This page is part of the Quality Improvement Core Framework (v5.0.0-ballot: STU 5 Ballot 1) based on FHIR R4. The current version which supercedes this version is 4.1.1. For a full list of available versions, see the Directory of published versions

Quality Data Model (QDM)v5.6 to QI-Core R5 Mapping

Care Goal

QDM defines Care Goal as a defined target or measure to be achieved in the process of patient care, that is, an expected outcome. A typical goal is expressed as a change in status expected at a defined future time. That change can be an observation represented by other QDM categories (diagnostic tests, laboratory tests, symptoms, etc.) scheduled for some time in the future and with a particular value. A goal can be found in the plan of care (care plan), the structure used by many stakeholders to define the management actions for the various conditions, problems, or issues identified for the target of the plan. This structure, through which the goals and care-planning actions and processes can be organized, planned, communicated, and checked for completion, is represented in QDM as a Record Artifact in which Care Goal is found.

QDM Context	QI-Core R5	Comments
Care Goal	Goal
	Goal.achievementStatus
QDM Attributes
code	Goal.target.measure
	Goal.target.detail[x]
id	Goal.id
statusDate
targetOutcome	Goal.target.detail[x]
relevantPeriod	Goal.start[x]
	Goal.target.due[x]
statusDate	Goal.statusDate
relatedTo	Goal.addresses
performer	Goal.expressedBy

Communication

QDM defines Communication as the transmission, receipt, or acknowledgement of information sent from a source to a recipient, such as from one clinician to another regarding findings, assessments, plans of care, consultative advice, instructions, educational resources, etc.  The following text from the FHIR Communication and Procedure Resources may help to differentiate when to use Communication.

FHIR Communication Resource

This resource is a record of a communication. A communication is a conveyance of information from one entity, a sender, to another entity, a receiver. The sender and receivers may be patients, practitioners, related persons, organizations, or devices. Communication use cases include:

• A reminder or alert delivered to a responsible provider

• A recorded notification from the nurse to the on-call physician (or any other specified person) that a patient’s temperature exceeds a value

• A notification to a public health agency of a patient presenting with a communicable disease reportable to the public health agency

• Patient educational material sent by a provider to a patient

• Unable to deliver lab results to ordering physician

Non-patient specific communication use cases may include:

• A nurse call from a hall bathroom

• Advisory for battery service from a pump

Boundaries and Relationships (Section 8.20.2) - Communication and Encounter

• The Communication is about the transfer of information (which might or might not occur as part of an encounter), while Encounter is about the coming together (in person or virtually) of a Patient with a Practitioner. Communication does not deal with the duration of a call, it represents the fact that information was transferred at a particular point in time.

• The phone calls involving the Patient should be handled using Encounter. Phone calls not involving the patient (e.g. between practitioners or practitioner to relative) that are tracked for billing or other purposes can use Communication to represent the information transferred but are not ideal to represent the call itself. A better mechanism for handling such calls will be explored in a future release.

HL7 FHIR Procedure Resource

The boundary between determining whether an action is a Procedure (training or counseling) as opposed to a Communication is based on whether there’s a specific intent to change the mind-set of the patient. Mere disclosure of information would be considered a Communication. A process that involves verification of the patient’s comprehension or to change the patient’s mental state would be a Procedure.

Communication, Performed

QDM Context	QI-Core R5	Comments
Communication, Performed	Communication
	Communication.status	constrain to completed
QDM Attributes
code	Communication.reasonCode
id	Communication.id
category	Communication.category	alert, notification, reminder, instruction
medium	Communication.medium
sentDatetime	Communication.sent
receivedDatetime	Communication.received
authorDatetime	Communication.extension:recorded	for use with negationRationale
relatedTo	Communication.basedOn	An order, proposal or plan fulfilled in whole or in part by this Communication.
	Communication.inResponseTo	Response to a communication
sender	Communication.sender
recipient	Communication.recipient
negationRationale	See Below

Negation Rationale for Communication, Performed

Use QICoreCommunicationNotDone, which contains:

• Communication.status - Fixed Value: “not-done”
• Communication.statusReason - Use value set NegationReasonCodes
• Communication.extension:recorded - dateTime when this was made available
• Communication.reasonCode.extension:notDoneValueSet - Use qicore-notDoneValueSet to indicate the specific Communication that was not performed

Device

QDM defines Device as an instrument, apparatus, implement, machine, contrivance, implant, in-vitro reagent, or other similar or related article, including a component part or accessory, intended for use in the diagnosis, cure, mitigation, treatment, or prevention of disease and not dependent on being metabolized to achieve any of its primary intended purposes.

FHIR defines the Device Resource as a type of a manufactured item that is used in the provision of healthcare without being substantially changed through that activity. The device may be a medical or non-medical device.

FHIR and US Core further differentiate devices into two “classes”:

• Devices that interact with the human body but do not stay in it are referred to as non-implantable medical devices.
• Implantable devices are those which stay in the human body with a medical objective for an extended period of time, or even a lifetime.

[Definition reference: Imam W. How to use ISO 13485:2016 to manage implantable devices, ISO 13485 Blog. July 4, 2016. Available at: https://advisera.com/13485academy/blog/2017/07/04/how-to-use-iso-134852016-to-manage-implantable-medical-devices/. Accessed 28 January 2020.]

The FHIR Device Resource addresses both implantable and non-implantable devices. US Core only references Implantable Device. QI-Core inherits Implantable Device from US Core and builds directly from FHIR for the QI-Core Device Resource.

Device, Applied

QDM originally designed Device, Applied to allow access to documentation of device usage. However, evaluation over time indicates that all documentation about usage of a device occurs as an observation. Thus, information about an implanted pacemaker status check, utilization of a patient-use Continuous Positive Airway Pressure (CPAP) device, results from a glucometer, or use of a wheelchair or cane should use the QDM datatype, Assessment, Performed, or QI-Core Observation. Use of Device, Applied has been synonymous with Procedure, Performed, i.e., placement of or adjustment to a device.

“Device Applied” has been retired in QDM 5.6 in favor of using “Procedure, Performed” or “Assessment, Performed” as appropriate.

