ecqm.measure

CMS117v7 - Childhood Immunization Status

Rationale:

Childhood Immunization Status. Infants and toddlers are particularly vulnerable to infectious diseases because their immune systems have not built up the necessary defenses to fight infection (Centers for Disease Control and Prevention 2017a). Most childhood vaccines are between 90 and 99 percent effective in preventing diseases (HealthyChildren 2015). Vaccination of each U.S. birth cohort with the current childhood immunization schedule prevents approximately 42,000 deaths and 20 million cases of disease, and saves nearly $14 billion in direct costs and $69 billion in societal costs each year (Zhou 2014). Immunizing a child not only protects that child's health but also the health of the community, especially for those who are not immunized or are unable to be immunized due to other health complications (Centers for Disease Control and Prevention 2017b). When the majority of the community is immunized against a disease, other members of the community are also protected because herd immunity shields them. (National Institute of Allergy and Infectious Diseases 2014).

Data Elements

AnaphylaxisDueToRotavirusVaccineDisorderDiagnosis

Diagnosis: Condition/Diagnosis/Problem represents a practitioner’s identification of a patient’s disease, illness, injury, or condition. This category contains a single datatype to represent all of these concepts: Diagnosis. A practitioner determines the diagnosis by means of examination, diagnostic test results, patient history, and/or family history. Diagnoses are usually considered unfavorable, but may also represent neutral or favorable conditions that affect a patient’s plan of care (e.g., pregnancy). The QDM does not prescribe the source of diagnosis data in the EHR. Diagnoses may be found in a patient’s problem list, encounter diagnosis list, claims data, or other sources within the EHR. The preferred terminology for diagnoses is SNOMED-CT, but diagnoses may also be encoded using ICD-9/10. The Diagnosis datatype should not be used for differential diagnoses or rule-out diagnoses (neither of which are currently supported by the QDM).

DataType

Cardinality

AnaphylaxisDueToRotavirusVaccineDisorderDiagnosis

0..*

NeomycinAdverseReactionDisorderDiagnosis

Diagnosis: Condition/Diagnosis/Problem represents a practitioner’s identification of a patient’s disease, illness, injury, or condition. This category contains a single datatype to represent all of these concepts: Diagnosis. A practitioner determines the diagnosis by means of examination, diagnostic test results, patient history, and/or family history. Diagnoses are usually considered unfavorable, but may also represent neutral or favorable conditions that affect a patient’s plan of care (e.g., pregnancy). The QDM does not prescribe the source of diagnosis data in the EHR. Diagnoses may be found in a patient’s problem list, encounter diagnosis list, claims data, or other sources within the EHR. The preferred terminology for diagnoses is SNOMED-CT, but diagnoses may also be encoded using ICD-9/10. The Diagnosis datatype should not be used for differential diagnoses or rule-out diagnoses (neither of which are currently supported by the QDM).

DataType

Cardinality

NeomycinAdverseReactionDisorderDiagnosis

0..*

PneumococcalVaccineAdverseReactionDisorderDiagnosis

Diagnosis: Condition/Diagnosis/Problem represents a practitioner’s identification of a patient’s disease, illness, injury, or condition. This category contains a single datatype to represent all of these concepts: Diagnosis. A practitioner determines the diagnosis by means of examination, diagnostic test results, patient history, and/or family history. Diagnoses are usually considered unfavorable, but may also represent neutral or favorable conditions that affect a patient’s plan of care (e.g., pregnancy). The QDM does not prescribe the source of diagnosis data in the EHR. Diagnoses may be found in a patient’s problem list, encounter diagnosis list, claims data, or other sources within the EHR. The preferred terminology for diagnoses is SNOMED-CT, but diagnoses may also be encoded using ICD-9/10. The Diagnosis datatype should not be used for differential diagnoses or rule-out diagnoses (neither of which are currently supported by the QDM).

