1. Questions for Modeling Decisions
QDM to QI Core / FHIR

2. Topics Use of “components” with observations
Identification of “Medication at discharge”
“Expired”
Determining “Ordered” Vs. “Recommended” QDM concepts

3. Use of Components in Observations
Assessment, Performed
Where to use an individual observation Vs. and observation with components
Observation.code – describes what was observed. Sometimes called the observation name. (CodeableConcept)
Observation.value[x] – information determined as a result of making the observation (CodeableConcept, string, Boolean, Range, Ratio, SampledData, Attachment, time, dateTime, Period) Vs
Observation.component.code
Observation.component.value[x]

4. Use of Components in Observations
Tenet – use component only when the inherent value of the observation is defined by the ‘parent’ observation
Example: Physical exam, Performed
Observation
Physical exam, Performed: Cardiac Point Maximum Impulse (PMI)
Physical exam, Performed: Heart Rate
Physical exam, Performed: Auscultation findings
NOT:
Physical exam, Performed: Cardiac exam
Component – Cardiac Point Maximum Impulse (PMI)
Component – Heart Rate
Component – Auscultation findings

5. Use of Components in Observations
Tenet – use component only when the inherent value of the observation is defined by the ‘parent’ observation
Example: Physical exam, Performed (Needs discussion)
Observation
Physical exam, Performed: Blood Pressure
Component – Systolic blood pressure
Component – Diastolic blood pressure
NOT:
Physical exam, Performed: Systolic blood pressure
Physical exam, Performed: Diastolic blood pressure
Where to differentiate in a standard way across FHIR?

6. Use of Components in Observations
Tenet – use component only when the inherent value of the observation is defined by the ‘parent’ observation
Example: Assessment, Performed (Needs discussion)
Observation
Assessment, Performed: Braden Scale Pressure Ulcer Risk Score
Component – Question 1
Component – Question 2
Component – Question 3
Etc.
NOT:
Assessment, Performed: Braden Scale Question 1
Assessment, Performed: Braden Scale Question 2
Assessment, Performed: Braden Scale Question 3
Where the component element has value only on the context of the evaluation/risk tool

7. Use of Components in Observations
Tenet – use component only when the inherent value of the observation is defined by the ‘parent’ observation
Example: Laboratory Test, Performed (Needs discussion)
DiagnosticReport.code
Observation.code – Laboratory Test, Performed: WBC
Observation.code – Laboratory Test, Performed: Hemoglobin
Observation.code – Laboratory Test, Performed: Hematocrit
Etc.
NOT:
Observation.code – Laboratory Test, Performed: Complete Blood Count
Component – WBC
Component – Hemoglobin
Component – Hematocrit
Diagnostic Report addresses tests that represent panels

8. Use of Components in Observations
Tenet – use component only when the inherent value of the observation is defined by the ‘parent’ observation
How does one model an imaging study that uses individual images to calculate a single result? i.e., which is correct?
A Diagnostic Report with one observation with each image as a component of the observation?
In this case, the DiagnosticReport.coded represents the conclusion from all images resulted within the report [Diagnosis for the coded conclusion
Each image result is referenced by DiagnosticReport.result [Observations that are part of this diagnostic report. Observations can be simple name/value pairs (e.g. "atomic" results), or they can be grouping observations that include references to other members of the group (e.g. "panels").]
Each image is specified as DiagnosticReport.imagingStudy but the result is identified in the DiagnosticReport as a DiagnosticReport.result. And how does one link the DiagnosticReport.result to the individual DiagnosticReport.imagingStudy within the report.

9. Identifying Medications at Discharge
“QDM datatype” Medications at Discharge references the list of medication the patient is expected to take at home after hospital discharge. There are several ways to represent the concept in QI Core/FHIR but each with some issue.
MedicationStatement.medication[x] (CodeableConcept)
MedicationStatement.status (code – intended – Medication may be taken at some time in the future)
Effective[x] – should address dateTime/Period when taken (past tense) – challenge is that discharge plan may be written prior to discharge and the plan needs to be tied to the discharge action

10. Identifying Medications at Discharge
“QDM datatype” Medications at Discharge references the list of medication the patient is expected to take at home after hospital discharge. There are several ways to represent the concept in QI Core/FHIR but each with some issue.
MedicationRequest.medication[x] (CodeableConcept)
MedicationRequest.status (code – active)
Effective[x] – indicate effective time at which the request should be active – challenge is that discharge plan may be written prior to discharge and the plan needs to be tied to the discharge action / time – which may not yet be known
MedicationRequest.intent (code – plan)
Same issue with Effective[x] as MedicationRequest.status
Concern – an individual patient ‘request’ may indicate a dateTime but the concept of “discharge” as a future time is more complex –
Note – ProcedureRequest.intent has similar concerns with respect to the time for the “request-intent” code “plan”

11. Expired Patient.deceased[x]
No FHIR / QI Core representation of “cause of death”

12. Order Vs Recommended ProcedureRequest.status ProcedureRequest.intent
Draft, active, suspended, cancelled, completed, entered-in-error, unknown
ProcedureRequest.intent
Proposal: The request is a suggestion made by someone/something that doesn't have an intention to ensure it occurs and without providing an authorization to act
Plan: The request represents an intension to ensure something occurs without providing an authorization for others to act
Order: The request represents a request/demand and authorization for action
QI Core Suggests: “proposed” for recommended, “Requested” for ordered. Neither is in the suggested value sets.