There are two ways a practice may know of a Laboratory Test that has been performed:

1. There is a record of the actual test in the EHR,with a recorded result.
2. The provider has seen evidence of a laboratory test (paper, PDF, etc).

In the case of #2 above, EHRs often support input of the external documentation into the system, but it is unclear how that data is queried and reported for use in eCQMs. For example, how is it associated with the proper code (or is it)? How is it reported in QRDA Cat I docs? In some cases, EHRs have provided a measure-/concept- specific checkbox in the workflow to allow providers to indicate they've seen documentation of the lab test in order to fulfill the measure requirements, but this is not an ideal solution.

An initial approach was to use LOINC codes and/or value sets to distinguish between #1 and #2 above, but the terminology experts have indicated that this is a misuse of the value sets / codes.

Solution

The following is a summary of the agreed upon approach, as suggested by Dr. Rob McClure in the comments, and accepted by the User Group on June 18, 2014.

• EHRs should allow users to enter an externally documented test into the system
• The test should be described using an appropriate LOINC code
• More general LOINC codes may need to be created for this purpose
• If desired, the user should be able to enter the result (as a SNOMED-CT code or a literal value)
• Ideally, the EHR should be able to flag the entry as "externally documented" with the date of the test
• Within the EHR, externally documented entries and "native" entries should be treated similarly (for measure execution, etc)

Given the above approach, measures would use the existing QDM datatypes and attributes to query for both external and internal tests:

• Laboratory test, performed: (LOINC value set noted) => The test was done but no result is required.
• Laboratory test, performed: (LOINC value set noted), (result) => The test was done and a result is documented in the record.
• Laboratory test, performed: (LOINC value set noted), (result:"Specific result value set") => The test was done and a "specific" result is documented in the record.
• Laboratory test, performed: (LOINC value set noted), (result < someQuantity someUnit) => The test was done and a result is documented in the record having a value less than someQuantity someUnit.

While this solution may require further work in terminology (like new LOINC codes), it does not require any changes to the QDM specification. Aspects of the solution may be appropriate for consideration in guidance documents.

It should be noted that this issue and solution is not necessarily unique to laboratory tests. It could apply to other concepts as well (e.g., vaccinations, procedures, etc).

Out of Scope

Measure developers may want to distinguish between externally documented tests and tests that were native to the system. While EHRs should support this distinction in the metadata of the record, making use of this distinction in measure logic will be captured as a separate issue.

Measure developers may also want to indicate if a test (external or internal) has been "seen" or "reviewed". This should also be treated as a separate issue.