DataType

Cardinality

PneumococcalVaccineAdverseReactionDisorderDiagnosis

0..*

PolymyxinBAdverseReactionDisorderDiagnosis

Diagnosis: Condition/Diagnosis/Problem represents a practitioner’s identification of a patient’s disease, illness, injury, or condition. This category contains a single datatype to represent all of these concepts: Diagnosis. A practitioner determines the diagnosis by means of examination, diagnostic test results, patient history, and/or family history. Diagnoses are usually considered unfavorable, but may also represent neutral or favorable conditions that affect a patient’s plan of care (e.g., pregnancy). The QDM does not prescribe the source of diagnosis data in the EHR. Diagnoses may be found in a patient’s problem list, encounter diagnosis list, claims data, or other sources within the EHR. The preferred terminology for diagnoses is SNOMED-CT, but diagnoses may also be encoded using ICD-9/10. The Diagnosis datatype should not be used for differential diagnoses or rule-out diagnoses (neither of which are currently supported by the QDM).

DataType

Cardinality

PolymyxinBAdverseReactionDisorderDiagnosis

0..*

AnaphylaxisDueToHepatitisBVaccineDisorderDiagnosis

Diagnosis: Condition/Diagnosis/Problem represents a practitioner’s identification of a patient’s disease, illness, injury, or condition. This category contains a single datatype to represent all of these concepts: Diagnosis. A practitioner determines the diagnosis by means of examination, diagnostic test results, patient history, and/or family history. Diagnoses are usually considered unfavorable, but may also represent neutral or favorable conditions that affect a patient’s plan of care (e.g., pregnancy). The QDM does not prescribe the source of diagnosis data in the EHR. Diagnoses may be found in a patient’s problem list, encounter diagnosis list, claims data, or other sources within the EHR. The preferred terminology for diagnoses is SNOMED-CT, but diagnoses may also be encoded using ICD-9/10. The Diagnosis datatype should not be used for differential diagnoses or rule-out diagnoses (neither of which are currently supported by the QDM).

DataType

Cardinality

AnaphylaxisDueToHepatitisBVaccineDisorderDiagnosis

0..*

InfluenzaVirusVaccineAdverseReactionDisorderDiagnosis

Diagnosis: Condition/Diagnosis/Problem represents a practitioner’s identification of a patient’s disease, illness, injury, or condition. This category contains a single datatype to represent all of these concepts: Diagnosis. A practitioner determines the diagnosis by means of examination, diagnostic test results, patient history, and/or family history. Diagnoses are usually considered unfavorable, but may also represent neutral or favorable conditions that affect a patient’s plan of care (e.g., pregnancy). The QDM does not prescribe the source of diagnosis data in the EHR. Diagnoses may be found in a patient’s problem list, encounter diagnosis list, claims data, or other sources within the EHR. The preferred terminology for diagnoses is SNOMED-CT, but diagnoses may also be encoded using ICD-9/10. The Diagnosis datatype should not be used for differential diagnoses or rule-out diagnoses (neither of which are currently supported by the QDM).

DataType

Cardinality

InfluenzaVirusVaccineAdverseReactionDisorderDiagnosis

0..*

AnaphylaxisDueToHaemophilusInfluenzaeTypeBVaccineDisorderDiagnosis

Diagnosis: Condition/Diagnosis/Problem represents a practitioner’s identification of a patient’s disease, illness, injury, or condition. This category contains a single datatype to represent all of these concepts: Diagnosis. A practitioner determines the diagnosis by means of examination, diagnostic test results, patient history, and/or family history. Diagnoses are usually considered unfavorable, but may also represent neutral or favorable conditions that affect a patient’s plan of care (e.g., pregnancy). The QDM does not prescribe the source of diagnosis data in the EHR. Diagnoses may be found in a patient’s problem list, encounter diagnosis list, claims data, or other sources within the EHR. The preferred terminology for diagnoses is SNOMED-CT, but diagnoses may also be encoded using ICD-9/10. The Diagnosis datatype should not be used for differential diagnoses or rule-out diagnoses (neither of which are currently supported by the QDM).

