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Difference between revisions of "Physical Exam (QDM)"

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(Created page with "[http://wiki.hl7.org/index.php?title=Harmonization_of_Health_Quality_Information_models Back to Harmonization of Health Quality Information Models Page]<br> __FORCETOC__ QDM d...")
 
 
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[http://wiki.hl7.org/index.php?title=Harmonization_of_Health_Quality_Information_models Back to Harmonization of Health Quality Information Models Page]<br>
 
[http://wiki.hl7.org/index.php?title=Harmonization_of_Health_Quality_Information_models Back to Harmonization of Health Quality Information Models Page]<br>
 
__FORCETOC__
 
__FORCETOC__
 +
The CQI Workgroup reviewed the mapping to QDM version 5.3 in April 2018. The content is updated on June 7, 2018 based on QDM version 5.4. The changes based on QDM 5.4 include:
 +
* Removal of the "method" attribute from "Physical Exam, Order" and "Physical Exam, Recommended"<br><br>
 
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. QDM defines three contexts for Physical Exam: Physical Exam, Order; Physical Exam, Performed; Physical Exam, Recommended.
 
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. QDM defines three contexts for Physical Exam: Physical Exam, Order; Physical Exam, Performed; Physical Exam, Recommended.
  
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| row2cell2 | ProcedureRequest.extension (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-procedurerequest-approachBodySite)
 
| row2cell2 | ProcedureRequest.extension (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-procedurerequest-approachBodySite)
 
| row2cell3 | Note QI Core ProcedureRequest.extension (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-procedurerequest-appropriatenessScore) - not included in QDM but may potentially apply to Appropriate Use Criteria
 
| row2cell3 | Note QI Core ProcedureRequest.extension (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-procedurerequest-appropriatenessScore) - not included in QDM but may potentially apply to Appropriate Use Criteria
−
|-
 
−
| row2cell1 | Method
 
−
| row2cell2 |
 
−
| row2cell3 | Not addressed in QI Core
 
 
|-
 
|-
 
| row2cell1 | Negation Rationale
 
| row2cell1 | Negation Rationale
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|-
 
|-
 
| row2cell1 | Author dateTime
 
| row2cell1 | Author dateTime
−
| row2cell2 | ProcedureRequest.AuthoredOn
+
| row2cell2 | ProcedureRequest.authoredOn
−
| row2cell3 | Note - ProcedureRequest.occurrence(x) defines a dateTime when the event should occur - not addressed in QDM
+
| row2cell3 | Note - ProcedureRequest.occurrence[x] defines a dateTime when the event should occur - not addressed in QDM<br>
 +
Note: FHIR Provenance generally addresses the author of the message; the identifier/source of the original resource element is defined by the resource. Individual resource element provenance is summarized in the FHIR W5 Report (http://hl7.org/fhir/w5.html).
 
|-
 
|-
 
| row2cell1 | Code
 
| row2cell1 | Code
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| row2cell3 | Author, orderer - note also, ProcedureRequest.requester.agent for device, practitioner or organization who initiated the request; or ProcedureRequest.requester.onBehalfOf  - the organization the device or practitioner was acting on behalf of
 
| row2cell3 | Author, orderer - note also, ProcedureRequest.requester.agent for device, practitioner or organization who initiated the request; or ProcedureRequest.requester.onBehalfOf  - the organization the device or practitioner was acting on behalf of
 
|}
 
|}
 +
 
==Physical Exam, Recommended==
 
==Physical Exam, Recommended==
  
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| row2cell2 | ProcedureRequest.extension (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-procedurerequest-approachBodySite)
 
| row2cell2 | ProcedureRequest.extension (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-procedurerequest-approachBodySite)
 
| row2cell3 | Note QI Core ProcedureRequest.extension (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-procedurerequest-appropriatenessScore) - not included in QDM but may potentially apply to Appropriate Use Criteria
 
| row2cell3 | Note QI Core ProcedureRequest.extension (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-procedurerequest-appropriatenessScore) - not included in QDM but may potentially apply to Appropriate Use Criteria
−
|-
 