Device, Order – Non-Patient-use Devices

QDM Context	QI-Core R5	Comments
Device Request	ServiceRequest
	ServiceRequest.status	Constrain to active, completed
Device, Order	ServiceRequest.intent	Constrain to “order” (include children)
QDM Attributes
code	ServiceRequest.code
id	ServiceRequest.id
reason	ServiceRequest.reasonCode
authorDatetime	ServiceRequest.authoredOn	FHIR allows dateTime or Period for desired time or schedule for use.
negationRationale	See Below
requester	ServiceRequest.requester

Negation Rationale for Device, Order

Use QICoreServiceNotRequested, which contains:

• ServiceRequest.doNotPerform - Fixed value: “true”
• ServiceRequest.status - Fixed value: “completed”
• ServiceRequest.extension:reasonRefused - Use value set NegationReasonCodes
• ServiceRequest.authoredOn - dateTime when this was made available
• ServiceRequest.code.extension:notDoneValueSet - Use qicore-notDoneValueSet to indicate the specific ServiceRequest that was not performed

Device, Order – Personal Use Devices

QDM Context	QI-Core R5	Comments
Device Request	DeviceRequest
	DeviceRequest.status	Constrain to active, completed
Device, Order	DeviceRequest.intent	Constrain to “Order” (include children)
QDM Attributes
code	DeviceRequest.code[x]
id	DeviceRequest.id
reason	DeviceRequest.reasonCode
authorDatetime	DeviceRequest.authoredOn	FHIR allows dateTime or Period for deseired time or schedule for use.
negationRationale	See Below
requester	DeviceRequest.requester

Negation Rationale for Device, Order – Personal Use Devices

Use QICoreDeviceNotRequested, which contains:

• DeviceRequest.modifierExtension:doNotPerform - Fixed value: “true”
• DeviceRequest.status - Fixed value: “completed”
• DeviceRequest.extension:doNotPerformReason - Use value set NegationReasonCodes
• DeviceRequest.authoredOn - dateTime when this was made available
• DeviceRequest.code[x].extension:doNotPerformValueSet - Use qicore-notDoneValueSet to indicate the specific DeviceRequest that was not performed

Device, Recommended – Non-Patient-use Devices

QDM Context	QI-Core R5	Comments
Device Request	ServiceRequest
	ServiceRequest.status	Constrain to active, completed
Device, Order	ServiceRequest.intent	Constrain to “order” (include children)
QDM Attributes
code	ServiceRequest.code
id	ServiceRequest.id
reason	ServiceRequest.reasonCode
authorDateTime	ServiceRequest.authoredOn	FHIR allows dateTime or Period for desired time or schedule for use.
negationRationale	See Below
requester	ServiceRequest.requester

Negation Rationale for Device, Recommended

Use QICoreServiceNotRequested, which contains:

• ServiceRequest.doNotPerform - Fixed value: “true”
• ServiceRequest.status - Fixed value: “completed”
• ServiceRequest.extension:reasonRefused - Use value set NegationReasonCodes
• ServiceRequest.authoredOn - dateTime when this was made available
• ServiceRequest.code.extension:notDoneValueSet - Use qicore-notDoneValueSet to indicate the specific ServiceRequest that was not performed

Device, Recommended – Personal Use Devices

QDM Context	QI-Core R5	Comments
Device Request	DeviceRequest
	DeviceRequest.status	Constrain to active, completed
Device, Order	DeviceRequest.intent	Constrain to “Order” (include children)
QDM Attributes
code	DeviceRequest.code[x]
id	DeviceRequest.id
reason	DeviceRequest.reasonCode
authorDatetime	DeviceRequest.authoredOn	FHIR allows dateTime or Period for deseired time or schedule for use.
negationRationale	See Below
requester	DeviceRequest.requester

Negation Rationale for Device, Recommended – Personal Use Devices

Use QICoreDeviceNotRequested, which contains:

• DeviceRequest.modifierExtension:doNotPerform - Fixed value: “true”
• DeviceRequest.status - Fixed value: “completed”
• DeviceRequest.extension:doNotPerformReason - Use value set NegationReasonCodes
• DeviceRequest.authoredOn - dateTime when this was made available
• DeviceRequest.code[x].extension:doNotPerformValueSet - Use qicore-notDoneValueSet to indicate the specific DeviceRequest that was not performed

Encounter

QDM defines Encounter as an identifiable grouping of healthcare-related activities characterized by the entity relationship between the subject of care and a healthcare provider; such a grouping is determined by the healthcare provider. A patient encounter represents interaction between a healthcare provider and a patient with a face-to-face patient visit to a clinician’s office, or any electronically remote interaction with a clinician for any form of diagnostic treatment or therapeutic event.

Encounter Timing

Implementation considerations must be considered when referencing encounter periods (start to end time).  Some clinical sites may leave Encounters “open” until all documentation has been completed which may take 72 hours or more.  However, the actual encounter may have lasted for a much shorter time period (e.g., 15 minutes for an ambulatory encounter). This issue is addressed in The Office of the National Coordinator for Health IT (ONC) Issue Tracking System as item QDM-235. Two approaches clinical sites have used to manage this issue include:

• Include a patient check-in and check-out time as part of the visit documentation. These times represent when the patient arrives and leaves, respectively, and these times are used for the Encounter relevant period. However, patient arrival at a location does not necessarily mean the start of the encounter (e.g. a patient arrives an hour earlier than he or she is actually seen by a practitioner).

• Default an Encounter end as 23:59 on the date of the Encounter date if it is left open to allow completion of documentation and update the end time if the practitioner closing the chart enters a specific time that the encounter ended.

Undoubtedly, other clinical sites have implemented other solutions to documenting end times for ambulatory visits. Quality measure and clinical decision support (CDS) artifact authors should consider such issues when testing the validity and reliability of retrieved responses to data queries.

Encounter-Related Diagnoses and Procedures

Encounter.diagnosis refers to the list of diagnosis/diagnoses relevant to the encounter. The Encounter.diagnosis.use value differentiates if the diagnosis is the admission diagnosis (AD), the discharge diagnosis (DD), the chief complaint (CC), a comorbidity diagnosis (CM), a pre-op diagnosis (pre-op), a post-op diagnosis (post-op) or a billing diagnosis (billing).

Some quality measures used to evaluate care provided in hospital settings use concepts to define principal diagnosis and present on admission:

• Principal diagnosis is 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 US Core concepts Encounter.diagnosis.use value=billing with an diagnosis.rank=1.

• Present on admission (POA) is an indicator assigned to Inpatient Encounter diagnoses and is used in quality and patient safety measures. QDM version 5.5 references this indicator as a component of each Encounter, Performed diagnosis The US Core and FHIR Encounter resources do not address present on admission. However, the FHIR Claim resource includes a claim.diagnosis.onAdmission element referencing similar terms as the US UB-04 claim form to indicate present on admission – yes (y), no (n), unknown (u), and undetermined (w). QI-Core includes an extension on Encounter.diagnosis to reference the onAdmission element, thus enabling specification of an Encounter.diagnosis that is present on admission.