DataType

Cardinality

AnaphylaxisDueToHaemophilusInfluenzaeTypeBVaccineDisorderDiagnosis

0..*

PoliomyelitisVaccineAdverseReactionDisorderDiagnosis

Diagnosis: Condition/Diagnosis/Problem represents a practitioner’s identification of a patient’s disease, illness, injury, or condition. This category contains a single datatype to represent all of these concepts: Diagnosis. A practitioner determines the diagnosis by means of examination, diagnostic test results, patient history, and/or family history. Diagnoses are usually considered unfavorable, but may also represent neutral or favorable conditions that affect a patient’s plan of care (e.g., pregnancy). The QDM does not prescribe the source of diagnosis data in the EHR. Diagnoses may be found in a patient’s problem list, encounter diagnosis list, claims data, or other sources within the EHR. The preferred terminology for diagnoses is SNOMED-CT, but diagnoses may also be encoded using ICD-9/10. The Diagnosis datatype should not be used for differential diagnoses or rule-out diagnoses (neither of which are currently supported by the QDM).

DataType

Cardinality

PoliomyelitisVaccineAdverseReactionDisorderDiagnosis

0..*

StreptomycinAdverseReactionDisorderDiagnosis

Diagnosis: Condition/Diagnosis/Problem represents a practitioner’s identification of a patient’s disease, illness, injury, or condition. This category contains a single datatype to represent all of these concepts: Diagnosis. A practitioner determines the diagnosis by means of examination, diagnostic test results, patient history, and/or family history. Diagnoses are usually considered unfavorable, but may also represent neutral or favorable conditions that affect a patient’s plan of care (e.g., pregnancy). The QDM does not prescribe the source of diagnosis data in the EHR. Diagnoses may be found in a patient’s problem list, encounter diagnosis list, claims data, or other sources within the EHR. The preferred terminology for diagnoses is SNOMED-CT, but diagnoses may also be encoded using ICD-9/10. The Diagnosis datatype should not be used for differential diagnoses or rule-out diagnoses (neither of which are currently supported by the QDM).

DataType

Cardinality

StreptomycinAdverseReactionDisorderDiagnosis

0..*

MalignantNeoplasmOfLymphaticAndHematopoieticTissueDiagnosis

Clinical Focus:

Data Element Scope:

Inclusion Criteria:

Exclusion Criteria:

ResultValue constrained to codes in the Malignant Neoplasm of Lymphatic and Hematopoietic Tissue valueset (2.16.840.1.113883.3.464.1003.108.12.1009)

Diagnosis: Condition/Diagnosis/Problem represents a practitioner’s identification of a patient’s disease, illness, injury, or condition. This category contains a single datatype to represent all of these concepts: Diagnosis. A practitioner determines the diagnosis by means of examination, diagnostic test results, patient history, and/or family history. Diagnoses are usually considered unfavorable, but may also represent neutral or favorable conditions that affect a patient’s plan of care (e.g., pregnancy). The QDM does not prescribe the source of diagnosis data in the EHR. Diagnoses may be found in a patient’s problem list, encounter diagnosis list, claims data, or other sources within the EHR. The preferred terminology for diagnoses is SNOMED-CT, but diagnoses may also be encoded using ICD-9/10. The Diagnosis datatype should not be used for differential diagnoses or rule-out diagnoses (neither of which are currently supported by the QDM).

DataType

Cardinality

MalignantNeoplasmOfLymphaticAndHematopoieticTissueDiagnosis

0..*

HepatitisADiagnosis

Clinical Focus:

Data Element Scope:

Inclusion Criteria:

Exclusion Criteria:

ResultValue constrained to codes in the Hepatitis A valueset (2.16.840.1.113883.3.464.1003.110.12.1024)

Diagnosis: Condition/Diagnosis/Problem represents a practitioner’s identification of a patient’s disease, illness, injury, or condition. This category contains a single datatype to represent all of these concepts: Diagnosis. A practitioner determines the diagnosis by means of examination, diagnostic test results, patient history, and/or family history. Diagnoses are usually considered unfavorable, but may also represent neutral or favorable conditions that affect a patient’s plan of care (e.g., pregnancy). The QDM does not prescribe the source of diagnosis data in the EHR. Diagnoses may be found in a patient’s problem list, encounter diagnosis list, claims data, or other sources within the EHR. The preferred terminology for diagnoses is SNOMED-CT, but diagnoses may also be encoded using ICD-9/10. The Diagnosis datatype should not be used for differential diagnoses or rule-out diagnoses (neither of which are currently supported by the QDM).