−
| row2cell1 | Method
 
−
| row2cell2 |
 
−
| row2cell3 | Not addressed in QI Core
 
 
|-
 
|-
 
| row2cell1 | Negation Rationale
 
| row2cell1 | Negation Rationale
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|-
 
|-
 
| row2cell1 | Author dateTime
 
| row2cell1 | Author dateTime
−
| row2cell2 | ProcedureRequest.AuthoredOn
+
| row2cell2 | ProcedureRequest.authoredOn
−
| row2cell3 | Note - ProcedureRequest.occurrence(x) defines a dateTime when the event should occur - not addressed in QDM
+
| row2cell3 | Note - ProcedureRequest.occurrence[x] defines a dateTime when the event should occur - not addressed in QDM<br>
 +
Note: FHIR Provenance generally addresses the author of the message; the identifier/source of the original resource element is defined by the resource. Individual resource element provenance is summarized in the FHIR W5 Report (http://hl7.org/fhir/w5.html).
 
|-
 
|-
 
| row2cell1 | Code
 
| row2cell1 | Code
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| row2cell3 | Author, orderer - note also, ProcedureRequest.requester.agent for device, practitioner or organization who initiated the request; or ProcedureRequest.requester.onBehalfOf  - the organization the device or practitioner was acting on behalf of
 
| row2cell3 | Author, orderer - note also, ProcedureRequest.requester.agent for device, practitioner or organization who initiated the request; or ProcedureRequest.requester.onBehalfOf  - the organization the device or practitioner was acting on behalf of
 
|}
 
|}
 +
 
==Physical Exam, Performed==
 
==Physical Exam, Performed==
−
 
+
* Note - Physical Exam, Performed uses the US FHIR Core Observation Profile referenced by QI Core. Specifically for Vital Signs, QI Core addresses the [http://hl7.org/fhir/us/core/us-core-vitalsigns.html US FHIR Core Vital Signs Profile] which specifies LOINC Codes and definitions for each references vital sign and Observation.component.code for each of diastolic blood pressure and systolic blood pressure.
 
{|border="1" cellpadding="2" cellspacing="0"  
 
{|border="1" cellpadding="2" cellspacing="0"  
 
| align="center" style="background:#f0f0f0;"|'''QDM Attribute'''
 
| align="center" style="background:#f0f0f0;"|'''QDM Attribute'''
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|-
 
|-
 
| row3cell1 | Author dateTime
 
| row3cell1 | Author dateTime
−
| row3cell2 | FHIR.provenance.recorded
+
| row3cell2 | Observation.issued
−
| row3cell3 | FHIR references authorDatetime as part of the provenance resource for all resources. Is authorDatetime still appropriate for this datatype?
+
| row3cell3 | QDM matched to QI Core / FHIR<br>
 +
Note: FHIR Provenance generally addresses the author of the message; the identifier/source of the original resource element is defined by the resource. Individual resource element provenance is summarized in the FHIR W5 Report (http://hl7.org/fhir/w5.html).
 
|-
 
|-
 
| row3cell1 | Status
 
| row3cell1 | Status
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| row3cell3 | QDM matched to QI Core / FHIR
 