• Principal procedure is the procedure performed for definitive treatment rather than diagnostic or exploratory purposes, or which is necessary to take care of a complication.
  [https://manual.jointcommission.org/releases/TJC2015B/DataElem0685.html] Principal procedure defines a procedures relationship to an encounter (most often an inpatient encounter). It has not relationship to the inherent nature of the procedure. Therefore, QI-Core includes an extension modeling Encounter.procedure in the same way as Encounter.diagnosis. The Encounter.procedure has a code to indicate the procedure code and a rank to indicate its ordinality such that rank=1 identifies the procedure as a principal procedure.

• Elective procedure is another concept used in quality measurement, especially in hospital measures. A specific measure may have interest in evaluating care provided for elective procedures (e.g., hip surgery due to osteoarthritis) while excluding emergency, non-planned procedures (e.g., hip surgery due to acute fracture). The procedure code does not necessarily allow differentiation of the two concepts. A ServiceRequest.priority does have the ability to differentiate the urgency with which the request (or order) should be fulfilled. However, there is no element within the FHIR Procedure resource to address the issue. Encounter.priority allows specification of whether the encounter is elective. Since the Encounter.procedure can be linked to the ServiceRequest with its priority, there is no need to add a specific extension in QI-Core for Encounter.procedure.priority. Therefore, there is no direct mapping from the QDM Procedure priority attribute to QI-Core and measures considering the concept should reference QDM’s Encounter, Order with its priority.

Encounter, Order

QDM Context	QI-Core R5	Comments
Encounter, Order	ServiceRequest
	ServiceRequest.status	Constrain to active, completed
	ServiceRequest.intent	Constrain only to “order” (include children: original-order, reflex-order, filler-order, instance-order)
QDM Attributes
code	ServiceRequest.code
id	ServiceRequest.id
reason	ServiceRequest.reasonCode
authorDatetime	ServiceRequest.authoredOn	When the request transitioned to being actionable.
facilityLocation	ServiceRequest.locationCode
priority	ServiceRequest.modifierExtension:isElective
negationRationale	See Below
requester	ServiceRequest.requester

Negation Rationale for Encounter, Order

Use QICoreServiceNotRequested, which contains:

• ServiceRequest.doNotPerform - Fixed value: “true”
• ServiceRequest.status - Fixed value: “completed”
• ServiceRequest.extension:reasonRefused - Use value set NegationReasonCodes
• ServiceRequest.authoredOn - dateTime when this was made available
• ServiceRequest.code.extension:notDoneValueSet - Use qicore-notDoneValueSet to indicate the specific ServiceRequest that was not performed

Encounter, Recommended

QDM Context	QI-Core R5	Comments
Encounter, Recommended	ServiceRequest
	ServiceRequest.status	Constrain to active, completed
	ServiceRequest.intent	Constrain only to “plan”
QDM Attributes
code	ServiceRequest.code
id	ServiceRequest.id
reason	ServiceRequest.reasonCode
authorDatetime	ServiceRequest.authoredOn	When the request transitioned to being actionable.
facilityLocation	ServiceRequest.locationCode
priority	ServiceRequest.modifierExtension:isElective
negationRationale	See Below
requester	ServiceRequest.requester

Negation Rationale for Encounter, Recommended

Use QICoreServiceNotRequested, which contains:

• ServiceRequest.doNotPerform - Fixed value: “true”
• ServiceRequest.status - Fixed value: “completed”
• ServiceRequest.extension:reasonRefused - Use value set NegationReasonCodes
• ServiceRequest.authoredOn - dateTime when this was made available
• ServiceRequest.code.extension:notDoneValueSet - Use qicore-notDoneValueSet to indicate the specific ServiceRequest that was not performed

Family History

QDM defines Family History as a diagnosis or problem experienced by a family member of the patient. Typically, a family history will not contain very much detail, but the simple identification of a diagnosis or problem in the patient’s family history may be relevant to the care of the patient.

QDM Context	QI-Core R5	Comments
Family History	FamilyMemberHistory
	FamilyMemberHistory.status	Constrain to partial, completed
QDM Attributes
code	FamilyMemberHistory.condition.code
id	FamilyMemberHistory.id
authorDatetime	FamilyMemberHistory.date
relationship	FamilyMemberHistory.relationship
recorder	N/A

Immunization

QDM defines Immunization as vaccines administered to patients in healthcare settings but does not include non-vaccine agents. The FHIR Immunization Recommendation resource is specifically designed to provide an immunization forecast from a forecasting engine to a provider, basically to carry clinical decision support recommendations specific to immunizations and, therefore, is not consistent with the intent of the QDM datatype “Immunization, Order” or “Immunization, Administered.” The FHIR Immunization Evaluation references an appraisal of an immunization that was administered to determine if it is valid with respect to the expected immunization schedule. The US Core Immunization profile is most consistent with the QDM datatype Immunization, Administered.  The mapping tables provided include mapping from QDM Immunization, Administered and a reference to the FHIR Immunization Evaluation resource. Note, the mapping table includes additional metadata about immunizations that QDM does not address, but that may be relevant to quality measures or clinical decision support (CDS) artifacts.

Immunization, Administered

QDM Context	US Core R5	Comments
Immunization, Administered	Immunization
	Immunization.status	Constrain to “completed”
QDM Attributes
code	Immunization.vaccineCode
id	Immunization.id
dosage	Immunization.doseQuantity
negationRationale	See Below
route	Immunization.route
reason	Immunization.reasonCode
relevantDatetime	Immunization.occurrence[x]
authorDatetime	Immunization.recorded
performer	Immunization.performer.actor

Immunization, Administered

Use QICoreImmunizationNotDone, which contains:

• Immunization.status - Fixed value: “not-done”
• Immunization.statusReason - Use value set NegationReasonCodes
• Immunization.recorded - dateTime
• Immunization.vaccineCode.extension:notDoneValueSet - Use qicore-notDoneValueSet to indicate the specific immunization that was not administered

Immunization, Order

This QDM context references the QI-Core MedicationRequest profile as there is no other FHIR resource to reference an order for an immunization. The mapping uses the QI-Core MedicationRequest resource with the MedicationRequest.intent = order and MedicationRequest.setting set to the setting most appropriate for the intended meaning of the quality measure or clinical decision support (CDS) expression.