DataType

Cardinality

HepatitisADiagnosis

0..*

HepatitisBDiagnosis

Clinical Focus:

Data Element Scope:

Inclusion Criteria:

Exclusion Criteria:

ResultValue constrained to codes in the Hepatitis B valueset (2.16.840.1.113883.3.464.1003.110.12.1025)

Diagnosis: Condition/Diagnosis/Problem represents a practitioner’s identification of a patient’s disease, illness, injury, or condition. This category contains a single datatype to represent all of these concepts: Diagnosis. A practitioner determines the diagnosis by means of examination, diagnostic test results, patient history, and/or family history. Diagnoses are usually considered unfavorable, but may also represent neutral or favorable conditions that affect a patient’s plan of care (e.g., pregnancy). The QDM does not prescribe the source of diagnosis data in the EHR. Diagnoses may be found in a patient’s problem list, encounter diagnosis list, claims data, or other sources within the EHR. The preferred terminology for diagnoses is SNOMED-CT, but diagnoses may also be encoded using ICD-9/10. The Diagnosis datatype should not be used for differential diagnoses or rule-out diagnoses (neither of which are currently supported by the QDM).

DataType

Cardinality

HepatitisBDiagnosis

0..*

MumpsDiagnosis

Clinical Focus:

Data Element Scope:

Inclusion Criteria:

Exclusion Criteria:

ResultValue constrained to codes in the Mumps valueset (2.16.840.1.113883.3.464.1003.110.12.1032)

Diagnosis: Condition/Diagnosis/Problem represents a practitioner’s identification of a patient’s disease, illness, injury, or condition. This category contains a single datatype to represent all of these concepts: Diagnosis. A practitioner determines the diagnosis by means of examination, diagnostic test results, patient history, and/or family history. Diagnoses are usually considered unfavorable, but may also represent neutral or favorable conditions that affect a patient’s plan of care (e.g., pregnancy). The QDM does not prescribe the source of diagnosis data in the EHR. Diagnoses may be found in a patient’s problem list, encounter diagnosis list, claims data, or other sources within the EHR. The preferred terminology for diagnoses is SNOMED-CT, but diagnoses may also be encoded using ICD-9/10. The Diagnosis datatype should not be used for differential diagnoses or rule-out diagnoses (neither of which are currently supported by the QDM).

DataType

Cardinality

MumpsDiagnosis

0..*

RubellaDiagnosis

Clinical Focus:

Data Element Scope:

Inclusion Criteria:

Exclusion Criteria:

ResultValue constrained to codes in the Rubella valueset (2.16.840.1.113883.3.464.1003.110.12.1037)

Diagnosis: Condition/Diagnosis/Problem represents a practitioner’s identification of a patient’s disease, illness, injury, or condition. This category contains a single datatype to represent all of these concepts: Diagnosis. A practitioner determines the diagnosis by means of examination, diagnostic test results, patient history, and/or family history. Diagnoses are usually considered unfavorable, but may also represent neutral or favorable conditions that affect a patient’s plan of care (e.g., pregnancy). The QDM does not prescribe the source of diagnosis data in the EHR. Diagnoses may be found in a patient’s problem list, encounter diagnosis list, claims data, or other sources within the EHR. The preferred terminology for diagnoses is SNOMED-CT, but diagnoses may also be encoded using ICD-9/10. The Diagnosis datatype should not be used for differential diagnoses or rule-out diagnoses (neither of which are currently supported by the QDM).

