This page is part of the Quality Improvement Core Framework (v6.0.0-ballot: STU6 (v6.0.0) Ballot 1) based on FHIR R4. The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions

Quality Data Model (QDM)v5.6 to QI-Core R6 Mapping

This page is part of the Quality Improvement Core Framework (v6.0.0: STU 6) based on FHIR R4. This is the current published version. For a full list of available versions, see the Directory of published versions.

Introduction

The CMS Quality Data Model (QDM) has been used to express electronic clinical quality measures (eCQMs) in HQMF since 2012. QDM is a conceptual data model that has evolved based on feedback, testing and use. The current version (Version 5.6 for eCQM implementation 2023, 2024 and 2025) and QDM’s complete history can be found on the eCQI Resource Center. Most of the QDM concepts map directly to US Core R5, FHIR R4 resources or extensions represented in QI-Core.

This version of QI Core updates mappings from QI-Core to QDM based on US Core STU6 (v6.1.0) and FHIR R4 and QDM version 5.6. Reviewers can evaluate the comparisons, represented in the Mappings table for each QI-Core resource. Each mapping table shows the QI-Core concept in the right-hand column and the corresponding QDM datatype(s) and attributes in the left-hand column. Only QI-Core metadata concepts represented in QDM are included in the mapping tables. The effort mapped the intended meaning of each QDM datatype and attribute to a QI-Core resource metadata element. In some cases, multiple QDM datatypes map to a single QI-Core resource as indicated in the QI-Core mapping table. Since QDM is a conceptual data model some of the elements may not have a direct mapping to a QI-Core profile or one of the items in its respective Key Element Table. Content in the QI-Core profile Key Element Table tabs is based on US Core 6.1.0 requirements and basic needs to express concepts driven by existing quality measurement and clinical decision support data retrieval.

In addition to the QI-Core to QDM comparisons presented with each QI-Core resource, this section of the implementation guide presents the mapping directly from QDM concepts. Thus, the IG provides a view of the mappings in both directions (QI-Core to QDM, and QDM to QI-Core). This section is divided into 55 sections, one for each QDM concept, or QDM datatype. Each QDM datatype includes a general description of the concept and a table mapping each of the QDM datatype-related attributes to QI-Core metadata elements. Refer to the eCQI Resource Center for the full QDM 5.6 documentation.

QDM does not include an attribute to address the additional elements available in QI-Core: AdverseEvent.suspectEntity (the suspected cause), or the AdverseEvent.resultingCondition. As an example to differentiate these elements:

• AdverseEvent.event = fall
• AdverseEvent.resultingCondition = fracture
• AdverseEvent.suspectEntity = area rug

QDM version 5.6 (and earlier versions) only address one of these elements, the event. Therefore, QDM AdverseEvent code maps to AdverseEvent.event. Measure developers seeking to retrieve data about the cause of an AdverseEvent may be able to relate the occurrence timing of a potential causative event and the AdverseEvent.event timing. Further detail about the AdverseEvent will require use of FHIR or potentially a subsequent version of QDM after QDM 5.6.

QDM Context	QI-Core STU6	Comments
Adverse Event	AdverseEvent
	AdverseEvent.actuality	Although not specified in QDM, QI-Core provides the ability to differentiate between potential versus actual events
QDM Attributes
code	AdverseEvent.event	Type of the event itself in relation to the subject; reference SNOMED-CT event hierarchy to represent the event in an eCQM. Note: QDM does not include an attribute to address additional elements available in QI-Core: AdverseEvent.suspectEntity (the suspected cause), or the AdverseEvent.resultingCondition.
type	AdverseEvent.category
severity	AdverseEvent.severity
relevantdateTime	AdverseEvent.date
facilityLocations	AdverseEvent.location
authorDatetime	AdverseEvent.recordedDate
id	AdverseEvent.id
recorder	AdverseEvent.recorder
	AdverseEvent.suspectEntity.instance	The actual instance of what caused the adverse event. May be a substance, medication, medication administration, medication statement or a device.

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.