QDM Context	QI-Core R5	Comments
Immunization, Order	MedicationRequest
	MedicationRequest.status	Constrain to active, completed
	MedicationRequest.statusReason	The reason for ordering or not ordering the medication
	MedicationRequest.intent	Constrain to “order” for Medication, Order - note that QDM does not include Medication, Recommended - should that concept be desired, use MedicationRequest.intent constrained to “plan”
QDM Attributes
code	MedicationRequest.medication[x]	RxNorm
id	MedicationRequest.id
activeDatetime	MedicationRequest.dosageInstruction.timing with Timing.repeat.bounds[x] Period	QDM defines active dateTime as when the order indicates the first immunization administration should occur. Active dateTime is most often used to specify immunizations for which administration is intended at a specific time in the future. FHIR allows specification of the period during which the immunization should occur (start dateTime to end dateTime)
authorDatetime	MedicationRequest.authoredOn
dosage	MedicationRequest.dosageInstruction.doseAndRate.dose[x]	Range, quantity
route	MedicationRequest.dosageInstruction.route
reason	MedicationRequest.reasonCode	The reason for ordering or not ordering the medication
supply	MedicationRequest.dispenseRequest.quantity	Amount to be dispensed in one fill
negationRationale	See Below
	MedicationRequest.reasonCode	The reason for ordering or not ordering the medication.
requester	MedicationRequest.requester	Note - MedicationRequest.performer indicates the performer expected to administer the medication

Negation Rationale for Immunization, Order

Use QICoreMedicationNotRequested, which contains:

• MedicationRequest.doNotPerform - Fixed value: “true”
• MedicationRequest.status - Fixed value: “completed”
• MedicationRequest.reasonCode - Use value set NegationReasonCodes
• MedicationRequest.authoredOn - dateTime when this was made available
• MedicationRequest.medication[x].extension:notDoneValueSet - Use qicore-notDoneValueSet to indicate the specific MedicationRequest that was not performed

Individual Characteristics

QDM’s approach to defining information about participants In the healthcare process by defining Individual Characteristics. These properties of a patient, clinician, provider, or facility include demographics, behavioral factors, social or cultural factors, available resources, and preferences. Behaviors reference responses or actions that affect (either positively or negatively) health or healthcare. Included in this category are mental health issues, adherence issues unrelated to other factors or resources, coping ability, grief issues, and substance use/abuse. Social/cultural factors are characteristics of an individual related to family/caregiver support, education, and literacy (including health literacy), primary language, cultural beliefs (including health beliefs), persistent life stressors, spiritual and religious beliefs, immigration status, and history of abuse or neglect. Resources are means available to a patient to meet health and healthcare needs, which might include caregiver support, insurance coverage, financial resources, and community resources to which the patient is already connected and from which the patient is receiving benefit. Preferences are choices made by patients and their caregivers relative to options for care or treatment (including scheduling, care experience, and meeting of personal health goals) and the sharing and disclosure of their health information.

FHIR more effectively represents these concepts in the Level 3 Administration Module – base data that is linked into other modules for clinical content, finance/billing, workflow, etc. The Administration Module specifies information about the patient, related person, practitioner and organization that is the basis of healthcare-related interactions such as encounters. QDM version 5.5 adopted a similar approach to such information by adding a new concept called Entities. Entities  represent concepts that can be used to specify details about an actor (or performer) participant in any activity represented by a QDM datatype. These entities are analogous to the FHIR resources Patient, RelatedPerson, Practitioner, and Organization, respectively called Patient, CarePartner, Practitioner and Organization in QDM. The mapping tables show these direct relationships to FHIR resources. However, to maintain backward compatibility with prior QDM versions, QDM 5.5 retains the concept of Patient Characteristics for some metadata about a patient; most of these characteristics map directly to metadata elements in the FHIR Patient resource. QDM 5.5 removed the Provider Characteristics QDM datatype in favor of the Practitioner and Organization entities since there had been little, if any, use of these QDM elements.

Accommodating patient-related metadata requires QI-Core extensions for several elements including:

• Clinical Trial – Patients may be excluded from some quality measures or clinical decision support (CDS) workflows if they are participating in clinical trials. It is often necessary to determine the nature of the trial as exclusions may only apply if the clinical trial addresses the same clinical condition as the measure or CDS artifact, or if treatments potentially used in the clinical trial or the measure or CDS intervention conflict.

QDM 5.5 also added a new QDM datatype Related Person to allow reference to an individual who has a personal or non-healthcare-specific professional relationship with a patient. Modeled the same as the CarePartner entity, the Related Person is an individual from whose record clinical information should be retrieved to support care provided to the index patient. 

• Example 1: An infant’s gestational age at the time of birth may be calculated as the difference between the days between the mother’s estimated date of delivery (EDD) and the actual birth date. The mother’s EDD might be entered directly on the infant’s record as an observable entity about a Related Person (the infant’s mother). Alternatively, a cross-context query might request the information from the Related Person’s (mother’s) record.

• Example 2: An organ recipient risk factor may include a donor’s positive Hepatitis C antibody result. The result relates to the donor (Related Person) whether that result is present on the recipient’s record or if the a cross-context query to the donor’s record retrieves the information.

QDM Entities

QDM Entities & Attributes	QI-Core R5	Comment
Patient	Patient
identifier	Patient.identifier.value
id	Patient.id
Care Partner	RelatedPerson	Related Person
identifier	RelatedPerson.identifier
id	RelatedPerson.id
relationship	RelatedPerson.relationship
Practitioner	Practitioner
identifier	Practitioner.identifier (or specific practitioner identifier types: Practitioner.identifier:ein)
id	Practitioner.id
role	PractitionerRole.code
specialty	PractitionerRole.specialty
qualification	Practitioner.qualification.code
Organization	Organization
identifier	Organization.identifier (or specific organizational identifier types: Organization.identifier:ccn, Organization.identifier:ein)
id	Organization.id
organizationType	Organization.type	QDM attribute name update in QDM 5.6
Location	Location	New in QDM 5.6
identifier	Location.identifier.value	New in QDM 5.6
id	Location.id	New in QDM 5.6
locationType	Location.type	New in QDM 5.6

Patient Characteristics

QDM Attribute	US Core R5	Comments
Race		See US CoreRaceExtension for details
code	Patient.extension:race
id
Ethnicity
code	Patient.extention:ethnicity	See US CoreEthnicityExtension for details
id
Sex
code	Patient.extension:birthsex
code	Patient.gender	Administrative Gender
id
Birthdate
birthDatetime	Patient.birthdate	Fixed code 21112-8
id
Clinical Trial Participant		Clinical Trial Participant should be handled as an Observation (i.e., Assessment, Performed) in QDM rather than a Patient Characteristic
Expired
code	Patient.deceased[x] boolean
id
cause		Expiration cause requires use of Observation
expirationDatetime	Patient.deceased[x] dateTime
Payer	Coverage
code	Coverage.payor	QI-Core currently maps to policy holder which actually references the person who owns the policy, not the payor.
relevantPeriod	Coverage.period
id	Coverage.id
Patient Characteristic (generic)
N/A		Requires definition for modeling a characteristic to QI-Core and FHIR

QDM datatype - Related Person

QDM Attribute	QI-Core R5	Comments
Related Person	RelatedPerson
identifier	RelatedPerson.identifier
id	RelatedPerson.id
linkedPatientId	N/A	Not present in QI-Core
code	RelatedPerson.relationship

Intervention

QDM defines Intervention as a course of action intended to achieve a result in the care of persons with health problems that does not involve direct physical contact with a patient. Examples include patient education and therapeutic communication.