| row3cell3 | QDM matched to QI Core / FHIR
 
|-
 
|-
−
| row3cell1 | Components
+
| row8cell1 | Components
−
| row3cell2 | Observation.component
+
| row8cell2 | Observation.component
−
| row3cell3 | QDM uses components to combine related observations to each other, e.g., a set of independent observations performed within an admission assessment for an inpatient admission. Each observation is unique (e.g., questions about tobacco usage, other substance usage, blood pressure, pulse, skin turgor, etc., etc.) but they are captured during the same patient-provider interaction. Such QDM components should map directly to QI Core / FHIR observations that can be linked to other observations. Other QDM component examples include multiple questions that are part of a validated evaluation tool (e.g., a Braden skin assessment scale). This latter example indicates individual questions that are inherently tied to the Braden scale instrument and the questions and answers do not have inherent value without being part of the instrument. QI Core / FHIR considers each such question as an Observation.component.  A general rule of thumb is QI Core / FHIR components apply only when the inherent value of the observation is defined by the parent observation. The result is that the content will determine if a QDM component maps to Observation.code or to Observation.component.code.  
+
| row8cell3 | QDM uses components to combine related observations to each other, e.g., a set of independent observations performed within an admission assessment for an inpatient admission. Each observation is unique (e.g., questions about tobacco usage, other substance usage, blood pressure, pulse, skin turgor, etc., etc.) but they are captured during the same patient-provider interaction. Such QDM components should map directly to QI Core / FHIR observations that can be linked to other observations. Other QDM component examples include multiple questions that are part of a validated evaluation tool (e.g., a Braden skin assessment scale). This latter example indicates individual questions that are inherently tied to the Braden scale instrument and the questions and answers do not have inherent value without being part of the instrument. QI Core / FHIR considers each such question as an Observation.component.  A general rule of thumb is QI Core / FHIR components apply only when the inherent value of the observation is defined by the parent observation. The result is that the content will determine if a QDM component maps to Observation.code or to Observation.component.code.  
 +
|-
 +
| row8cell1 | Component Code
 +
| row8cell2 | Observation.component.code
 +
| row8cell3 | See "Component" - Content-specific
 
|-
 
|-
−
| row3cell1 | Component Result
+
| row8cell1 | Component Result
−
| row3cell2 | Observation.component.result(x)
+
| row8cell2 | Observation.component.value(x)
−
| row3cell3 | QDM matched to QI Core / FHIR
+
| row8cell3 | See "Component" - Content-specific
 
|-
 
|-
 
| row8cell1 | Code
 
| row8cell1 | Code

Latest revision as of 04:21, 28 November 2018

Back to Harmonization of Health Quality Information Models Page

The CQI Workgroup reviewed the mapping to QDM version 5.3 in April 2018. The content is updated on June 7, 2018 based on QDM version 5.4. The changes based on QDM 5.4 include:

  • Removal of the "method" attribute from "Physical Exam, Order" and "Physical Exam, Recommended"

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. QDM defines three contexts for Physical Exam: Physical Exam, Order; Physical Exam, Performed; Physical Exam, Recommended.


Physical Exam, Order

QDM Attribute QI Core Metadata Element Comment
Physical Exam, Order ProcedureRequest.intent Procedure 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.
Anatomical Location Site ProcedureRequest.extension (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-procedurerequest-approachBodySite) Note QI Core ProcedureRequest.extension (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-procedurerequest-appropriatenessScore) - not included in QDM but may potentially apply to Appropriate Use Criteria
Negation Rationale ProcedureRequest.extension (http://hl7.org/fhir/StructureDefinition/procedurerequest-reasonRefused) QDM matched to QI Core / FHIR
Reason ProcedureRequest.reasonCode QDM matched to QI Core / FHIR
Author dateTime ProcedureRequest.authoredOn Note - ProcedureRequest.occurrence[x] defines a dateTime when the event should occur - not addressed in QDM

Note: FHIR Provenance generally addresses the author of the message; the identifier/source of the original resource element is defined by the resource. Individual resource element provenance is summarized in the FHIR W5 Report (http://hl7.org/fhir/w5.html).