DataType

Cardinality

RubellaDiagnosis

0..*

VaricellaZosterDiagnosis

Clinical Focus:

Data Element Scope:

Inclusion Criteria:

Exclusion Criteria:

ResultValue constrained to codes in the Varicella Zoster valueset (2.16.840.1.113883.3.464.1003.110.12.1039)

Diagnosis: Condition/Diagnosis/Problem represents a practitioner’s identification of a patient’s disease, illness, injury, or condition. This category contains a single datatype to represent all of these concepts: Diagnosis. A practitioner determines the diagnosis by means of examination, diagnostic test results, patient history, and/or family history. Diagnoses are usually considered unfavorable, but may also represent neutral or favorable conditions that affect a patient’s plan of care (e.g., pregnancy). The QDM does not prescribe the source of diagnosis data in the EHR. Diagnoses may be found in a patient’s problem list, encounter diagnosis list, claims data, or other sources within the EHR. The preferred terminology for diagnoses is SNOMED-CT, but diagnoses may also be encoded using ICD-9/10. The Diagnosis datatype should not be used for differential diagnoses or rule-out diagnoses (neither of which are currently supported by the QDM).

DataType

Cardinality

VaricellaZosterDiagnosis

0..*

MeaslesDiagnosis

Clinical Focus:

Data Element Scope:

Inclusion Criteria:

Exclusion Criteria:

ResultValue constrained to codes in the Measles valueset (2.16.840.1.113883.3.464.1003.110.12.1053)

Diagnosis: Condition/Diagnosis/Problem represents a practitioner’s identification of a patient’s disease, illness, injury, or condition. This category contains a single datatype to represent all of these concepts: Diagnosis. A practitioner determines the diagnosis by means of examination, diagnostic test results, patient history, and/or family history. Diagnoses are usually considered unfavorable, but may also represent neutral or favorable conditions that affect a patient’s plan of care (e.g., pregnancy). The QDM does not prescribe the source of diagnosis data in the EHR. Diagnoses may be found in a patient’s problem list, encounter diagnosis list, claims data, or other sources within the EHR. The preferred terminology for diagnoses is SNOMED-CT, but diagnoses may also be encoded using ICD-9/10. The Diagnosis datatype should not be used for differential diagnoses or rule-out diagnoses (neither of which are currently supported by the QDM).

DataType

Cardinality

MeaslesDiagnosis

0..*

EncephalopathyDueToChildhoodVaccinationDiagnosis

Clinical Focus:

Data Element Scope:

Inclusion Criteria:

Exclusion Criteria:

ResultValue constrained to codes in the Encephalopathy due to Childhood Vaccination valueset (2.16.840.1.113883.3.464.1003.114.12.1007)

Diagnosis: Condition/Diagnosis/Problem represents a practitioner’s identification of a patient’s disease, illness, injury, or condition. This category contains a single datatype to represent all of these concepts: Diagnosis. A practitioner determines the diagnosis by means of examination, diagnostic test results, patient history, and/or family history. Diagnoses are usually considered unfavorable, but may also represent neutral or favorable conditions that affect a patient’s plan of care (e.g., pregnancy). The QDM does not prescribe the source of diagnosis data in the EHR. Diagnoses may be found in a patient’s problem list, encounter diagnosis list, claims data, or other sources within the EHR. The preferred terminology for diagnoses is SNOMED-CT, but diagnoses may also be encoded using ICD-9/10. The Diagnosis datatype should not be used for differential diagnoses or rule-out diagnoses (neither of which are currently supported by the QDM).

DataType

Cardinality

EncephalopathyDueToChildhoodVaccinationDiagnosis

0..*

DisordersOfTheImmuneSystemDiagnosis

Clinical Focus:

Data Element Scope:

Inclusion Criteria:

Exclusion Criteria:

ResultValue constrained to codes in the Disorders of the Immune System valueset (2.16.840.1.113883.3.464.1003.120.12.1001)

