Data Exchange For Quality Measures Implementation Guide
4.0.0-ballot - STU Ballot US

This page is part of the Da Vinci Data Exchange for Quality Measures (DEQM) FHIR IG (v4.0.0-ballot: STU4 (v4.0.0) Ballot 1) based on FHIR R4. The current version which supercedes this version is 3.1.0. For a full list of available versions, see the Directory of published versions

Resource Profile: DEQM Gaps In Care Composition Profile

Official URL: http://hl7.org/fhir/us/davinci-deqm/StructureDefinition/gaps-composition-deqm Version: 4.0.0-ballot
Active as of 2021-04-23 Computable Name: DEQMGapsInCareCompositionProfile

The DEQM Gaps In Care Composition Profile defines a document composition consisting of one or more indivdiual MeasureReport(s). Each section of this composition corresponds to an indivdiual MeasureReport for a specific measure. The subject of each individual MeasureReport referenced by the section must be for the same individual specified in the subject of this Composition.

This profile builds on Composition.

Mandatory Data Elements and Terminology

The following data-elements are mandatory (i.e data MUST be present).

Each must have:

  1. A Composition.type
  2. A Composition.subject references QI Core Patient who is the subject of the Gaps in Care Report
  3. A Composition.date that is the datetime of the Gaps in Care Report was created
  4. A Composition.title that is the title of the Gaps in Care Report
  5. A Composition.section.focus references a measure report using the DEQM Individual MeasureReport Profile
  6. A Composition.section.entry references detected issue for a measure using the DEQM Gaps In Care DetectedIssue Profile

Each should have (Must Support):

  1. A Composition.custodian references the organization that is responsible for ongoing maintenance of the Gaps in Care Report

Note: The date range for the Gaps in Care Report is specified using the period element in the DEQM Individual MeasureReport Profile.

Usage:

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

This structure is derived from Composition

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 0..*CompositionA set of resources composed into a single coherent clinical statement with clinical attestation
... type S1..1CodeableConceptKind of composition (LOINC if possible)
Required Pattern: At least the following
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: 96315-7
... subject S1..1Reference(QICorePatient)What individual the gaps in care report is for. All individual MeasureReports referenced must be for this same individual.
... date S1..1dateTimeThe datetime the gaps in care report was created
... title S1..1stringThe title of the gaps in care report
... custodian S0..1Reference(QICoreOrganization)Identifies the organization who is responsible for ongoing maintenance of and accessing to this gaps in care report
... section 1..*BackboneElementMust contain at least one section, each section corresponds to an indivdiual MeasureReport for a specific measure
.... title 0..1stringThe title of the measure that is referenced
.... focus S1..1Reference(DEQM Individual MeasureReport Profile)This references a DEQM individual MeasureReport
.... entry S1..*Reference(DEQM Gaps In Care Detected Issue Profile)This references a gaps in care DetectedIssue

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 0..*CompositionA set of resources composed into a single coherent clinical statement with clinical attestation
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... status ?!Σ1..1codepreliminary | final | amended | entered-in-error
Binding: CompositionStatus (required): The workflow/clinical status of the composition.

... type SΣ1..1CodeableConceptKind of composition (LOINC if possible)
Binding: FHIRDocumentTypeCodes (preferred): Type of a composition.


Required Pattern: At least the following
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: 96315-7
... subject SΣ1..1Reference(QICorePatient)What individual the gaps in care report is for. All individual MeasureReports referenced must be for this same individual.
... date SΣ1..1dateTimeThe datetime the gaps in care report was created
... author Σ1..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the composition
... title SΣ1..1stringThe title of the gaps in care report
... custodian SΣ0..1Reference(QICoreOrganization)Identifies the organization who is responsible for ongoing maintenance of and accessing to this gaps in care report
... section C1..*BackboneElementMust contain at least one section, each section corresponds to an indivdiual MeasureReport for a specific measure
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... title 0..1stringThe title of the measure that is referenced
.... focus S1..1Reference(DEQM Individual MeasureReport Profile)This references a DEQM individual MeasureReport
.... entry SC1..*Reference(DEQM Gaps In Care Detected Issue Profile)This references a gaps in care DetectedIssue

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Composition.statusrequiredCompositionStatus
Composition.typepreferredPattern: LOINC code 96315-7
NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 0..*CompositionA set of resources composed into a single coherent clinical statement with clinical attestation
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..1IdentifierVersion-independent identifier for the Composition
... status ?!Σ1..1codepreliminary | final | amended | entered-in-error
Binding: CompositionStatus (required): The workflow/clinical status of the composition.

... type SΣ1..1CodeableConceptKind of composition (LOINC if possible)
Binding: FHIRDocumentTypeCodes (preferred): Type of a composition.