Code ProcedureRequest.code QDM matched to QI Core / FHIR
id ProcedureRequest.id QDM matched to QI Core / FHIR
Source ProcedureRequest.requester Author, orderer - note also, ProcedureRequest.requester.agent for device, practitioner or organization who initiated the request; or ProcedureRequest.requester.onBehalfOf - the organization the device or practitioner was acting on behalf of

Physical Exam, Recommended

QDM Attribute QI Core Metadata Element Comment
Physical Exam, Recommended ProcedureRequest.intent Procedure 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.
Anatomical Location Site ProcedureRequest.extension (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-procedurerequest-approachBodySite) Note QI Core ProcedureRequest.extension (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-procedurerequest-appropriatenessScore) - not included in QDM but may potentially apply to Appropriate Use Criteria
Negation Rationale ProcedureRequest.extension (http://hl7.org/fhir/StructureDefinition/procedurerequest-reasonRefused) QDM matched to QI Core / FHIR
Reason ProcedureRequest.reasonCode QDM matched to QI Core / FHIR
Author dateTime ProcedureRequest.authoredOn Note - ProcedureRequest.occurrence[x] defines a dateTime when the event should occur - not addressed in QDM

Note: FHIR Provenance generally addresses the author of the message; the identifier/source of the original resource element is defined by the resource. Individual resource element provenance is summarized in the FHIR W5 Report (http://hl7.org/fhir/w5.html).

Code ProcedureRequest.code QDM matched to QI Core / FHIR
id ProcedureRequest.id QDM matched to QI Core / FHIR
Source ProcedureRequest.requester Author, orderer - note also, ProcedureRequest.requester.agent for device, practitioner or organization who initiated the request; or ProcedureRequest.requester.onBehalfOf - the organization the device or practitioner was acting on behalf of

Physical Exam, Performed

  • Note - Physical Exam, Performed uses the US FHIR Core Observation Profile referenced by QI Core. Specifically for Vital Signs, QI Core addresses the US FHIR Core Vital Signs Profile which specifies LOINC Codes and definitions for each references vital sign and Observation.component.code for each of diastolic blood pressure and systolic blood pressure.
QDM Attribute QI Core Metadata Element Comment
Physical Exam, Performed Observation (the .status metadata allows conformance to the specific QDM datatype context) QDM matched to QI Core / FHIR
Anatomical Location Site Observation.bodySite QDM matched to QI Core / FHIR
Method Observaton.method QDM matched to QI Core / FHIR
Relevant Period observation.effective.x QDM matched to QI Core / FHIR
Negation Rationale Observation.dataAbsentReason The value set is required. Many eCQMs use a measure developer-specific value set. Note, component also has a Observation.component.dataAbsentReason in QI Core.
Reason Observaton.basedOn QDM matched to QI Core / FHIR
Result Observation.value(x) Note - QI Core also includes Observation.interpretation and Observation.comment - eCQMs have addressed interpretation as an implementation issue. Perhaps that approach should be reconsidered.
Author dateTime Observation.issued QDM matched to QI Core / FHIR

Note: FHIR Provenance generally addresses the author of the message; the identifier/source of the original resource element is defined by the resource. Individual resource element provenance is summarized in the FHIR W5 Report (http://hl7.org/fhir/w5.html).

Status Procedure.status QDM matched to QI Core / FHIR
Components Observation.component QDM uses components to combine related observations to each other, e.g., a set of independent observations performed within an admission assessment for an inpatient admission. Each observation is unique (e.g., questions about tobacco usage, other substance usage, blood pressure, pulse, skin turgor, etc., etc.) but they are captured during the same patient-provider interaction. Such QDM components should map directly to QI Core / FHIR observations that can be linked to other observations. Other QDM component examples include multiple questions that are part of a validated evaluation tool (e.g., a Braden skin assessment scale). This latter example indicates individual questions that are inherently tied to the Braden scale instrument and the questions and answers do not have inherent value without being part of the instrument. QI Core / FHIR considers each such question as an Observation.component. A general rule of thumb is QI Core / FHIR components apply only when the inherent value of the observation is defined by the parent observation. The result is that the content will determine if a QDM component maps to Observation.code or to Observation.component.code.
Component Code Observation.component.code See "Component" - Content-specific
Component Result Observation.component.value(x) See "Component" - Content-specific
Code Observation.code QDM matched to QI Core / FHIR
id Observation.id QDM matched to QI Core / FHIR
Source Observation.performer QDM matched to QI Core / FHIR
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