Diagnosis: Condition/Diagnosis/Problem represents a practitioner’s identification of a patient’s disease, illness, injury, or condition. This category contains a single datatype to represent all of these concepts: Diagnosis. A practitioner determines the diagnosis by means of examination, diagnostic test results, patient history, and/or family history. Diagnoses are usually considered unfavorable, but may also represent neutral or favorable conditions that affect a patient’s plan of care (e.g., pregnancy). The QDM does not prescribe the source of diagnosis data in the EHR. Diagnoses may be found in a patient’s problem list, encounter diagnosis list, claims data, or other sources within the EHR. The preferred terminology for diagnoses is SNOMED-CT, but diagnoses may also be encoded using ICD-9/10. The Diagnosis datatype should not be used for differential diagnoses or rule-out diagnoses (neither of which are currently supported by the QDM).

DataType

Cardinality

DisordersOfTheImmuneSystemDiagnosis

0..*

HivDiagnosis

Clinical Focus:

Data Element Scope:

Inclusion Criteria:

Exclusion Criteria:

ResultValue constrained to codes in the HIV valueset (2.16.840.1.113883.3.464.1003.120.12.1003)

Diagnosis: Condition/Diagnosis/Problem represents a practitioner’s identification of a patient’s disease, illness, injury, or condition. This category contains a single datatype to represent all of these concepts: Diagnosis. A practitioner determines the diagnosis by means of examination, diagnostic test results, patient history, and/or family history. Diagnoses are usually considered unfavorable, but may also represent neutral or favorable conditions that affect a patient’s plan of care (e.g., pregnancy). The QDM does not prescribe the source of diagnosis data in the EHR. Diagnoses may be found in a patient’s problem list, encounter diagnosis list, claims data, or other sources within the EHR. The preferred terminology for diagnoses is SNOMED-CT, but diagnoses may also be encoded using ICD-9/10. The Diagnosis datatype should not be used for differential diagnoses or rule-out diagnoses (neither of which are currently supported by the QDM).

DataType

Cardinality

HivDiagnosis

0..*

AnaphylacticReactionToHepatitisAVaccineDiagnosis

Clinical Focus:

Data Element Scope:

Inclusion Criteria:

Exclusion Criteria:

ResultValue constrained to codes in the Anaphylactic Reaction to Hepatitis A Vaccine valueset (2.16.840.1.113883.3.464.1003.199.12.1026)

Diagnosis: Condition/Diagnosis/Problem represents a practitioner’s identification of a patient’s disease, illness, injury, or condition. This category contains a single datatype to represent all of these concepts: Diagnosis. A practitioner determines the diagnosis by means of examination, diagnostic test results, patient history, and/or family history. Diagnoses are usually considered unfavorable, but may also represent neutral or favorable conditions that affect a patient’s plan of care (e.g., pregnancy). The QDM does not prescribe the source of diagnosis data in the EHR. Diagnoses may be found in a patient’s problem list, encounter diagnosis list, claims data, or other sources within the EHR. The preferred terminology for diagnoses is SNOMED-CT, but diagnoses may also be encoded using ICD-9/10. The Diagnosis datatype should not be used for differential diagnoses or rule-out diagnoses (neither of which are currently supported by the QDM).

DataType

Cardinality

AnaphylacticReactionToHepatitisAVaccineDiagnosis

0..*

AnaphylacticReactionToDTaPVaccineDiagnosis

Clinical Focus:

Data Element Scope:

Inclusion Criteria:

Exclusion Criteria:

ResultValue constrained to codes in the Anaphylactic Reaction to DTaP Vaccine valueset (2.16.840.1.113883.3.464.1003.199.12.1031)

Diagnosis: Condition/Diagnosis/Problem represents a practitioner’s identification of a patient’s disease, illness, injury, or condition. This category contains a single datatype to represent all of these concepts: Diagnosis. A practitioner determines the diagnosis by means of examination, diagnostic test results, patient history, and/or family history. Diagnoses are usually considered unfavorable, but may also represent neutral or favorable conditions that affect a patient’s plan of care (e.g., pregnancy). The QDM does not prescribe the source of diagnosis data in the EHR. Diagnoses may be found in a patient’s problem list, encounter diagnosis list, claims data, or other sources within the EHR. The preferred terminology for diagnoses is SNOMED-CT, but diagnoses may also be encoded using ICD-9/10. The Diagnosis datatype should not be used for differential diagnoses or rule-out diagnoses (neither of which are currently supported by the QDM).

