Substance (QDM)

Back to Harmonization of Health Quality Information Models Page

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). QDM defines three contexts for Substance: Substance, Administered; Substance, Order; Substance, Recommended. Since QDM addresses substance a something that is administered, ordered or recommended, the actions are analogous to medications. Hence, the QDM category Substance is mapped to QI core Medication concepts.

The mapping was first uploaded to the wiki on April 3, 2018. The CQI Workgroup reviewed the content on 13 April and required additional review and consideration. A QI Core ballot item from the January ballot suggested that NutritionOrder be included in QI Core. The context might be consistent with Substance, Order and/or Substance, Recommended, however, there are some gaps and the NutritionOrder is specifically focused on different diet types (i.e., enteral diet, supplement usage and parenteral diets) rather than specific dietary substance use. Therefore, the following QDM Substance category items address substance similar to medications OR procedures. The NutritionOrder references, created on 17 April 2018 content were added as considerations for future evaluation once the FHRI resources mature. Similarly, use of Substance for blood product orders and administration provide considerations for future evaluation as well.

Use of MedicationAdministration and Procedure FHIR Resources to reference QDM Substance datatypes
The current mapping reflects additional considerations in that NutritionOrder and Administration of blood products are not yet mature concepts in FHIR 3.0. The potential mapping considerations remain as points for review and discussion. However, the near-term mapping references for Substance, Administration, Substance, Order and Substance, Recommended for instances inconsistent with the Medication resources should use the QDM datatypes Procedure, Performed; Procedure, Order and Procedure, Recommended.
Instances inconsistent with the Medication resources include the following two use cases:

• Determination that blood products (a biological product in FHIR resources) are ordered or are administered within specific time relationships to other data elements
• Determination that human breast milk (not considered a biological product in the FHIR resource discussions) is used exclusively to feed newborn infants during the initial stay in the hospital after birth.
  

This section was updated on 24 April 2018.

Nutrition
The nutrition mappings remain for discussion and review as related FHIR resources become more mature.
Note the reference in FHIR NutritionOrder Resource:
The Nutrition Order is a record of the request for the supply of a diet, oral supplement or enteral formulas for a patient. However, to initiate the request requires the use of the Task resource and its associated workflow with the Nutrition Order referenced from Task.basedOn, or by using the Nutrition Task resource in the context of a messaging or service workflow where the request is explicit or implicit.
Based on the quoted reference, Substance is modeled as either medication or nutrition. The NutritionOrder resource is used for requesting oral diets, oral nutrition supplements and enteral feedings in an in-patient setting. The MedicationRequest resource should be used for requesting parenteral (IV) nutrition and prescribing dietary supplements such as vitamin or mineral supplements.
FHIR Tracker Items 15942 and 15943 address these concerns in current FHIR modeling.

Blood Products
The blood product mappings remain for discussion and review as related FHIR resources become more mature.
Also note a different mapping for blood products addressing SupplyRequest, SupplyDelivery and BiologicallyDerivedProducts.
FHIR Tracker Item 15945 addresses concerns about the Supply resources to address blood products.

Substance, Administered [When consistent with medication use cases]

QDM Attribute	QI Core Metadata Element	Comment
Medication, Administered	MedicationAdministration (the .status metadata allows conformance to the specific QDM datatype context)	QDM matched to QI Core / FHIR
Dosage	MedicationAdministration.dosage.dose	QDM matched to QI Core / FHIR
Supply		Not addressed in QI Core
Frequency	Not referenced	Medication Administration documents a single administration, thus frequency is not a concept in the Medication Administered resource.
Negation Rationale	MedicationAdministration.reasonNotGiven	QDM matched to QI Core / FHIR
Route	MedicationAdministration.dosage.route	QDM matched to QI Core / FHIR
Relevant Period	MedicationAdministration.effective[x]	QDM matched to QI Core / FHIR
Author dateTime	FHIRprovenance.recorded	FHIR references authorDatetime as part of the provenance resource for all resources. Is authorDatetime still appropriate for this datatype?
Code	MedicationAdministration.medication[x]	QDM matched to QI Core / FHIR
id	MedicationAdministration.id	QDM matched to QI Core / FHIR

Substance, Order [when consistent with medication use cases]

