Representation of Order Times

Background

A question recently came up regarding what the start datetime on QDM Order datatypes is mapped to. While the QDM-based HQMF IG clearly indicates it refers to effectiveTime, it seems that the intent of measure developers might be author/time.

The main concern is that when a measure developer says something like "Procedure, Order: ABC" starts during "Encounter, Performed: XYZ", they likely mean that the physician ordered the procedure during the encounter. Based on the current mapping to effectiveTime, however, this actually means that the ordered procedure was scheduled to occur during the encounter.

This issue pertains to all Order datatypes:

• Device, Order
• Diagnostic Study, Order
• Encounter, Order
• Functional Status, Order
• Intervention, Order
• Laboratory Test, Order
• Medication, Order
• Physical Exam, Order
• Procedure, Order
• Substance, Order

This is not the first time this has been discussed.

QRDA–44, which was closed over a year ago, discusses this same topic. The last comment contains the conclusion:

“On further investigation, we have confirmed that in all cases (EH and EP), when an order-type pattern is used in a criterion, the intent of the measure developer when asserting a temporal comparison was to compare against the author/time and not the effectiveTime.”

Recent QRDA guidance and errata focus on Orders’ author/time.

2014 CMS QRDA I Implementation Guides for Eligible Professionals Clinical Quality Measures (published in April 2014) associates all Order Date Times (in Order templates) to author/time.

The recent errata to the HL7 Implementation Guide for CDA® Release 2: Quality Reporting Document Architecture – Category I, DSTU Release 2 (US Realm) requires every Order template to report author/time but does not require (or even suggest) that effectiveTime be reported.

This essentially means that QRDA Cat-I reported data may not contain sufficient data to compare orders on effectiveTime.

HQMF R2.1 and the QDM-based HQMF IG focus on Orders’ effectiveTime.

HL7 Version 3 Standard: Representation of the Health Quality Measures Format (eMeasure), DSTU Release 2.1 indicates that temporal relationships are always based on effectiveTime:

Implicit in the understanding of the table is that whenever a temporal comparison is performed, it is made between the source act’s effectiveTime and the target act’s effectiveTime.

The QDM team has developed an extension to HQMF R2.1 that does allow for temporal relations to be based on other QDM datetime attributes– but the default remains as effectiveTime (and an author/time-based attribute is only available on Medication, Order).

HL7 Version 3 Implementation Guide: Quality Data Model (QDM)-based Health Quality Measure Format (HQMF), DSTU Release 1 – US Realm maps QDM’s start datetime and stop datetime to effectiveTime for all datatypes (including Order datatypes).

This essentially means that QDM-based HQMF and QRDA Cat-I are currently out of alignment. QDM-based HQMF does not allow relationships based on author time to be expressed and QRDA Cat-I does not require Orders to report the one date that QDM-based HQMF does allow: effectiveTime.

Status of Current Tooling (MAT, Bonnie, Cypress)

The Measure Authoring Tool currently generates HQMF templates with Orders’ start and stop datetimes mapped to effectiveTime (as indicated by the current QDM-based HQMF IG).

Bonnie and Cypress map QRDA CAT-I Orders to their internal patient/order models using author/time, but look at the effectiveTime in the HQMF representation of orders. This is how Bonnie and Cypress have managed to fit the intent of the measures despite the current problems in representation.

Any changes to the mapping of Order datetimes will require changes in all of these tools (particularly in their generation / interpretation of HQMF).

Solution: Change primary datetime of Orders to author/time

This solution aligns with the latest QRDA and QRDA IG. It could potentially be implemented in two phases:

• Phase 1: Change Orders’ start datetime, stop datetime, and comparison datetime to author/time
  • Update QDM specification to reflect change
  • Update QDM-based HQMF IG templates to reflect change
  • Update MAT’s HQMF R2.1 generator to use author/time when generating Orders and temporal relationships w/ Orders
  • Update Bonnie and Cypress to properly process/execute the author/time on Orders and temporal relationships w/ Orders
• Phase 2: Add new attributes to Orders to allow authors to work on effectiveTime when desired
  • Update all of the same artifacts/tools as in Phase 1, plus QRDA templates

Timing

This solution should ideally be implemented in coordination with the upcoming MAT release supporting HQMF R2.1.