the location.
Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to represent concepts for encounters for preventive care.
Data Element Scope: This value set may use a model element related to Encounter.
Inclusion Criteria: Includes concepts that represent an encounter for comprehensive preventive medicine reevaluation and management of a patient 18 years or over.
Exclusion Criteria: No exclusions.

Constrained to codes in the Encounter, Performed: Preventive Care Services-Initial Office Visit, 18 and Up value set (2.16.840.1.113883.3.464.1003.101.12.1023)

QDM Datatype and Definition (QDM Version 5.5 Guidance Update)

"Encounter, Performed"

Data elements that meet criteria using this datatype should document that the encounter indicated by the QDM category and its corresponding value set is in progress or has been completed.

The "Encounter, Performed" participant references the primary participant.

Previous versions of QDM included an attribute principal diagnosis, defined as the condition that, after study, was determined to be the principal cause of the admission. QDM version 5.5 addresses that concept using the diagnosis rank=1.

Timing:

  • The relevantPeriod addresses:
    • startTime - The time the encounter began (admission time).
    • stopTime - The time the encounter ended (discharge time).
  • author dateTime references the time the action was recorded.
  • Refer to the eCQM expression to determine allowable timings to meet measure criteria.

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.
  • The locationPeriod is an attribute of the attribute facility location that addresses:
    • startTime - the time the patient arrived at the location. The time the encounter began (admission time).
    • stopTime - the time the patient departed from the location.
Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to represent concepts for encounters for preventative care.
Data Element Scope: This value set may use a model element related to Encounter.
Inclusion Criteria: Includes concepts that represent an encounter for comprehensive preventive medicine reevaluation and management of an individual 0 to 17 years of age.
Exclusion Criteria: No exclusions.

Constrained to codes in the Encounter, Performed: Preventive Care, Established Office Visit, 0 to 17 value set (2.16.840.1.113883.3.464.1003.101.12.1024)

QDM Datatype and Definition (QDM Version 5.5 Guidance Update)

"Encounter, Performed"

Data elements that meet criteria using this datatype should document that the encounter indicated by the QDM category and its corresponding value set is in progress or has been completed.

The "Encounter, Performed" participant references the primary participant.

Previous versions of QDM included an attribute principal diagnosis, defined as the condition that, after study, was determined to be the principal cause of the admission. QDM version 5.5 addresses that concept using the diagnosis rank=1.

Timing:

  • The relevantPeriod addresses:
    • startTime - The time the encounter began (admission time).
    • stopTime - The time the encounter ended (discharge time).
  • author dateTime references the time the action was recorded.
  • Refer to the eCQM expression to determine allowable timings to meet measure criteria.

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.
  • The locationPeriod is an attribute of the attribute facility location that addresses:
    • startTime - the time the patient arrived at the location. The time the encounter began (admission time).
    • stopTime - the time the patient departed from the location.
Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to represent concepts for encounters for telephone visits.
Data Element Scope: This value set may use a model element related to Encounter.
Inclusion Criteria: Includes concepts that represent an encounter for assessment, evaluation and management services to a patient by telephone.
Exclusion Criteria: Excludes concepts that represent an encounter for telephone assessment, evaluation and management services that last for less than five minutes.

Constrained to codes in the Encounter, Performed: Telephone Visits value set (2.16.840.1.113883.3.464.1003.101.12.1080)

QDM Datatype and Definition (QDM Version 5.5 Guidance Update)

"Encounter, Performed"

Data elements that meet criteria using this datatype should document that the encounter indicated by the QDM category and its corresponding value set is in progress or has been completed.

The "Encounter, Performed" participant references the primary participant.

Previous versions of QDM included an attribute principal diagnosis, defined as the condition that, after study, was determined to be the principal cause of the admission. QDM version 5.5 addresses that concept using the diagnosis rank=1.

Timing:

  • The relevantPeriod addresses:
    • startTime - The time the encounter began (admission time).
    • stopTime - The time the encounter ended (discharge time).
  • author dateTime references the time the action was recorded.
  • Refer to the eCQM expression to determine allowable timings to meet measure criteria.

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.
  • The locationPeriod is an attribute of the attribute facility location that addresses:
    • startTime - the time the patient arrived at the location. The time the encounter began (admission time).
    • stopTime - the time the patient departed from the location.
Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to represent concepts of interventions to identify patients receiving hospice care outside of a hospital or long term care facility.
Data Element Scope: This value set may use a model element related to Procedure or Intervention.
Inclusion Criteria: Includes concepts that represent a procedure or intervention for hospice care.
Exclusion Criteria: Excludes concepts that represent palliative care or comfort measures.

Constrained to codes in the Intervention, Order: Hospice care ambulatory value set (2.16.840.1.113762.1.4.1108.15)

QDM Datatype and Definition (QDM Version 5.5 Guidance Update)

"Intervention, Order"

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

Timing: The time the order is signed; author dateTime.