Procedure Vs Intervention

FHIR references both of these concepts using the Procedure resource, specifically noting a process that involves verification of the patient’s comprehension or to change the patient’s mental state would be a Procedure. Therefore, both QDM datatypes, Procedure and Intervention are included in this section of the QDM to QI-Core mapping especially since all of the QDM attributes for each of these QDM datatypes are identical.

Intervention, Order

QDM Context	QI-Core R5	Comments
Intervention, Order	ServiceRequest
	ServiceRequest.status	Constrain to active, completed
	ServiceRequest.intent	Constrain only to “order” (include children: original-order, reflex-order, filler-order, instance-order)
QDM Attributes
code	ServiceRequest.code
id	ServiceRequest.id
reason	ServiceRequest.reasonCode
authorDatetime	ServiceRequest.authoredOn	When the request transitioned to being actionable.
negationRationale	See Below
requester	ServiceRequest.requester

Negation Rationale for Intervention, Order

Use QICoreServiceNotRequested, which contains:

• ServiceRequest.doNotPerform - Fixed value: “true”
• ServiceRequest.status - Fixed value: “completed”
• ServiceRequest.extension:reasonRefused - Use value set NegationReasonCodes
• ServiceRequest.authoredOn - dateTime when this was made available
• ServiceRequest.code.extension:notDoneValueSet - Use qicore-notDoneValueSet to indicate the specific ServiceRequest that was not performed

Intervention, Recommended

QDM Context	QI-Core R5	Comments
Intervention, Recommended	ServiceRequest
	ServiceRequest.status	Constrain to active, completed
	ServiceRequest.intent	Constrain only to “plan”
QDM Attributes
code	ServiceRequest.code
id	ServiceRequest.id
reason	ServiceRequest.reasonCode
authorDatetime	ServiceRequest.authoredOn	When the request transitioned to being actionable.
negationRationale	See Below
requester	ServiceRequest.requester

Negation Rationale for Intervention, Recommended

Use QICoreServiceNotRequested, which contains:

• ServiceRequest.doNotPerform - Fixed value: “true”
• ServiceRequest.status - Fixed value: “completed”
• ServiceRequest.extension:reasonRefused - Use value set NegationReasonCodes
• ServiceRequest.authoredOn - dateTime when this was made available
• ServiceRequest.code.extension:notDoneValueSet - Use qicore-notDoneValueSet to indicate the specific ServiceRequest that was not performed

Laboratory Test, Recommended

QDM Context	QI-Core R5	Comments
Laboratory Test, Recommended	ServiceRequest
	ServiceRequest.status	Constrain to active, completed
	ServiceRequest.intent	Constrain only to “plan”
QDM Attributes
code	ServiceRequest.code
id	ServiceRequest.id
reason	ServiceRequest.reasonCode
authorDatetime	ServiceRequest.authoredOn	When the request transitioned to being actionable.
negationRationale	See Below
requester	ServiceRequest.requester

Negation Rationale for Laboratory Test, Recommended

Use QICoreServiceNotRequested, which contains:

• ServiceRequest.doNotPerform - Fixed value: “true”
• ServiceRequest.status - Fixed value: “completed”
• ServiceRequest.extension:reasonRefused - Use value set NegationReasonCodes
• ServiceRequest.authoredOn - dateTime when this was made available
• ServiceRequest.code.extension:notDoneValueSet - Use qicore-notDoneValueSet to indicate the specific ServiceRequest that was not performed

Medication

QDM defines Medication as clinical drugs or chemical substances intended for use in the medical diagnosis, cure, treatment, or prevention of disease. Medications are defined as direct referenced values or value sets containing values derived from code systems such as RxNorm. QDM defines five contexts for Medication, each of which is listed below referencing the US Core or FHIR resource which provides the expected context:

Medication, Active

This QDM context correlates with a medication on a patient’s active medication list. In QI-Core STU3, Medication, Active was mapped to MedicationStatement. However, consistent with US Core R4 Update, medication list should use MedicationRequest and not MedicationStatement. The mapping table provides guidance about how to use MedicationRequest.requester to specify medications ordered directly, those reported by a physician and those reported by the patient for a medication list.

The MedicationRequest SHALL include all prescribed and “self-prescribed” medications reported by the Provider, Patient or Related Person.

• SHALL use reported[x] to indicate the MedicationRequest record was captured as a secondary “reported” record rather than an original primary source-of-truth record. It may also indicate the source of the report
• When recording “self-prescribed” medications SHALL use intent = “plan”
• When recording “self-prescribed” orders, SHOULD use the requester to indicate the Patient or RelatedPerson as the prescriber

QDM Context	QI-Core R5	Comments
Medication, Active	MedicationRequest
	MedicationRequest.status	Constrain to “active”
	MedicationRequest.intent	When recording “self-prescribed” medications SHALL use intent = “plan” for prescribed use intent = “order”
	MedicationRequest.reported[x]	When recording “self-prescribed” medications SHALL use reported[x] to indicate the MedicationRequest record was captured as a secondary “reported” record rather than an original primary source-of-truth record
	MedicationRequest.category	inpatient, outpatient, community, patient-specified
QDM Attribute
code	MedicationRequest.medication[x]
id	MedicationRequest.id
dosage	MedicationRequest.dosageInstruction.doseAndRate.dose[x]	Amount of medication per dose
frequency	MedicationRequest.dosageInstruction.timing
route	MedicationRequest.dosageInstruction.route
	MedicationRequest.reasonCode
relevantDatetime	MedicationRequest.dosageInstruction.timing with Timing.event dateTime
relevantPeriod	MedicationRequest.dosageInstruction.timing with Timing.repeat.bounds[x] Period
	MedicationRequest.authoredOn	Author dateTime not referenced in QDM
recorder	MedicationRequest.requester	To address all medications on a medication list, use MedicationRequest with status = active; intent = order; and requester = organization (for prescribed medications for which an order exists), requester = practitioner (for medications entered by clinicians but not ordered), and intent = plan and requester = patient or RelatedPerson (for patient/related person reported)

Medication, Administered

This QDM context correlates with a record of a patient consuming or otherwise being administered a medication. It references individual medication administration events and, therefore, may not reference frequency of administration. Note that a separate QDM and US Core profile address Immunization, Administered.