Required Pattern: At least the following
.... id0..1idUnique id for inter-element referencing
.... extension0..*ExtensionAdditional content defined by implementations
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... id0..1idUnique id for inter-element referencing
..... extension0..*ExtensionAdditional content defined by implementations
..... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
..... version0..1stringVersion of the system - if relevant
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: 96315-7
..... display0..1stringRepresentation defined by the system
..... userSelected0..1booleanIf this coding was chosen directly by the user
.... text0..1stringPlain text representation of the concept
... category Σ0..*CodeableConceptCategorization of Composition
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.


... subject SΣ1..1Reference(QICorePatient)What individual the gaps in care report is for. All individual MeasureReports referenced must be for this same individual.
... encounter Σ0..1Reference(Encounter)Context of the Composition
... date SΣ1..1dateTimeThe datetime the gaps in care report was created
... author Σ1..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the composition
... title SΣ1..1stringThe title of the gaps in care report
... confidentiality Σ0..1codeAs defined by affinity domain
Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition.

... attester 0..*BackboneElementAttests to accuracy of composition
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... mode 1..1codepersonal | professional | legal | official
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.

.... time 0..1dateTimeWhen the composition was attested
.... party 0..1Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization)Who attested the composition
... custodian SΣ0..1Reference(QICoreOrganization)Identifies the organization who is responsible for ongoing maintenance of and accessing to this gaps in care report
... relatesTo 0..*BackboneElementRelationships to other compositions/documents
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code 1..1codereplaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.

.... target[x] 1..1Target of the relationship
..... targetIdentifierIdentifier
..... targetReferenceReference(Composition)
... event Σ0..*BackboneElementThe clinical service(s) being documented
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code Σ0..*CodeableConceptCode(s) that apply to the event being documented
Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.


.... period Σ0..1PeriodThe period covered by the documentation
.... detail Σ0..*Reference(Resource)The event(s) being documented
... section C1..*BackboneElementMust contain at least one section, each section corresponds to an indivdiual MeasureReport for a specific measure
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... title 0..1stringThe title of the measure that is referenced
.... code 0..1CodeableConceptClassification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.

.... author 0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the section
.... focus S1..1Reference(DEQM Individual MeasureReport Profile)This references a DEQM individual MeasureReport
.... text C0..1NarrativeText summary of the section, for human interpretation
.... mode 0..1codeworking | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.

.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.

.... entry SC1..*Reference(DEQM Gaps In Care Detected Issue Profile)This references a gaps in care DetectedIssue
.... emptyReason C0..1CodeableConceptWhy the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.

.... section C0..*See section (Composition)Nested Section

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Composition.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
Composition.statusrequiredCompositionStatus
Composition.typepreferredPattern: LOINC code 96315-7
Composition.categoryexampleDocumentClassValueSet
Composition.confidentialityrequiredv3.ConfidentialityClassification
Composition.attester.moderequiredCompositionAttestationMode
Composition.relatesTo.coderequiredDocumentRelationshipType
Composition.event.codeexampleActCode
Composition.section.codeexampleDocumentSectionCodes
Composition.section.moderequiredListMode
Composition.section.orderedBypreferredListOrderCodes
Composition.section.emptyReasonpreferredListEmptyReasons

Differential View

This structure is derived from Composition

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 0..*CompositionA set of resources composed into a single coherent clinical statement with clinical attestation
... type S1..1CodeableConceptKind of composition (LOINC if possible)
Required Pattern: At least the following
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: 96315-7
... subject S1..1Reference(QICorePatient)What individual the gaps in care report is for. All individual MeasureReports referenced must be for this same individual.
... date S1..1dateTimeThe datetime the gaps in care report was created
... title S1..1stringThe title of the gaps in care report
... custodian S0..1Reference(QICoreOrganization)Identifies the organization who is responsible for ongoing maintenance of and accessing to this gaps in care report
... section 1..*BackboneElementMust contain at least one section, each section corresponds to an indivdiual MeasureReport for a specific measure
.... title 0..1stringThe title of the measure that is referenced
.... focus S1..1Reference(DEQM Individual MeasureReport Profile)This references a DEQM individual MeasureReport
.... entry S1..*Reference(DEQM Gaps In Care Detected Issue Profile)This references a gaps in care DetectedIssue

doco Documentation for this format

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 0..*CompositionA set of resources composed into a single coherent clinical statement with clinical attestation
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... status ?!Σ1..1codepreliminary | final | amended | entered-in-error
Binding: CompositionStatus (required): The workflow/clinical status of the composition.

... type SΣ1..1CodeableConceptKind of composition (LOINC if possible)
Binding: FHIRDocumentTypeCodes (preferred): Type of a composition.


