We've received several comments that it is unclear what a diagnosis represents-- only confirmed diagnoses, or also problems, complaints, other findings, etc.? Some of the other Health IT specs represent "conditions" or "problems" as a single type, but have an attribute to provide more specificity.

For example, FHIR's Condition specifies different categories of conditions (as defined in the ConditionCategory Value Set):

• complaint
• symptom
• finding
• diagnosis

C-CDA R2's Problem Observation also distinguishes different problem types (as defined in the Problem Type Value Set):

• Clinical finding
• Complaint
• Diagnosis interpretation
• Disease
• Finding of functional performance and activity
• Finding reported by subject or history provider
• Problem

We need to determine if QDM should support this level of specifity. If so, how should it be represented and what categories should be supported? If not, then what things does Diagnosis represent? Should the datatype name be changed to indicate a broader definition?

UG Accepted Solution

Continue to represent diagnoses, problems, and conditions as a single concept. Update the definition of Diagnosis to be:

A diagnosis represents a practitioner’s identification of a patient’s disease, illness, injury, or condition. A practitioner determines the diagnosis by means of examination, diagnostic test results, patient history, and/or family history. Diagnoses are usually considered unfavorable, but may also represent neutral or favorable conditions that affect a patient’s plan of care (e.g., pregnancy).

The QDM does not prescribe the source of diagnosis data in the EHR. Diagnoses may be found in a patient’s problem list, encounter diagnosis list, claims data, or other sources within the EHR. The preferred terminology for diagnoses is SNOMED-CT, but diagnoses may also be encoded using ICD-9/10.

The Diagnosis datatype should not be used for differential diagnoses or rule-out diagnoses (neither of which are currently supported by the QDM).

For details on why this decision was made, see the QDM-103 attachments and comments.