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.topic.extension:notDoneValueSet - Use qicore-notDoneValueSet to indicate the specific Communication that was not performed

Diagnosis

QDM defines Condition/Diagnosis/Problem as a practitioner’s identification of a patient’s disease, illness, injury, or condition. This category contains a single datatype to represent all of these concepts: Diagnosis. A practitioner determines the diagnosis by means of examination, diagnostic test results, patient history, and/or family history. Diagnoses are usually considered unfavorable, but they may also represent neutral or favorable conditions that affect a patient’s plan of care (e.g., pregnancy).

Based on changes in US Core STU5, QI-Core now has two methods for expressing conditions, QICore Condition Problems and Health Concerns Profile, and QICore Condition Encounter Diagnosis Profile. Please reference the respective profile pages for explanation of the rationale for using each of these profiles. Briefly, the Condition Problems and Health Concerns Profile meets the US Core Data for Interoperability (USCDI) version 2 ‘Problems’ and ‘Health Concerns’ and SDOH Problems/Health Concerns requirements. The Condition Encounter Diagnosis Profile further meets the USCDI v2 requirement to define Encounter Diagnosis.

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.

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

Diagnostic Study

QDM defines Diagnostic Study as any kind of medical test performed as a specific test or series of steps to aid in diagnosing or detecting disease (e.g., to establish a diagnosis, measure the progress or recovery from disease, confirm that a person is free from disease). The QDM differentiates diagnostic studies from laboratory tests in that diagnostic studies are those that are not performed in organizations that perform testing on samples of human blood, tissue, or other substance from the body. Diagnostic studies may make use of digital images and textual reports. Such studies include but are not limited to imaging studies, cardiology studies (electrocardiogram, treadmill stress testing), pulmonary-function testing, vascular laboratory testing, and others.

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.

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.

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.

Negation Rationale for 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.

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 STU6	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	QI-Core STU6	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.extension:us-core-sex	Required binding to Sex
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 STU6	Comments
Related Person	RelatedPerson
identifier	RelatedPerson.identifier
id	RelatedPerson.id
linkedPatientId	N/A	Not present in QI-Core
code	RelatedPerson.relationship	The nature of the relationship; preferred binding to PatientRelationshipType

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.

Negation Rationale for Intervention, Performed

Use QICoreProcedureNotDone, which contains:

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

Laboratory Test

QDM defines Laboratory Test as a medical procedure that involves testing a sample of blood, urine, or other body fluids or specimens. Tests can help determine a diagnosis, plan treatment, check to see if treatment is working, or monitor the disease over time. This QDM data category for Laboratory Test is only used for information about the subject of record.

Each laboratory test may be ordered individually or in a panel. Many use panels for convenience for ordering laboratory tests. Since new laboratory panels regularly become available and the myriad of potential laboratory panels available, a complete list cannot be assured. LOINC observable entities may indicate specific methods for determination of results. Measure and CDS developers can reference direct reference codes or value sets using such LOINC codes to specify the type of testing considered acceptable to provide sufficient fidelity to their requests.

Laboratory Test, Order

“Laboratory Test, Order” should reference orders for studies that will generate results for activities that meet criteria for Observation Lab Result.

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

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.

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.

Negation Rationale for Medication, Dispensed

Use QICoreMedicationDispenseDeclined, 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.

Medication, Order

This QDM context references the QI-Core MedicationRequest resource with MedicationRequest.intent = order and MedicationRequest.setting as the most appropriate for the intended meaning of the quality measure or clinical decision support (CDS) expression.

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.

Physical Exam

QDM defines Physical Exam as the evaluation of the patient’s body and/or mental status exam to determine its state of health. The techniques of examination can include palpation (feeling with the hands or fingers), percussion (tapping with the fingers), auscultation (listening), visual inspection or observation, inquisition and smell. Measurements may include vital signs (blood pressure, pulse, respiration) as well as other clinical measures (such as expiratory flow rate and size of lesion). Physical exam includes psychiatric examinations.