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.

Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to represent concepts of interventions to identify patients receiving hospice care outside of a hospital or long term care facility.
Data Element Scope: This value set may use a model element related to Procedure or Intervention.
Inclusion Criteria: Includes concepts that represent a procedure or intervention for hospice care.
Exclusion Criteria: Excludes concepts that represent palliative care or comfort measures.

Constrained to codes in the Intervention, Performed: Hospice care ambulatory value set (2.16.840.1.113762.1.4.1108.15)

QDM Datatype and Definition (QDM Version 5.5 Guidance Update)

"Intervention, Performed"

Data elements that meet criteria using this datatype should document the completion of the intervention indicated by the QDM category and its corresponding value set.

Timing:

  • relevant dateTime references the time the intervention is performed when the intervention occurs at a single point in time.
  • relevantPeriod references a start and stop time for an intervention that occurs over a time interval. relevantPeriod addresses:
    • startTime - The time the intervention begins.
    • stopTime - The time the intervention ends.
  • author dateTime references the time the action was recorded.
  • Refer to the eCQM expression to determine allowable timings to meet measure criterion.

Notes:

  • Timing refers to a single instance of an intervention. If a measure seeks to evaluate multiple interventions over a period of time, the measure developer should use CQL logic to represent the query request.
  • 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.
     
Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to represent concepts for laboratory tests conducted during pregnancy.
Data Element Scope: This value set may use a model element related to Laboratory Test.
Inclusion Criteria: Includes concepts that represent tests conducted during pregnancy.
Exclusion Criteria: Excludes concepts that represent an order only.

Constrained to codes in the Laboratory Test, Order: Lab Tests During Pregnancy value set (2.16.840.1.113883.3.464.1003.111.12.1007)

QDM Datatype and Definition (QDM Version 5.5 Guidance Update)

"Laboratory Test, Order"

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

Timing: The time the order is signed; author dateTime.

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.

Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to represent concepts for laboratory tests for sexually transmitted infections.
Data Element Scope: This value set may use a model element related to Laboratory Test.
Inclusion Criteria: Includes concepts that represent tests for sexually transmitted infections.
Exclusion Criteria: Excludes concepts that represent an order only.

Constrained to codes in the Laboratory Test, Order: Lab Tests for Sexually Transmitted Infections value set (2.16.840.1.113883.3.464.1003.110.12.1051)

QDM Datatype and Definition (QDM Version 5.5 Guidance Update)

"Laboratory Test, Order"

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

Timing: The time the order is signed; author dateTime.

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.

Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to represent concepts for cervical cytology tests.
Data Element Scope: This value set may use a model element related to Laboratory Test.
Inclusion Criteria: Includes concepts that represent tests for cervical cytology.
Exclusion Criteria: Excludes concepts that represent tests for cervical cytology conducted on non-cervical or non-vaginal samples and tests that are ordered only.

Constrained to codes in the Laboratory Test, Order: Pap Test value set (2.16.840.1.113883.3.464.1003.108.12.1017)

QDM Datatype and Definition (QDM Version 5.5 Guidance Update)

"Laboratory Test, Order"

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

Timing: The time the order is signed; author dateTime.

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.

Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to represent concepts for pregnancy tests.
Data Element Scope: This value set may use a model element related to Laboratory Test.
Inclusion Criteria: Includes concepts that represent tests for pregnancy including in urine, serum or plasma.
Exclusion Criteria: Excludes concepts that represent an order only.

Constrained to codes in the Laboratory Test, Order: Pregnancy Test value set (2.16.840.1.113883.3.464.1003.111.12.1011)

QDM Datatype and Definition (QDM Version 5.5 Guidance Update)

"Laboratory Test, Order"

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

Timing: The time the order is signed; author dateTime.

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.

Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to represent concepts for chlamydia tests.
Data Element Scope: This value set may use a model element related to Laboratory Test.
Inclusion Criteria: Includes concepts that represent screening for chlamydia infections.
Exclusion Criteria: Excludes concepts that represent an order only.

Constrained to codes in the Laboratory Test, Performed: Chlamydia Screening value set (2.16.840.1.113883.3.464.1003.110.12.1052)

QDM Datatype and Definition (QDM Version 5.5 Guidance Update)

"Laboratory Test, Performed"

Data elements that meet criteria using this datatype should document the laboratory test indicated by the QDM category and its corresponding value set was performed.

Timing:

  • relevant dateTime references the time the laboratory test is performed when the laboratory test occurs at a single point in time.
  • relevantPeriod references a start and stop time for a laboratory test that occurs over a time interval. relevantPeriod addresses:
    • startTime - The time the laboratory test begins.
    • stopTime - The time the laboratory test ends.
  • author dateTime references the time the action was recorded.
  • Refer to the eCQM expression to determine allowable timings to meet measure criterion.

