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

7.21.0 Substance

QDM defines Substance as a homogeneous material with definite composition that includes allergens, biological materials, chemicals, foods, drugs and materials. QDM distinguishes between medications from non-medication substances by separately listing medication datatypes. Substance may or may not have a code or be classified by a code system such RxNorm. Examples of a substance may include environmental agents (e.g., pollen, dust) and food (e.g., vitamins). Where a substance can be addressed using medication terminology (e.g. egg albumin) used the Medication mappings listed in this QDM-to-QI-Core section.

FHIR defines substance as a homogeneous material with a definite composition. Medications are classified as substances. However, to reference other substances, especially using the SubstanceDefinition resource is challenging since the resource is still undergoing development.

Ideally, use of a substance-related resource should be driven by use cases and examples. Two such use cases currently exist in the quality measure community::

  • Determination that blood products (a biological product in FHIR resources) are ordered or are administered within specific time relationships to other data elements – The FHIR Resource, BiologicallyDerivedProduct, possibly using Procedure and ServiceRequest might have promise. However, the resource is still in development. Therefore, until further information is available, rather than expressing the QDM datatype Substance, Administration to address administration of blood transfusion, quality measure and clinical decision support (CDS) authors should consider using the procedure resource with a code representing transfusion.
  • Determination that human breast milk is used exclusively to feed newborn infants during the initial stay in the hospital after birth – Currently, FHIR includes a NutritionOrder resource to reference a request for a specific diet, or supplements to a diet. However, a resource for documenting administration of nutrition-related substances is still in development. Therefore, for this use case a quality measure or a clinical decision support (CDS) author could reference a NutritionOrder for an exclusive breast milk diet for the infant; however, such an expression could not reference clinical intake and output records to determine if anything other than human breast milk was administered to the infant. Moreover, classification of human breast milk requires clarification as to whether it is a BiologicallyDerivedProduct, or if it should be referenced as a Substance.

7.21.1 NutritionOrder

To provide some context and guidance, this QDM-to-QI-Core mapping includes reference to the QDM datatypes Substance, Order and Substance, Recommended using the NutritionOrder resource. As noted in the second example provided, the resource is relatively new and it allows expressions to address only the type of diet ordered, not the foods or substances administered to a patient.

The CQI Workgroup seeks comment and advice regarding the best method for addressing existing and new use cases regarding substance administration.

QDM Context FHIR R4 Comments
Substance, Order/Recommended - For Diet Orders NutritionOrder Limited to orders for diets or diets with supplements
Substance Order/Recommended Activity NutritionOrder.status Constrain to Active, on-hold, Completed
Substance, Order NutritionOrder.intent Constrain to "plan"
Substance, Recommended NutritionOrder.intent Constrain to "order" and child concepts
QDM Attributes
ORAL DIET NutritionOrder.oralDiet
code (to represent a diet order) NutritionOrder.oralDiet.type
NutrientOrder.oralDiet.nutrient.modifier
id NutritionOrder.id
dosage N/A
frequency NutritionOrder.Diet.schedule
negation rationale N/A
author dateTime NutritionOrder.dateTime
relevant period N/A
reason N/A
supply N/A
refills N/A
route NutritionOrder.oralDiet
Requester NutritionOrder.orderer
ENTERAL FORMULA NutritionOrder.enteralFormula
code (to represent a diet order) NutritionOrder.enteralFormula.baseFormulaType
Additive to diet order NutritionOrder.enteralFormula.additiveType
id N/A
dosage NutritionOrder.enterealFormula.administration.quantity
frequency NutritionOrder.enteralFormula.administration.rate{x}
negation rationale N/A
author dateTime NutritionOrder.dateTime
relevant period NutritionOrder.enteralFormula.administration.schedule
reason N/A
supply N/A
refills NutritionOrder.enteralFormula
route NutritionOrder.enteralFormula.routeofAdministration
Requester NutritionOrder.orderer