QI-Core Implementation Guide: STU 4 (v4.0.0 for FHIR 4.0.0)

QI-Core Implementation Guide, Clinical Quality Improvement WG - CI build for vesion 4.0.0). This version is based on the current content of https://github.com/cqframework/qi-core/ and changes regularly. See the Directory of published versions

7.15.0 Laboratory Test

QDM defines Laboratory Test as a medical procedure that involves testing a sample of blood, urine, or other body fluids or specimens. Tests can help determine a diagnosis, plan treatment, check to see if treatment is working, or monitor the disease over time. This QDM data category for Laboratory Test is only used for information about the subject of record.

Thus far, consensus opinion suggests that the US-Core Observation-Lab Profile best fits the laboratory test use case for querying clinical data to retrieve information about the event and/or the result of the study. Individual studies may use the US-Core DiagnosticReport-lab (http://hl7.org/fhir/us/core/StructureDefinition-us-core-diagnosticreport-lab.html) to provide information about an individual laboratory test although some have considered use of other reporting resources and artifacts. Each laboratory test may be ordered individually or in a panel. Many use panels for convenience for ordering laboratory tests. Since new laboratory panels regularly become available and the myriad of potential laboratory panels available, a complete list cannot be assured. Therefore, a quality measure or clinical decision support (CDS) artifacts seeking a specific result value should use the US-Core Observation-Lab profile to request a retrieve of the result value desired. This practice will enable implementers to determine which is the best source for the desired observation. LOINC observable entities may indicate specific methods for determination of results. Measure and CDS developers can reference direct reference codes or value sets using the such LOINC codes to specify the type of testing considered acceptable to provide sufficient fidelity to their requests.

7.15.1 Laboratory Test, Performed

QDM Context USCore R4 US Core R3 Observation Comments
Laboratory Test, Performed Observation Observation
Observation.status Observation.status Constrain status to - final, amended, corrected
QDM Attribute
code Observation.code Observation.code
id Observation.id Observation.id
method Observation.method Observation.method
Observation.bodySite Observation.bodySite
negation rationale Observation.dataAbsentReason Observation.dataAbsentReason NOTE: Differential view indicates Extensible
Observation.issued Observation.issued Issued - the date and time this version of the observation was made available to providers, typically after the results have been reviewed and verified. Consider if QI-Core should include an extension to manage timing of the dataAbsentReason.
reason Observation.basedOn Observation.basedOn the observation fulfills a plan, proposal or order - trace for authorization. Possibly not a fit for the intent in QDM (e.g., observation "reason" = a diagnosis) Is an extension needed?
result value[x] Observation.value[x]
Observation.interpretation Observation.interpretation
Observation.specimen Observation.specimen
result dateTime Observation.issued Observation.issued
Relevant dateTime Observation.effective[x] dateTime Observation.effective[x]
Relevant Period Observation.effective[x] Period Observation.effective[x]
Status Observation.status Observation.status Constrain status to - final, amended, corrected
Author datTime Observation.issued Observation.issued Issued - the date and time this version of the observation was made available to providers, typically after the results have been reviewed and verified. Consider if QI-Core should include an extension to manage timing of the dataAbsentReason.
Reference Range High Observation.referenceRange.high Observation.referenceRange.high
Reference Range Low Observation.referenceRange.low Observation.referenceRange.low
Component Observation.component Observation.component
Observation.Component.id Observation.component.id
Component code Observation.component.code Observation.component.code
Component result Observation.component.value[x] Observation.component.value[x]
Observation.component.interpretation Observation.component.interpretation
Observation.component.dataAbsentReason Observation.component.dataAbsentReason
Component reference range high Observation.component.referenceRange Observation.component.referenceRange
Component reference range low Observation.component.referenceRange Observation.component.referenceRange
Performer Observation.performer Observation.performer

7.15.2 Laboratory Test, Order

To address the QDM attribute Laboratory Test, Order see Service Request

7.15.3 Laboratory Test, Recommended

To address the QDM attribute Laboratory Test, Recommended see Service Request