QDM Context	QI-Core R5	Comments
Medication, Administered	MedicationAdministration
	MedicationAdministration.status	Constrain status to “In-progress” or “completed” Note: Measures that look for evidence of potential adverse events might use MedicationAdministration.status = on-hold, or stopped as possible indicators of such events.
	MedicationAdministration.category	Allows specification of Inpatient, Outpatient, Community
QDM Attributes
code	MedicationAdministration.medication[x]	ֵ Example uses SNOMED substance codes
id	MedicationAdministration.id
dosage	MedicationAdministration.dosage.dose	Simple Quantity - Amount of medication for one administration
route	MedicationAdministration.dosage.route
frequency	MedicationAdministration.request	Reference to original MedicationRequest with content about prescription
	MedicationAdministration.dosage.rate[x]	Identifies the speed with which the medication was or will be introduced into the patient (e.g., infusion rate).
	MedicationRequest.dosageInstruction.timing	Timing schedule (e.g., every 8 hours). MedicationAdministration.request provides reference to the applicable MedicationRequest for this information.
reason	MedicationAdministration.reasonCode	None, given as ordered, emergency
relevant dateTime	MedicationAdministration.effective[x] dateTime
relevant Period	MedicationAdministration.effective[x] Period
author dateTime	MedicationAdministration.extension:recorded
Negation Rationale	See Below
Performer	MedicationAdministration.performer.actor

Negation Rationale for Medication, Administered

Use QICoreMedicationAdministrationNotDone, which contains:

• MedicationAdministration.status - Fixed value: “not-done”
• MedicationAdministration.statusReason - Use value set NegationReasonCodes
• MedicationAdministration.extension:recorded - dateTime when this was made available
• MedicationAdministration.medication[x].extension:notDoneValueSet - Use qicore-notDoneValueSet to indicate the specific MedicationAdministration that was not performed

Medication, Discharge

This QDM context specifically references the discharge medication list provided to a patient at the time of discharge from an inpatient setting. The list may include reference to new prescriptions sent to a pharmacy for dispensing and self-administration after discharge. It may also include over-the-counter medications and those medications already present in the patient’s home for which new prescriptions are not necessary.  The QDM Medication, Discharge concept is mapped to MedicationRequest as a request to the patient to take the medication with MedicationRequest.intent = plan and MedicationRequest.setting = discharge.

MedicationRequest.intent should always be order even if the medication is patient reported and the order is not processed as an e-prescription. The reporter is specified as MedicationRequest.reported[x] which is a reportedBoolean and uses reportedReference (patient, practitioner, practitionerRole, relatedPerson, organization).

This change should also be used to reference the mapping from QDM Medication, Order which can address order or recommended.

QDM Context	QI-Core R5	Comments
Medication, Discharge	MedicationRequest
Medication, Discharge active	MedicationRequest.status	Constrain to “active”
	MedicationRequest.statusReason
QDM Attributes
code	MedicationRequest.medication[x]	RxNorm
id	MedicationRequest.id
dosage	MedicationRequest.dosageInstruction.doseAndRate.dose[x]	Range, quantity
supply	MedicationRequest.dispenseRequest.quantity	Amount to be dispensed in one fill
daysSupplied	MedicationRequest.dispenseRequest.expectedSupplyDuration	Duration
frequency	MedicationRequest.dosageInstruction.timing	Timing schedule (e.g., every 8 hours)
refills	MedicationRequest.dispenseRequest.numberOfRepeatsAllowed	Integer
route	MedicationRequest.dosageInstruction.route
setting	MedicationRequest.category	Constrain category to “Community”
reason	MedicationRequest.reasonCode	The reason for ordering or not ordering the medication
relevantDatetime	MedicationRequest.dosageInstruction.timing with Timing.event dateTime
relevantPeriod	MedicationRequest.dosageInstruction.timing with Timing.repeat.bounds[x] Period
authorDatetime	MedicationRequest.authoredOn
negationRationale	See Below
prescriber	MedicationRequest.requester	Note - MedicationRequest.performer indicates the performer expected to administer the medication

Negation Rationale for Medication, Discharge

Use QICoreMedicationNotRequested, which contains:

• MedicationRequest.doNotPerform - Fixed value: “true”
• MedicationRequest.status - Fixed value: “completed”
• MedicationRequest.reasonCode - Use value set NegationReasonCodes
• MedicationRequest.authoredOn - dateTime when this was made available
• MedicationRequest.medication[x].extension:notDoneValueSet - Use qicore-notDoneValueSet to indicate the specific MedicationRequest that was not performed

Medication, Dispensed

This QDM context maps to the QI-Core MedicationDispense resource, indicating information about medications that have been dispensed.

QDM Context	QI-Core R5	Comments
Medication, Dispensed	MedicationDispense
	MedicationDispense.status	Constrain MedicationDispense.status to completed
QDM Attributes
code	MedicationDispense.medication[x]
id	MedicationDispense.id
dosage	MedicationDispense.dosageInstruction	ordered, calculated
supply	MedicationDispense.quantity
daysSupplied	MedicationDispense.daysSupply
frequency	MedicationDispense.dosageInstruction.timing	See dosageInstruction
refills	MedicationDispense.authorizingPrescription	Reference authorizing prescription (MedicationRequest) which contains Medication.Request.dispsenseRequest.numberOfRepeatsAllowed
	MedicationRequest.dispenseRequest.numberOfRepeatsAllowed	Timing schedule (e.g., every 8 hours). MedicationDispense.authorizingPrescription provides reference to the applicable MedicationRequest for this information.
route	MedicationDispense.dosageInstruction.route	See dosageInstruction
setting	MedicationDispense.category	Inpatient, Outpatient, Community, Discharge
reason	MedicationDispense.statusReason[x]	The reason for ordering or not ordering the medication
relatedTo	MedicationDispense.authorizingPrescription	New in QDM 5.6
relevant dateTime	MedicationDispense.whenHandedOver	When provided to patient or representative. Recommendations from pharmacy experts suggest that all medication dispensing events include a time for MedicationDispense.whenPrepared (i.e., when the dispensed product was packaged and reviewed. The time the medication was handed over to the patient or representative may not be populated. Note that medications not picked up are restocked such that a MedicationDispense.status = completed will assure the patient or representative received the medication even if whenHandedOver is not available. Therefore, measure developers should consider including the time whenPrepared if whenHandedOver is null and status = completed.
relevant Period	MedicationRequest.dosageInstruction.timing with Timing.repeat.bounds[x] Period	The anticipated time from starting to stopping an ordered or dispensed medication can also be computed in an expression and derived from the duration attribute
author dateTime	MedicationDispense.extension:recorded
Negation Rationale	See Below
Prescriber	MedicationDispense.authorizingPrescription	Reference authorizing prescription (MedicationRequest) which contains Medication.Request.requester
	MedicationRequest.requester
dispenser	MedicationDispense.performer.actor

Negation Rationale for Medication, Dispensed

Use QICoreMedicationDispenseNotDone, which contains:

• MedicationDispense.status - Fixed value: “declined”
• MedicationDispense.statusReason[x] - Use value set NegationReasonCodes
• MedicationDispense.extension:recorded - dateTime when this was made available
• MedicationDispense.medication[x].extension:notDoneValueSet - Use qicore-notDoneValueSet to indicate the specific MedicationDispense that was not performed

The MedicationDispensed.status is fixed to “declined” which is defined as “The dispense was declined and not performed.” Considering the clinical workflow, only the pharmacist likely performs the “decline” status - based on medication interaction or on failure of insurance authorization (perhaps due to patient declining when the cost/co-pay is identified). But the patient would not enter the status, only the pharmacist would do so. The use case likely still works for the measure developer intent (that a valid reason exists for not dispensing the medication). However, if the measure developer wants to address patient’s decisions to avoid dispensing, the patient will likely not show up at the pharmacy for the medication to be dispensed - hence, there will be no dispensing event. The best way to capture that scenario may be to assure the MedicationRequest includes a Patient reason.