Examples:

  • Initiation of a venipuncture for a fasting blood glucose to the time venipuncture for the fasting blood glucose is completed – use relevant dateTime to reference this single point in time for many specimen collections
  • Initiation of a 24-hour urine collection for measured creatinine clearance until completion of the 24-hour urine collection – use relevantPeriod to reference the start to stop time for this event.

Notes:

  • The time that the result report is available is a separate attribute than the time of the study (specimen collection).
  • 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.
     
Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to represent concepts for contraceptive medications.
Data Element Scope: This value set may use a model element related to Medication.
Inclusion Criteria: Includes concepts that represent generic, human use and prescribable contraceptive medications.
Exclusion Criteria: Excludes concepts that represent non-prescribable or branded drugs and excludes concepts that represent components or ingredients.

Constrained to codes in the Medication, Active: Contraceptive Medications value set (2.16.840.1.113883.3.464.1003.196.12.1080)

QDM Datatype and Definition (QDM Version 5.5 Guidance Update)

"Medication, Active"

Data elements that meet criteria using this datatype should document that the medication indicated by the QDM category and its corresponding value set is being taken by the patient. Keep in mind that when this datatype is used with timing relationships, the criterion is looking for a medication being taken for the time frame indicated by the timing relationships.

Timing:

  • relevant dateTime references the time the medication is active on the medication record if it was given or taken at a single point in time.
  • relevantPeriod references a start and stop time for an active medication on the medication record that is given or taken over a time interval:
  • The relevantPeriod addresses:
    • startTime - when the medication is first known to be used (generally the time of entry on the medication list).
    • stopTime - when the medication is no longer active.

In the original QDM 5.5 publication, stopTime stated: when the medication is discontinued (generally, the time discontinuation is recorded on the medication list). See Appendix 6.3 for clarification regarding definition of "Medication, Active" relevantPeriod stopTime.

Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to represent concepts for contraceptive medications.
Data Element Scope: This value set may use a model element related to Medication.
Inclusion Criteria: Includes concepts that represent generic, human use and prescribable contraceptive medications.
Exclusion Criteria: Excludes concepts that represent non-prescribable or branded drugs and excludes concepts that represent components or ingredients.

Constrained to codes in the Medication, Order: Contraceptive Medications value set (2.16.840.1.113883.3.464.1003.196.12.1080)

QDM Datatype and Definition (QDM Version 5.5 Guidance Update)

"Medication, Order"

Data elements that meet criteria using this datatype should document a request to a pharmacy to provide the medication 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 medication order (prescription) is authored.

Notes:

  • When calculating cumulative medication duration, the stopTime may be present directly in the medication order. If the stopTime is not available, the duration in days is the difference between the relevantPeriod start and stop times multiplied by (1 + the number of refills).
  • 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.

Refer to Special Cases in Appendix A (Section 5.7) for scenarios to consider in calculating cumulative medication duration.

Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to represent concepts for isotretinoin medications.
Data Element Scope: This value set may use a model element related to Medication.
Inclusion Criteria: Includes concepts that represent generic, human use, prescribable isotretinoin and isotretinoin in combination with other medications.
Exclusion Criteria: Excludes concepts that represent non-prescribable, branded drugs and excludes concepts that represent components or ingredients.

Constrained to codes in the Medication, Order: Isotretinoin value set (2.16.840.1.113883.3.464.1003.196.12.1143)

QDM Datatype and Definition (QDM Version 5.5 Guidance Update)

"Medication, Order"

Data elements that meet criteria using this datatype should document a request to a pharmacy to provide the medication 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 medication order (prescription) is authored.

Notes:

  • When calculating cumulative medication duration, the stopTime may be present directly in the medication order. If the stopTime is not available, the duration in days is the difference between the relevantPeriod start and stop times multiplied by (1 + the number of refills).
  • 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.

Refer to Special Cases in Appendix A (Section 5.7) for scenarios to consider in calculating cumulative medication duration.

Direct Reference Code

Constrained to 'Birth date' LOINC code

QDM Datatype and Definition (QDM Version 5.5 Guidance Update)

"Patient Characteristic, Birthdate"

The "Patient Characteristic Birthdate" should document the patient’s date of birth.

Timing: The "Patient Characteristic, Birthdate" is a single point in time representing the date and time of birth. It does not have a start and stop time.

Note: "Patient Characteristic Birthdate" is fixed to LOINC code 21112-8 (Birth date) and therefore cannot be further qualified with a value set.