Required Pattern: At least the following
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: 96315-7
... subject SΣ1..1Reference(QICorePatient)What individual the gaps in care report is for. All individual MeasureReports referenced must be for this same individual.
... date SΣ1..1dateTimeThe datetime the gaps in care report was created
... author Σ1..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the composition
... title SΣ1..1stringThe title of the gaps in care report
... custodian SΣ0..1Reference(QICoreOrganization)Identifies the organization who is responsible for ongoing maintenance of and accessing to this gaps in care report
... section C1..*BackboneElementMust contain at least one section, each section corresponds to an indivdiual MeasureReport for a specific measure
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... title 0..1stringThe title of the measure that is referenced
.... focus S1..1Reference(DEQM Individual MeasureReport Profile)This references a DEQM individual MeasureReport
.... entry SC1..*Reference(DEQM Gaps In Care Detected Issue Profile)This references a gaps in care DetectedIssue

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Composition.statusrequiredCompositionStatus
Composition.typepreferredPattern: LOINC code 96315-7

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 0..*CompositionA set of resources composed into a single coherent clinical statement with clinical attestation
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..1IdentifierVersion-independent identifier for the Composition
... status ?!Σ1..1codepreliminary | final | amended | entered-in-error
Binding: CompositionStatus (required): The workflow/clinical status of the composition.

... type SΣ1..1CodeableConceptKind of composition (LOINC if possible)
Binding: FHIRDocumentTypeCodes (preferred): Type of a composition.


Required Pattern: At least the following
.... id0..1idUnique id for inter-element referencing
.... extension0..*ExtensionAdditional content defined by implementations
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... id0..1idUnique id for inter-element referencing
..... extension0..*ExtensionAdditional content defined by implementations
..... system1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
..... version0..1stringVersion of the system - if relevant
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: 96315-7
..... display0..1stringRepresentation defined by the system
..... userSelected0..1booleanIf this coding was chosen directly by the user
.... text0..1stringPlain text representation of the concept
... category Σ0..*CodeableConceptCategorization of Composition
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.


... subject SΣ1..1Reference(QICorePatient)What individual the gaps in care report is for. All individual MeasureReports referenced must be for this same individual.
... encounter Σ0..1Reference(Encounter)Context of the Composition
... date SΣ1..1dateTimeThe datetime the gaps in care report was created
... author Σ1..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the composition
... title SΣ1..1stringThe title of the gaps in care report
... confidentiality Σ0..1codeAs defined by affinity domain
Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition.

... attester 0..*BackboneElementAttests to accuracy of composition
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... mode 1..1codepersonal | professional | legal | official
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.

.... time 0..1dateTimeWhen the composition was attested
.... party 0..1Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization)Who attested the composition
... custodian SΣ0..1Reference(QICoreOrganization)Identifies the organization who is responsible for ongoing maintenance of and accessing to this gaps in care report
... relatesTo 0..*BackboneElementRelationships to other compositions/documents
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code 1..1codereplaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.

.... target[x] 1..1Target of the relationship
..... targetIdentifierIdentifier
..... targetReferenceReference(Composition)
... event Σ0..*BackboneElementThe clinical service(s) being documented
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code Σ0..*CodeableConceptCode(s) that apply to the event being documented
Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.


.... period Σ0..1PeriodThe period covered by the documentation
.... detail Σ0..*Reference(Resource)The event(s) being documented
... section C1..*BackboneElementMust contain at least one section, each section corresponds to an indivdiual MeasureReport for a specific measure
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... title 0..1stringThe title of the measure that is referenced
.... code 0..1CodeableConceptClassification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.

.... author 0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the section
.... focus S1..1Reference(DEQM Individual MeasureReport Profile)This references a DEQM individual MeasureReport
.... text C0..1NarrativeText summary of the section, for human interpretation
.... mode 0..1codeworking | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.

.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.

.... entry SC1..*Reference(DEQM Gaps In Care Detected Issue Profile)This references a gaps in care DetectedIssue
.... emptyReason C0..1CodeableConceptWhy the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.

.... section C0..*See section (Composition)Nested Section

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Composition.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
Composition.statusrequiredCompositionStatus
Composition.typepreferredPattern: LOINC code 96315-7
Composition.categoryexampleDocumentClassValueSet
Composition.confidentialityrequiredv3.ConfidentialityClassification
Composition.attester.moderequiredCompositionAttestationMode
Composition.relatesTo.coderequiredDocumentRelationshipType
Composition.event.codeexampleActCode
Composition.section.codeexampleDocumentSectionCodes
Composition.section.moderequiredListMode
Composition.section.orderedBypreferredListOrderCodes
Composition.section.emptyReasonpreferredListEmptyReasons

 

Other representations of profile: CSV, Excel, Schematron