QDM Attribute	QI Core Metadata Element	Comment
Substance, Order	MedicationRequest.intent	Medication Request intent uses the concepts proposal, plan, order, original-order, reflex-order, filler-order, instance-order, option. Constrain to "order" from the intent value set for QDM datatypes with the order context.
Dosage	MedicationRequest.dosageInstruction.dose[x]	QDM matched to QI Core / FHIR
Supply	MedicationRequest.dispenseRequest.quantity	QDM matched to QI Core / FHIR
Frequency	MedicationRequest.dosageInstruction.timing	QDM matched to QI Core / FHIR
Code	MedicationRequest.medication	QDM matched to QI Core / FHIR
Reason	MedicationRequest.reasonCode	QDM matched to QI Core / FHIR
Method	MedicationRequest.dosageInstruction.method	QDM matched to QI Core / FHIR
Negation Rationale	MedicationStatement.reasonNotTaken	Medication Request in QI Core does not reference negation rationale
Reason	MedicationRequest.reasonCode	QDM matched to QI Core / FHIR
Refills	MedicationRequest.dispenseRequest.numberOfRepeatsAllowed	QDM matched to QI Core / FHIR
Route	MedicationRequest.dosageInstruction.route	QDM matched to QI Core / FHIR
Author dateTime	MedicationRequest.authoredOn	QDM matched to QI Core / FHIR
id	MedicationRequest.id	QDM matched to QI Core / FHIR
Source	MedicationRequest.requester	QDM matched to QI Core / FHIR
Recorder	MedicationRequest.recorder	Possibly addressed in FHIR Provenance

Substance, Recommended [when consistent with medication use cases]

QDM Attribute	QI Core Metadata Element	Comment
Substance, Recommended	MedicationRequest.intent	Medication Request intent uses the concepts proposal, plan, order, original-order, reflex-order, filler-order, instance-order, option. "Proposal" is most consistent with the ProcedureRequest when applied to clinical decision support (CDS) in which the CDS proposes an action to a provider or to a patient. The QDM concept Recommended addresses expectations a provider gives to a patient. Such recommendations are most consistent with the MedicationRequest.intent value of "plan" (an intension to ensure something occurs without providing an authorization to act).
Dosage	MedicationRequest.dosageInstruction.dose[x]	QDM matched to QI Core / FHIR
Frequency	MedicationRequest.dosageInstruction.timing	QDM matched to QI Core / FHIR
Code	MedicationRequest.medication	QDM matched to QI Core / FHIR
Reason	MedicationRequest.reasonCode	QDM matched to QI Core / FHIR
Method	MedicationRequest.dosageInstruction.method	QDM matched to QI Core / FHIR
Negation Rationale	MedicationStatement.reasonNotTaken	Medication Request in QI Core does not reference negation rationale
Reason	MedicationRequest.reasonCode	QDM matched to QI Core / FHIR
Refills	MedicationRequest.dispenseRequest.numberOfRepeatsAllowed	QDM matched to QI Core / FHIR
Author dateTime	MedicationRequest.authoredOn	QDM matched to QI Core / FHIR
id	MedicationRequest.id	QDM matched to QI Core / FHIR
Source	MedicationRequest.requester	QDM matched to QI Core / FHIR
Recorder	MedicationRequest.recorder	Possibly addressed in FHIR Provenance

Substance, Order [For consideration for future review - Nutrition Use Cases]

