eCQMs have used the QDM datatypes Communication: from Patient to Provider; Communication: From Provider to Patient; and Communication: From Provider to Provider. The intent has generally been to identify that some interaction has occurred between a provider and a patient or between and provider and another provider.
The HL7 FHIR resource Procedure specifically defines a procedure as [bolding is added for emphasis]:
_The Procedure resource should not be used to capture an event if a more specific resource already exists - i.e. immunizations, drug administrations and communications. The boundary between determining whether an action is a Procedure (training or counseling) as opposed to a Communication is based on whether there's a specific intent to change the mind-set of the patient. Mere disclosure of information would be considered a Communication. A process that involves verification of the patient's comprehension or to change the patient's mental state would be a Procedure.
Note that many diagnostic processes are procedures that generate Observations and DiagnosticReports. In many cases, such an observation does not require an explicit representation of the procedure used to create the observation, but where there are details of interest about how the diagnostic procedure was performed, the procedure resource is used to describe the activity.
Some diagnostic procedures may not have a Procedure record. The Procedure record is only necessary when there is a need to capture information about the physical intervention that was performed to capture the diagnostic information (e.g. anesthetic, incision, scope size, etc.)
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The definition further defines Communication as:
_Communication is one of the event resources in the FHIR workflow specification. (http://hl7.org/fhir/communication.html0
This resource is a record of a communication. A communication is a conveyance of information from one entity, a sender, to another entity, a receiver. The sender and receivers may be patients, practitioners, related persons, organizations, or devices. Communication use cases include:
A reminder or alert delivered to a responsible provider
A recorded notification from the nurse that a patient's temperature exceeds a value
A notification to a public health agency of a patient presenting with a communicable disease reportable to the public health agency
Patient educational material sent by a provider to a patient
Non-patient specific communication use cases may include:
A nurse call from a hall bathroom
Advisory for battery service from a pump
This resource is a record of a communication that has occurred. It does not represent the actual flow of communication. While AuditEvent can track electronic disclosures of information, it cannot track conversations, phone calls, letters and other interactions that are not system-to-system. And even for system-to-system communications, the specific end recipients may not be known. As well, AuditEvents are not considered to be "part" of the patient record, while Communication instances are. The Communication resource is not used as a general audit mechanism to track every disclosure of every record. Rather, it is used when a clinician or other user wants to ensure a record of a particular communication is itself maintained as part of the reviewable health record.
Flag resources represent a continuous ongoing "communication" alerting anyone dealing with the patient of certain precautions to take or issues to be aware of. The flags are continuously present as an ongoing reminder. This is distinct from Communication where there is a specific intended sender and receiver and the information is delivered only once.
Communication and Encounter
The Communication is about the transfer of information (which may or may not occur as part of an encounter), while Encounter is about the coming together (in person or virtually) of a Patient with a Practitioner. Communication does not deal with the duration of a call, it represents the fact that information was transferred at a particular point in time.
The phone calls involving the Patient should be handled using Encounter. Phone calls not involving the patient (e.g. between practitioners or practitioner to relative) that are tracked for billing or other purposes can use Communication to represent the information transferred, but are not ideal to represent the call itself. A better mechanism for handling such calls will be explored in a future release.
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From the information provided in the HL7 FHIR descriptions, the current use cases should consider communications to patients as Procedure, Performed (see QDM-201) if they are intended to change the patient's mind set, and communications to other providers as Encounter, Order (i.e., ReferralRequest concepts in HL7 FHIR). eCQM developers addressing communications from patients that represent findings documented in the EHR should consider using Assessment, Performed with source of the information = patient. QDM should consider a single Communication datatype requiring a sender and receiver that addresses the use cases identified in the HL7 FHIR resources cited above.