Profile	Data element codes
US Core Vital Signs Profile	Vital Signs (panel) – Fixed Value: 85353-1
US Core Pediatric Head Occipital-frontal Circumference Percentile Profile	Head Occipital-Frontal Circumference Percentile - Fixed Value: 8289-1
US Core Blood Pressure Profile	•Blood Pressure Systolic and Diastolic – Fixed Value: 85354-9 •Systolic Blood Pressure – Fixed Value: 8480-6 •Diastolic Blood Pressure – Fixed Value: 8462-4 •valueQuantity - Fixed Value: mm[Hg]
US Core BMI Profile	•ValueQuantity.system - Fixed Value: http://unitsofmeasure.org •ValueQuantity.code - Coded responses from the common UCUM units for vital signs value set - Fixed Value: kg/m2
US Core Body Height Profile	•Body Height – Fixed Value: 8302-2 •ValueQuantity.system - Fixed Value: http://unitsofmeasure.org •ValueQuantity.code - - Coded responses from the common UCUM units for vital signs value set - Binding: BodyLengthUnits (required)
US Core Body Temperature Profile	•Body Temperature – Fixed Value: 8310-5 •ValueQuantity.system - Fixed Value: http://unitsofmeasure.org •ValueQuantity.code - - Coded responses from the common UCUM units for vital signs value set – Binding: BodyTemperatureUnits (required)
US Core Body Weight Profile	•Body Weight – Fixed Value: 29463-7 •ValueQuantity.system - Fixed Value: http://unitsofmeasure.org •ValueQuantity.code – Coded responses from the common UCUM units for vital signs value set – Binding: BodyWeightUnits (required)
US Core Head Circumference Profile	•Head Circumference – Fixed Value: 9843-4 •ValueQuantity.system - Fixed Value: http://unitsofmeasure.org •ValueQuantity.code - Coded responses from the common UCUM units for vital signs value set - Binding: BodyLengthUnits (required)
US Core Heart Rate Profile	•Vital Signs – Heart Rate – Fixed Value: 8867-4 •ValueQuantity.system - Fixed Value: http://unitsofmeasure.org •ValueQuantity.code - Fixed Value: /min
US Core Pediatric BMI for Age Observation Profile	•Pediatric BMI for Age – Fixed Value: 59576-9 •ValueQuantity.system - Fixed Value: http://unitsofmeasure.org
US Core Pediatric Weight for Height Observation Profile	•Pediatric Weight for Height – Fixed Value: 77606-2 •ValueQuantity.system - Fixed Value: http://unitsofmeasure.org •ValueQuantity.code - Coded responses from the common UCUM units for vital signs value set. Fixed Value: %
US Core Pulse Oximetry Profile	•Pulse Oximetry – Fixed Value: 59408-5 •O2 Saturation - Fixed Value: 2708-6 •Flow rate Fixed Value: 2708-6 •Flow rate Value quantity Fixed Value: L/min •Concentration Fixed Value: 3150-0 •ValueQuantity.system - Fixed Value: http://unitsofmeasure.org •ValueQuantity.code – Fixed Value: %
US Core Respiratory Rate Profile	•Vital Signs – Respiratory Rate – Fixed Value: 9279-1 •ValueQuantity.system - Fixed Value: http://unitsofmeasure.org •ValueQuantity.code - Coded responses from the common UCUM units for vital signs value set - Fixed Value: /min

Physical Exam, Order

QDM “Physical Exam, Order” should use ServiceRequest with intent = order for the specific examination requested.

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 TaskRejected 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

Procedure: priority has 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.

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.

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 STU6	Comments
Symptom	Simple Observation
	Observation.status	Constrain status to - preliminary, final, amended, corrected. While QDM does not have an attribute comparable to status, as a conceptual model, status is implied by the name “Assessment, Performed” datatype.
	Observation.category	Category helps to narrow the request to the class of observation required to meet measure intent. Each QI-Core or US Core profile has a specific binding to concepts appropriate to the respective profile. Note that QDM does not have an attribute comparable to category, the element may be helpful in expressing a quality measure.
QDM Attributes
code	Observation.value[x]	Note specific bindings based on the QI-Core or US Core profile used.
id	Observation.id
severity	Observation.interpretation	Explanation of significance of the observation result (e.g., critical, high, low).
prevalencePeriod	Observation.effective[x]	Time observation occurred if a point in time, or a period. Most likely Symptom will be recorded as a point in time.
recorder	Observation.performer	Although QDM includes this attribute it has not been used in existing measures and a clear use case has not been established. The original purpose for the QDM performer attribute was to designate the individual/organization responsible for reporting the measure results is the same individual/organization that performed the observation or task. However, clinical software generally tracks the individual user entering data and linking that individual to a clinical role, a specialty, or an organization is not easily accomplished.

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