Participation

QDM defines Participation as a patient’s coverage by a program such as an insurance or medical plan or a payment agreement. Such programs can include patient-centered medical home, disease-specific programs, etc. Definitions modeled similar to the FHIR R4 Coverage resource.

QDM Context	QI-Core R5	Comments
Participation	Coverage
	Coverage.status	Constrain to “active”
QDM Attributes
code	Coverage.type
id	Coverage.id
participationPeriod	Coverage.period

Procedure

QDM defines Procedure as an act whose immediate and primary outcome (post-condition) is the alteration of the physical condition of the subject. A procedure may be a surgery or other type of physical manipulation of a person’s body in whole or in part for purposes of making observations and diagnoses or providing treatment.

Procedure Vs Intervention

FHIR references both of these concepts using the Procedure resource, specifically noting a process that involves verification of the patient’s comprehension or to change the patient’s mental state would be a Procedure.

Procedure Vs Task

Some use cases have considered differentiating a FHIR Procedure Resource from a FHIR core Task Resource. For example, should a request to perform medication reconciliation be classified as a Task or a Procedure? The FHIR Procedure Resource Boundaries and Relationships (Section 9.3.2) provides some distinction between a Task and a Procedure:

A Task is a workflow step such as cancelling an order, fulfilling an order, signing an order, merging a set of records, admitting a patient. Procedures are actions that are intended to result in a physical or mental change to or for the subject (e.g. surgery, physiotherapy, training, counseling). A Task resource often exists in parallel with clinical resources. For example, a Task might request fulfillment of a ServiceRequest ordering a Procedure.

Based on the guidance provided above, the workflow step to reconcile medication lists may be considered a Task to perform the Procedure that includes reviewing the medication list with the patient to assure it is correct and to education the patient about proper medication usage.

The sponsoring work group is specifically seeking feedback on the following suggestions for use of Task rather than Procedure for workflow steps that require attestation such as medication list review or reconciliation: Example: A workflow step to review or to reconcile medication lists may be considered a Task to perform the Procedure that includes reviewing the medication list with the patient to assure it is correct and to educate the patient about proper medication usage. Thus, a Task can reference the Task.focus as a procedure.

QDM 5.6 does not address Task; therefore, there is no direct mapping from QDM Intervention or Procedure to the FHIR Task resource.  The mapping presented is from QDM to QI-Core referencing the FHIR Procedure resource.

Consistent with the method for specifying QDM’s concept negation rationale, a TaskNotDone is represented with the following content:

• Task.status with valueset-task-status constrained to “rejected” (The potential performer who claimed ownership of the task has decided not to execute it prior to performing any action.)
• Task.statusReason binding to Negation Reason Codes (extensible)
• Task.code (Codes to identify how the task manages fulfillment of activities - the specific choice depends on the measure context) the direct reference code, it needs a cardinality of 1..1 and binding to the code or value set (it would need a notDoneValueSet URL: notDoneValueSet to reference the value set not performed
• Task.focus to reference the Resource (likely procedure) the task was acting on
• Task.encounter (Healthcare event during which this task originated)
• Task.for (Beneficiary of the Task) Reference (qicore-patient)
• Task.executionPeriod for the period/dateTime - the timing the task was rejected and the reason.

Procedure Priority

QDM 5.6 includes a new attribute for Procedure: priority with the following definition:

Priority indicates the urgency of the procedure or the encounter referenced. In [electronic clinical quality measures] (eCQMs) the priority attribute will help specify elective from urgent encounters (e.g., hospital admissions) or procedures. Priority is a codeable concept (i.e., may use a direct reference code or a value set). For example, priority is used to express an elective procedure or encounter from an emergency procedure or encounter.

As noted in the QDM to QI-Core Mapping for Encounter-Related Diagnoses and Procedures, a specific measure may have interest in evaluating care provided for elective procedures (e.g., hip surgery due to osteoarthritis) while excluding emergency, non-planned procedures (e.g., hip surgery due to acute fracture). The procedure code does not necessarily allow differentiation of the two concepts. A ServiceRequest.priority does have the ability to differentiate the urgency with which the request (or order) should be fulfilled. However, there is no element within the FHIR Procedure resource to address the issue. Encounter.priority allows specification of whether the encounter is elective. An encounter with Encounter.priority = elective and an Encounter.extension.extension:rank.value[x] = 1 addresses the need to specify an elective encounter with a principal procedure. Therefore, based on the current use case QI-Core has not added an extension to address Procedure.priority and, as a result, there is no direct mapping from the QDM Procedure priority attribute to QI-Core.

Procedure, Order

QDM Context	QI-Core R5	Comments
Procedure, Order	ServiceRequest
	ServiceRequest.status	Constrain to one or more of active, completed
	ServiceRequest.intent	Constrain only to “order” (include children: original-order, reflex-order, filler-order, instance-order)
QDM Attributes
code	ServiceRequest.code
id	ServiceRequest.id
reason	ServiceRequest.reasonCode
authorDatetime	ServiceRequest.authoredOn	When the request transitioned to being actionable.
negationRationale	See Below
requester	ServiceRequest.requester

Negation Rationale for Procedure, Order

Use QICoreServiceNotRequested, which contains:

• ServiceRequest.doNotPerform - Fixed value: “true”
• ServiceRequest.status - Fixed value: “completed”
• ServiceRequest.extension:reasonRefused - Use value set NegationReasonCodes
• ServiceRequest.authoredOn - dateTime when this was made available
• ServiceRequest.code.extension:notDoneValueSet - Use qicore-notDoneValueSet to indicate the specific ServiceRequest that was not performed