QDM Attribute	QI Core Metadata Element	Comment
Substance, Order	NutritionOrder.status	SubstanceOrder.status includes proposed, draft, planned, requested, active, on-hold, completed, cancelled, entered-in-error. "Proposed" is most consistent with the NutritionOrder when applied to clinical decision support (CDS) in which the CDS proposes an action to a provider or to a patient. The QDM concept Recommended addresses expectations a provider gives to a patient. Such recommendations are most consistent with the NutritionOrder.status value of "planned" (an intention to ensure something occurs without providing an authorization to act). The QDM concept Order addresses a request that has been placed, and therefore is expected to be carried out. Such recommendations are most consistent with the NutritionOrder.status value of "requested" (The request has been placed.). Note - the "active" element is consistent with a NutritionOrder that has been reviewed by the dietician and, therefore, can be processed, but processing is not yet complete (the request is 'actionable', but not all actions that are implied by it have occurred yet).
Dosage	NutritionOrder.oralDiet.nutrient.amount NutritionOrder.supplement.quantity NutritionOrder.enteralFormula.administration.quantity	NutritionOrder.oralDiet.nutrient.amount (The quantity of the specified nutrient to include in diet.) NutritionOrder.supplement.quantity (The amount of the nutritional supplement to be given.) NutritionOrder.enteralFormula.administration.quantity (The volume of formula to provide to the patient per the specified administration schedule.)
Frequency	NutritionOrder.oralDiet.schedule NutritionOrder.supplement.schedule NutritionOrder.enteralFormula.administration.schedule	NutritionOrder.oralDiet.schedule (The time period and frequency at which the diet should be given. The diet should be given for the combination of all schedules if more than one schedule is present.) NutritionOrder.supplement.schedule (The time period and frequency at which the supplement(s) should be given. The supplement should be given for the combination of all schedules if more than one schedule is present.) NutritionOrder.enteralFormula.administration.schedule (The time period and frequency at which the enteral formula should be delivered to the patient.)
Code	NutritionOrder.oralDiet.nutrient Uncertain mapping for QDM code attribute for supplements or enteral formula	NutritionOrder.oralDiet.nutrient (Class that defines the quantity and type of nutrient modifications (for example carbohydrate, fiber or sodium) required for the oral diet.) Uncertain mapping for QDM code attribute for supplements or enteral formula
Reason	NutritionOrder.oralDiet.instruction NutritionOrder.supplement.instruction NutritionOrder.enteralFormula.administration	NutritionOrder does not address reason except, perhaps, as .instruction: NutritionOrder.oralDiet.instruction NutritionOrder.supplement.instruction NutritionOrder.enteralFormula.administration
Method	NutritionOrder.oralDiet.instruction NutritionOrder.supplement.instruction NutritionOrder.enteralFormula.administration	NutritionOrder.oralDiet.instruction (Free text or additional instructions or information pertaining to the oral diet.) NutritionOrder.supplement.instruction (Free text or additional instructions or information pertaining to the oral supplement.) NutritionOrder.enteralFormula.administration (Formula administration instructions as structured data. This repeating structure allows for changing the administration rate or volume over time for both bolus and continuous feeding. An example of this would be an instruction to increase the rate of continuous feeding every 2 hours.)
Negation Rationale		NutritionOrder does not address NegationRationale. NutritionOrder.excludeFoodModifier is used to convey order-specific modifiers about the type of food that should NOT be given. These can be derived from patient allergies, intolerances, or preferences such as No Red Meat, No Soy or No Wheat or Gluten-Free. While it should not be necessary to repeat allergy or intolerance information captured in the referenced AllergyIntolerance resource in the excludeFoodModifier, this element may be used to convey additional specificity related to foods that should be eliminated from the patient’s diet for any reason. This modifier applies to the entire nutrition order inclusive of the oral diet, nutritional supplements and enteral formula feedings.
Reason		NutritionOrder does not address reason.
Refills		NutritionOrder does not address refills.
Author dateTime	NutritionOrder.dateTime	QDM matched to FHIR
id		NutritionOrder does not address id.
Source	NutritionOrder.orderer	QDM matched to FHIR
Recorder	FHIR.provenance.recorder	Possibly addressed in FHIR Provenance

Substance, Recommended [For consideration for future review - Nutrition Use Cases]

