To help evaluate the feasibility and likelihood of retrieving data from an EHR for eCQMs, all QDM datatypes and attributes have been mapped to HL7 FHIR resources. The concepts "recommended" and "order" are capture in FHIR resources as part of the "intent" metadata element for a request (i.e., a ProcedureRequest, a ReferralRequest or a MedicationRequest, depending on the class of information under consideration). The intent metadata element include the concepts proposal, plan, order, original-order, reflex-order, filler-order, instance-order, option. Discussions in the HL7 Clinical Quality Information Work Group concluded that "Proposal" is most consistent with the Request.intent 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 with the intention that the action is carried out but without the direct authority to do so (i.e., the provider would need to write an order or the patient would need to personally take action for fulfill the recommendation or plan). Such recommendations are most consistent with the Request.intent value of "plan" (an intension to ensure something occurs without providing an authorization to act). QDM concepts referencing Order address the Request “order” concept.

The discussion also led to the question about whether an EHR would have discrete data about a recommendation. Many times recommendations occur through conversation and are documented in narrative text, if at all. Without some discrete evidence of the recommendation in structured form, implementers will have difficulty retrieving evidence of it. Recommendation may be useful in clinical decision support in which the CDS artifact provides the recommendation to the user. Such an artifact may be in the form of:
1. an order set - in which the order is placed or justification for not placing the order is listed
2. a documentation template - in which the recommendation can be provided as a structured plan, as with a care plan
3. a textual recommendation as with an event-condition-action rule - in which case the follow through might provide the option to order the action or document the action.
However, without clinical decision support "front-end" workflow, recommendations will be difficult to identify.

Question for the QDM users - Should QDM Recommendation Datatypes be removed, or can you recommend a clear path to encourage appropriate use of the datatypes in eCQM expressions/