Substance (QDM)

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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 reviewed by the CQI Workgroup on April 24, 2018 based on QDM version 5.3. The content on this page was updated on June 7, 2018 consistent with QDM version 5.4. The changes reflected due to QDM version 5.4 include:

• Removal of the "supply" attribute from "Substance, Administered"
• Remove the "method" attribute from "Substance, Order" and "Substance, Recommended"
  
  

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.
  

Nutrition [Considerations for Future Use]
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 [Considerations for Future Use]
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
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
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
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