Procedure, Recommended

QDM Context	QI-Core R5	Comments
Procedure, Recommended	ServiceRequest
	ServiceRequest.status	Constrain to one or more of active, completed
	ServiceRequest.intent	Constrain only to “plan”
QDM Attributes
code	ServiceRequest.code
id	ServiceRequest.id
reason	ServiceRequest.reasonCode
authorDateTime	ServiceRequest.authoredOn	When the request transitioned to being actionable.
negationRationale	See Below
requester	ServiceRequest.requester

Negation Rationale for Procedure, Recommended

Use QICoreServiceNotRequested, which contains:

• ServiceRequest.doNotPerform - Fixed value: “true”
• ServiceRequest.status - Fixed value: “completed”
• ServiceRequest.extension:reasonRefused - Use value set NegationReasonCodes
• ServiceRequest.authoredOn - dateTime when this was made available
• ServiceRequest.code.extension:notDoneValueSet - Use qicore-notDoneValueSet to indicate the specific ServiceRequest that was not performed

Substance

Substance, Administered; Substance, Order; Substance Recommended

QDM defines Substance as 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). Where a substance can be addressed using medication terminology (e.g. egg albumin) used the Medication mappings listed in this QDM-to-QI-Core section.

FHIR defines substance as a homogeneous material with a definite composition. Medications are classified as substances. However, to reference other substances, especially using the SubstanceDefinition resource is challenging since the resource is still undergoing development.

Ideally, use of a substance-related resource should be driven by use cases and examples. Two such use cases currently exist in the quality measure community::

• Determination that blood products (a biological product in FHIR resources) are ordered or are administered within specific time relationships to other data elements – The FHIR Resource, BiologicallyDerivedProduct, possibly using Procedure and ServiceRequest might have promise. However, the resource is still in development. Therefore, until further information is available, rather than expressing the QDM datatype Substance, Administration to address administration of blood transfusion, quality measure and clinical decision support (CDS) authors should consider using the procedure resource with a code representing transfusion.
• Determination that human breast milk is used exclusively to feed newborn infants during the initial stay in the hospital after birth – Currently, FHIR includes a NutritionOrder resource to reference a request for a specific diet, or supplements to a diet. However, a resource for documenting administration of nutrition-related substances is still in development. Therefore, for this use case a quality measure or a clinical decision support (CDS) author could reference a NutritionOrder for an exclusive breast milk diet for the infant; however, such an expression could not reference clinical intake and output records to determine if anything other than human breast milk was administered to the infant. Moreover, classification of human breast milk requires clarification as to whether it is a BiologicallyDerivedProduct, or if it should be referenced as a Substance.

To provide some context and guidance, this QDM-to-QI-Core mapping includes reference to the QDM datatypes Substance, Order and Substance, Recommended using the NutritionOrder resource. As noted in the second example provided, the resource is relatively new and it allows expressions to address only the type of diet ordered, not the foods or substances administered to a patient.

The CQI Workgroup suggests use of the Procedure resource for QDM’s Substance, Administered for nutritional and other non-medication substances. Indicate the procedure (e.g., oral feeding) and the Procedure.UsedCode to indicate the direct reference code or value set indicating the expected nutritional element expected. There is no current known eCQM use case or common practice for documenting NutritionOrder “negation rationale”. Further, the only expressed use cases for substance other than those that are modeled similar to medications are nutritional substance administered (human breast milk) and biologically-derived product administration (blood) - both of these use cases can use the Procedure resources as noted. Further work in base FHIR will advise how to reference specific administration details in QI-Core.

QDM Context	QI-Core R5	Comments
Substance, Order/Recommended - For Diet Orders	NutritionOrder	Limited to orders for diets or diets with supplements
Substance Order/Recommended Activity	NutritionOrder.status	Constrain to active, completed
Substance, Order	NutritionOrder.intent	Constrain to “order” and child concepts
Substance, Recommended	NutritionOrder.intent	Constrain to “plan”
QDM Attributes
ORAL DIET	NutritionOrder.oralDiet
code (to represent a diet order)	NutritionOrder.oralDiet.type
	NutrientOrder.oralDiet.nutrient.modifier
id	NutritionOrder.id
dosage	N/A
frequency	NutritionOrder.Diet.schedule
negationRationale	N/A
authorDatetime	NutritionOrder.dateTime
relevantPeriod	N/A
reason	N/A
supply	N/A
refills	N/A
route	NutritionOrder.oralDiet
requester	NutritionOrder.orderer
ENTERAL FORMULA	NutritionOrder.enteralFormula
code (to represent a diet order)	NutritionOrder.enteralFormula.baseFormulaType
Additive to diet order	NutritionOrder.enteralFormula.additiveType
id	N/A
dosage	NutritionOrder.enterealFormula.administration.quantity
frequency	NutritionOrder.enteralFormula.administration.rate[x]
negationRationale	N/A
authorDatetime	NutritionOrder.dateTime
relevantPeriod	NutritionOrder.enteralFormula.administration.schedule
reason	N/A
supply	N/A
refills	NutritionOrder.enteralFormula
route	NutritionOrder.enteralFormula.routeofAdministration
requester	NutritionOrder.orderer

Symptom

QDM defines Symptom as an indication that a person has a condition or disease. Some examples include headache, fever, fatigue, nausea, vomiting, and pain. Symptoms are subjective manifestations of the disease perceived by the patient. As an example to differentiate symptom from finding, the patient’s subjective symptom of fever is distinguished from the temperature (a finding). For a finding, there is either a source of a temperature-measuring device together with a recorder of the device (electronically) or an individual (healthcare provider, patient, etc.).

Note: Definitions regarding symptom on the FHIR condition resource Boundaries and Relationships (Section 9.2.2: http://hl7.org/fhir/condition.html):

• [The Condition] resource is not typically used to record information about subjective and objective information that might lead to the recording of a Condition resource. Such signs and symptoms are typically captured using the Observation resource; although in some cases a persistent symptom, e.g. fever, headache may be captured as a condition before a definitive diagnosis can be discerned by a clinician. By contrast, headache may be captured as an Observation when it contributes to the establishment of a meningitis Condition.

• Use the Observation resource when a symptom is resolved without long term management, tracking, or when a symptom contributes to the establishment of a condition.

• Use Condition when a symptom requires long term management, tracking, or is used as a proxy for a diagnosis or problem that is not yet determined.

Based on the FHIR referenced provided above, the QDM datatype Symptom maps to the FHIR Observation resource.

QDM Context	QI-Core R5	Comments
Symptom	Observation
	Observation.status	restrict to preliminary, final, amended, corrected
	Observation.category	add symptom concept
QDM Attributes
code	Observation.value[x]	Use codable concept
id	Observation.id
severity	Observation.interpretation	Definition suggests high, low, normal - perhaps consider severe, moderate, mild.
prevalencePeriod	Observation.effective[x]	dateTime, period, timing, instant
recorder	Observation.performer