Value Set Description from VSAC
Clinical Focus: n/a Data Element Scope: n/a Inclusion Criteria: n/a Exclusion Criteria: n/a

Constrained to codes in the Patient Characteristic, Ethnicity: Ethnicity value set (2.16.840.1.114222.4.11.837)

QDM Datatype and Definition (QDM Version 5.5 Guidance Update)

"Patient Characteristic, Ethnicity"

Data elements that meet criteria using this datatype should document that the patient has one or more of the ethnicities indicated by the QDM category and its corresponding value set.

Timing: Ethnicity does not have a specific timing. Measures using "Patient Characteristic, Ethnicity" should address the most recent entry in the clinical record.

Value Set Description from VSAC
Clinical Focus: Categories of types of health care payor entities as defined by the US Public Health Data Consortium SOP code system
Data Element Scope: @code in CCDA r2.1 template Planned Coverage [act: identifier urn:oid:2.16.840.1.113883.10.20.22.4.129 (open)] DYNAMIC
Inclusion Criteria: All codes in the code system
Exclusion Criteria: none

Constrained to codes in the Patient Characteristic, Payer: Payer value set (2.16.840.1.114222.4.11.3591)

QDM Datatype and Definition (QDM Version 5.5 Guidance Update)

"Patient Characteristic, Payer"

Data elements that meet criteria using this datatype should document that the patient has one or more of the payers indicated by the QDM category and its corresponding value set.

Timing:

The relevantPeriod addresses:

  • startTime – the first day of insurance coverage with the referenced payer.
  • stopTime – the last day of insurance coverage with the referenced payer.
Value Set Description from VSAC
Clinical Focus: n/a Data Element Scope: n/a Inclusion Criteria: n/a Exclusion Criteria: n/a

Constrained to codes in the Patient Characteristic, Race: Race value set (2.16.840.1.114222.4.11.836)

QDM Datatype and Definition (QDM Version 5.5 Guidance Update)

"Patient Characteristic, Race"

Data elements that meet criteria using this datatype should document the patient’s race.

Timing: Race does not have a specific timing. Measures using "Patient Characteristic, Race" should address the most recent entry in the clinical record.

Value Set Description from VSAC
Clinical Focus: Concepts that represent Female when assessing quality measures
Data Element Scope: Gender
Inclusion Criteria: Appropriate female gender concepts
Exclusion Criteria: Concepts representing Male gender

Constrained to codes in the Patient Characteristic, Sex: Female value set (2.16.840.1.113883.3.560.100.2)

QDM Datatype and Definition (QDM Version 5.5 Guidance Update)

"Patient Characteristic, Sex"

Data elements that meet criteria using this datatype should document that the patient's sex matches the QDM category and its corresponding value set.

Timing: Birth (administrative) sex does not have a specific timing.

Value Set Description from VSAC
Clinical Focus: Gender identity restricted to only Male and Female used in administrative situations requiring a restriction to these two categories.
Data Element Scope: Gender
Inclusion Criteria: Male and Female only.
Exclusion Criteria: Any gender identity that is not male or female.

Constrained to codes in the Patient Characteristic, Sex: ONC Administrative Sex value set (2.16.840.1.113762.1.4.1)

QDM Datatype and Definition (QDM Version 5.5 Guidance Update)

"Patient Characteristic, Sex"

Data elements that meet criteria using this datatype should document that the patient's sex matches the QDM category and its corresponding value set.

Timing: Birth (administrative) sex does not have a specific timing.

Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to represent procedures indicating history of sexual activity
Data Element Scope: This value set may use a model element related to Procedure.
Inclusion Criteria: Includes concepts that represent a procedure for pregnancy or postpartum or contraceptive use.
Exclusion Criteria: No exclusions.

Constrained to codes in the Procedure, Performed: Procedures Used to Indicate Sexual Activity value set (2.16.840.1.113883.3.464.1003.111.12.1017)

QDM Datatype and Definition (QDM Version 5.5 Guidance Update)

"Procedure, Performed"

Data elements that meet criteria using this datatype should document the completion of the procedure indicated by the QDM category and its corresponding value set.

Timing:

  • relevant dateTime references the time the procedure is performed when the procedure occurs at a single point in time.
  • relevantPeriod references a start and stop time for a procedure that occurs over a time interval. relevantPeriod addresses:
    • startTime - The time the procedure begins.
    • stopTime - The time the procedure ends.
  • author dateTime references the time the action was recorded.
  • Refer to the eCQM expression to determine allowable timings to meet measure criterion.

Notes: 

  • Timing refers to a single instance of a procedure. If a measure seeks to evaluate multiple procedures over a period of time, the measure developer should use CQL logic to represent the query request.
  • The incision dateTime is a single point in time available from the Operating Room and/or Anesthesia Record.
  • 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 clarification, see Appendix 6.6 with 2020 guidance about differentiating between successful and unsuccessful procedures.