QDM Attribute	QI Core Metadata Element	Comment
Substance, Recommended	NutritionOrder.status	SubstanceOrder.status includes proposed, draft, planned, requested, active, on-hold, completed, cancelled, entered-in-error. "Proposed" is most consistent with the NutritionOrder when applied to clinical decision support (CDS) in which the CDS proposes an action to a provider or to a patient. The QDM concept Recommended addresses expectations a provider gives to a patient. Such recommendations are most consistent with the NutritionOrder.status value of "planned" (an intention to ensure something occurs without providing an authorization to act). The QDM concept Order addresses a request that has been placed, and therefore is expected to be carried out. Such recommendations are most consistent with the NutritionOrder.status value of "requested" (The request has been placed.). Note - the "active" element is consistent with a NutritionOrder that has been reviewed by the dietician and, therefore, can be processed, but processing is not yet complete (the request is 'actionable', but not all actions that are implied by it have occurred yet).
Dosage	NutritionOrder.oralDiet.nutrient.amount NutritionOrder.supplement.quantity NutritionOrder.enteralFormula.administration.quantity	NutritionOrder.oralDiet.nutrient.amount (The quantity of the specified nutrient to include in diet.) NutritionOrder.supplement.quantity (The amount of the nutritional supplement to be given.) NutritionOrder.enteralFormula.administration.quantity (The volume of formula to provide to the patient per the specified administration schedule.)
Frequency	NutritionOrder.oralDiet.schedule NutritionOrder.supplement.schedule NutritionOrder.enteralFormula.administration.schedule	NutritionOrder.oralDiet.schedule (The time period and frequency at which the diet should be given. The diet should be given for the combination of all schedules if more than one schedule is present.) NutritionOrder.supplement.schedule (The time period and frequency at which the supplement(s) should be given. The supplement should be given for the combination of all schedules if more than one schedule is present.) NutritionOrder.enteralFormula.administration.schedule (The time period and frequency at which the enteral formula should be delivered to the patient.)
Code	NutritionOrder.oralDiet.nutrient Uncertain mapping for QDM code attribute for supplements or enteral formula	NutritionOrder.oralDiet.nutrient (Class that defines the quantity and type of nutrient modifications (for example carbohydrate, fiber or sodium) required for the oral diet.) Uncertain mapping for QDM code attribute for supplements or enteral formula
Reason	NutritionOrder.oralDiet.instruction NutritionOrder.supplement.instruction NutritionOrder.enteralFormula.administration	NutritionOrder does not address reason except, perhaps, as .instruction: NutritionOrder.oralDiet.instruction NutritionOrder.supplement.instruction NutritionOrder.enteralFormula.administration
Method	NutritionOrder.oralDiet.instruction NutritionOrder.supplement.instruction NutritionOrder.enteralFormula.administration	NutritionOrder.oralDiet.instruction (Free text or additional instructions or information pertaining to the oral diet.) NutritionOrder.supplement.instruction (Free text or additional instructions or information pertaining to the oral supplement.) NutritionOrder.enteralFormula.administration (Formula administration instructions as structured data. This repeating structure allows for changing the administration rate or volume over time for both bolus and continuous feeding. An example of this would be an instruction to increase the rate of continuous feeding every 2 hours.)
Negation Rationale		NutritionOrder does not address NegationRationale. NutritionOrder.excludeFoodModifier is used to convey order-specific modifiers about the type of food that should NOT be given. These can be derived from patient allergies, intolerances, or preferences such as No Red Meat, No Soy or No Wheat or Gluten-Free. While it should not be necessary to repeat allergy or intolerance information captured in the referenced AllergyIntolerance resource in the excludeFoodModifier, this element may be used to convey additional specificity related to foods that should be eliminated from the patient’s diet for any reason. This modifier applies to the entire nutrition order inclusive of the oral diet, nutritional supplements and enteral formula feedings.
Reason		NutritionOrder does not address reason.
Refills		NutritionOrder does not address refills.
Author dateTime	NutritionOrder.dateTime	QDM matched to FHIR
id		NutritionOrder does not address id.
Source	NutritionOrder.orderer	QDM matched to FHIR
Recorder	FHIR.provenance.recorder	Possibly addressed in FHIR Provenance

Substance, Administered [For consideration for future review - Blood Product Use Cases]

QDM Attribute	QI Core Metadata Element	Comment
Substance, Administered (Blood Products)	SupplyDelivery.status (the .status metadata should be constrained to "completed" to allow conformance to the specific QDM datatype context)	QDM matched to QI Core / FHIR
Dosage	SupplyDelivery.suppliedItem.quantity	QDM matched to FHIR core
Supply		Not addressed directly since SupplyDelivery.suppliedItem.quantity addresses the quantity for the single delivery (i.e., administration in this case)
Frequency		Substance Administration documents a single administration, thus frequency is not a concept in the Supply Delivery resource.
Negation Rationale		Not addressed in FHIR core
Route		Not addressed in FHIR core
Relevant Period	SupplyDelivery.occurrence[x]	QDM matched to FHIR core
Author dateTime	FHIRprovenance.recorded	FHIR references authorDatetime as part of the provenance resource for all resources. Is authorDatetime still appropriate for this datatype?
Code	SupplyDelivery.suppliedItem.item[x]	QDM matched to FHIR core
id	SupplyDelivery.id	QDM matched to FHIR core

Substance, Order [For consideration for future review - Blood Product Use Cases]

QDM Attribute	QI Core Metadata Element	Comment
Substance, Order (Blood Products)		There is no .intent metadata element consistent with other FHIR resources (e.g., proposed, draft, planned, requested, active, on-hold, completed, cancelled, entered-in-error).
Dosage	SupplyRequest.orderedItem.quantity	QDM maps to FHIR core
Frequency		SupplyRequest does not address frequency since it addresses a single occurrence
Code	SupplyRequest.category, OR SupplyRequest.orderedItem.item[x]	Category presumably to include the category biologicallyderivedproduct to address blood products, consider the same for .ordereditem[x]
Method		SupplyRequest does not address method
Negation Rationale		SupplyRequest does not address .notDoneReason
Reason	SupplyRequest.reason[x]	QDM maps to FHIR core
Refills		SupplyRequest does not address refills.
Author dateTime	SupplyRequest.authoredOn	QDM matched to FHIR core - note that FHIR core also includes SupplyRequest.occurrence[x] (when the request should be fulfilled).
id	SupplyRequest.id	QDM maps to FHIR core
Source	SupplyRequest.requester.agent	QDM matched to FHIR code - note that FHIR core includes SupplyRequest.supplier (who is intended to fulfill the request)
Recorder	FHIR.provenance.recorder	Possibly addressed in FHIR Provenance