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  2. CQM-1551

Need clarification on 'end dates' for patient data sections that are 'Orders'

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    • Patsy Russo
    • 515-224-7867
    • CSC contractor for the DECC PQRS program
    • need clarification on how to proceed in coding
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      The "start datetime" and "stop datetime" on Order data types do in fact represent the same time (the time the order was written).

      The QDM-based HQMF IG may confuse this matter by mapping them to author/time/low and author/time/high, but if you look at the QRDA I templates (and corresponding CDA schemas) for orders, it's clear that author/time is in fact a single timestamp (not an interval). The soon-to-be-released QRDA I DSTU R3 specification also states the following:


      QDM attributes: Start Datetime and Stop Datetime are represented by author/time and correspond to when the order was signed, it is expected that the two values will be the same.

      While I cannot speak authoritatively regarding the intent of the measure authors, I don't think the measures are purposefully trying to make a distinction between order start and end times.

      In CMS153v3, I expect "starts after end" was used simply because it sounded more natural. The logic is intended to determine if a pregnancy test was ordered prior to ordering an X-Ray (presumably as a precaution). Treating start/stop as a single timestamp does not affect this intent.

      In CMS52v3, the AND / AND NOT temporal phrases are just following the pattern for "overlaps" suggested in QDM guidance documents (the "overlaps" pattern indicates the "starts before or during" / "ends before start" temporal phrases). This is confirmed in CMS52v4, which replaces that pattern with the new QDM "overlaps" operator.
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      The "start datetime" and "stop datetime" on Order data types do in fact represent the same time (the time the order was written). The QDM-based HQMF IG may confuse this matter by mapping them to author/time/low and author/time/high, but if you look at the QRDA I templates (and corresponding CDA schemas) for orders, it's clear that author/time is in fact a single timestamp (not an interval). The soon-to-be-released QRDA I DSTU R3 specification also states the following: QDM attributes: Start Datetime and Stop Datetime are represented by author/time and correspond to when the order was signed, it is expected that the two values will be the same. While I cannot speak authoritatively regarding the intent of the measure authors, I don't think the measures are purposefully trying to make a distinction between order start and end times. In CMS153v3, I expect "starts after end" was used simply because it sounded more natural. The logic is intended to determine if a pregnancy test was ordered prior to ordering an X-Ray (presumably as a precaution). Treating start/stop as a single timestamp does not affect this intent. In CMS52v3, the AND / AND NOT temporal phrases are just following the pattern for "overlaps" suggested in QDM guidance documents (the "overlaps" pattern indicates the "starts before or during" / "ends before start" temporal phrases). This is confirmed in CMS52v4, which replaces that pattern with the new QDM "overlaps" operator.
    • Our Development team needs clarifcation on how to handle to finish their 2015 eCQM coding.

      Here are our questions:

      • Are start and end dates needed for patient data sections that are 'Orders'?
      • If only one date is needed for 'Orders' then should a JIRA ticket be written requesting that the two measure definitions (highlighted below) be clarified?
      • Alternately, can we get some clear guidance that we are allowed to use the single 'Order' date that we are persisting as both a start and an end date?
      • It two dates are truly needed then can someone point us to a constraint in the HL7 IG where we are supposed to find these dates?

      Obviously the simplest solution is just to treat the single date we are persisting as both a start and end date but, in light of the wording in the below two problem measures we are uncomfortable doing that without a confirmation that is the correct way to proceed.

      Below is a detailed description of the problem. (I put this together after discussions with the ME team. If I've misstated something then feel free to comment and correct me.)

      Any help you can provide would be appreciated.
      -Dave

      The six 'Order' sections are...

      • Diagnostic Study Order
      • Laboratory Test Order
      • Procedure Order
      • Intervention Order
      • Encounter Order
      • Medication Order

      The HL7 IG seems to clearly state that all 'Orders' have a single date associated with it. For example, Diagnostic Study Order has this constraint for the date...

      1.	SHALL contain exactly one [1..1] author (CONF:13419) such that it
	a.	SHALL contain exactly one [1..1] time (CONF:13420).

      Intuitively, it makes sense that an 'Order' only has only one date. An order isn't an activity that takes time. A prescription is written 'ordering' an activity and the writing of that prescription happens at a single point in time. A Medication Order prescribes a medication (at a single point in time) and then the associated Medication Activity would indicate when the patient started to take the medication and when they stopped.

      'Order' sections are used in a total of 20 different measures and in 18 of those measures this single date is all that is needed.

      Unfortunately, measures 153v3 and 52v3 indicate that the 'Order' has an end date. Measure 52v3 is especially troublesome because it clearly references the Medication Order 'start' AND 'end' date.

      Here are the problem passages in those two measures:

      Measure 153v3

      Denominator Exclusions =

      • AND: "Occurrence A of Laboratory Test, Order: Pregnancy Test" during "Measurement Period"
      • AND:
        • OR: "Medication, Order: Isotretinoin"
        • OR: "Diagnostic Study, Order: X-Ray Study (all inclusive)"
        • <= 7 day(s) starts after end of "Occurrence A of Laboratory Test, Order: Pregnancy Test"

      Measure 52v3

      • OR: "Occurrence A of Medication, Order: Leucovorin" concurrent with "Occurrence A of Medication, Order: Dapsone and pyrimethamine"
      • OR:
        • AND: "Occurrence A of Medication, Order: Dapsone and pyrimethamine" < 1 day(s) starts before or during "Occurrence A of Medication, Order: Leucovorin"
        • AND NOT: "Occurrence A of Medication, Order: Dapsone and pyrimethamine" ends before start of "Occurrence A of Medication, Order: Leucovorin"
      • OR:
        • AND: "Occurrence A of Medication, Order: Leucovorin" < 1 day(s) starts before or during "Occurrence A of Medication, Order: Dapsone and pyrimethamine"
        • AND NOT: "Occurrence A of Medication, Order: Leucovorin" ends before start of "Occurrence A of Medication, Order: Dapsone and pyrimethamine"

            edave Mathematica EC eCQM Team
            Patsy.Russo Patsy (Inactive)
            Balu Balasubramanyam (Inactive), Marc Hadley (Inactive), Patsy (Inactive)
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