DataType

Cardinality

AnaphylacticReactionToDTaPVaccineDiagnosis

0..*

AnaphylacticReactionToCommonBakersYeastDiagnosis

Clinical Focus:

Data Element Scope:

Inclusion Criteria:

Exclusion Criteria:

ResultValue constrained to codes in the Anaphylactic Reaction to Common Baker's Yeast valueset (2.16.840.1.113883.3.464.1003.199.12.1032)

Diagnosis: Condition/Diagnosis/Problem represents a practitioner’s identification of a patient’s disease, illness, injury, or condition. This category contains a single datatype to represent all of these concepts: Diagnosis. A practitioner determines the diagnosis by means of examination, diagnostic test results, patient history, and/or family history. Diagnoses are usually considered unfavorable, but may also represent neutral or favorable conditions that affect a patient’s plan of care (e.g., pregnancy). The QDM does not prescribe the source of diagnosis data in the EHR. Diagnoses may be found in a patient’s problem list, encounter diagnosis list, claims data, or other sources within the EHR. The preferred terminology for diagnoses is SNOMED-CT, but diagnoses may also be encoded using ICD-9/10. The Diagnosis datatype should not be used for differential diagnoses or rule-out diagnoses (neither of which are currently supported by the QDM).

DataType

Cardinality

AnaphylacticReactionToCommonBakersYeastDiagnosis

0..*

SevereCombinedImmunodeficiencyDiagnosis

Clinical Focus:

Data Element Scope:

Inclusion Criteria:

Exclusion Criteria:

ResultValue constrained to codes in the Severe Combined Immunodeficiency valueset (2.16.840.1.113883.3.464.1003.120.12.1007)

Diagnosis: Condition/Diagnosis/Problem represents a practitioner’s identification of a patient’s disease, illness, injury, or condition. This category contains a single datatype to represent all of these concepts: Diagnosis. A practitioner determines the diagnosis by means of examination, diagnostic test results, patient history, and/or family history. Diagnoses are usually considered unfavorable, but may also represent neutral or favorable conditions that affect a patient’s plan of care (e.g., pregnancy). The QDM does not prescribe the source of diagnosis data in the EHR. Diagnoses may be found in a patient’s problem list, encounter diagnosis list, claims data, or other sources within the EHR. The preferred terminology for diagnoses is SNOMED-CT, but diagnoses may also be encoded using ICD-9/10. The Diagnosis datatype should not be used for differential diagnoses or rule-out diagnoses (neither of which are currently supported by the QDM).

DataType

Cardinality

SevereCombinedImmunodeficiencyDiagnosis

0..*

IntussusceptionDiagnosis

Clinical Focus:

Data Element Scope:

Inclusion Criteria:

Exclusion Criteria:

ResultValue constrained to codes in the Intussusception valueset (2.16.840.1.113883.3.464.1003.199.12.1056)

Diagnosis: Condition/Diagnosis/Problem represents a practitioner’s identification of a patient’s disease, illness, injury, or condition. This category contains a single datatype to represent all of these concepts: Diagnosis. A practitioner determines the diagnosis by means of examination, diagnostic test results, patient history, and/or family history. Diagnoses are usually considered unfavorable, but may also represent neutral or favorable conditions that affect a patient’s plan of care (e.g., pregnancy). The QDM does not prescribe the source of diagnosis data in the EHR. Diagnoses may be found in a patient’s problem list, encounter diagnosis list, claims data, or other sources within the EHR. The preferred terminology for diagnoses is SNOMED-CT, but diagnoses may also be encoded using ICD-9/10. The Diagnosis datatype should not be used for differential diagnoses or rule-out diagnoses (neither of which are currently supported by the QDM).

DataType

Cardinality

IntussusceptionDiagnosis

0..*

EncounterInpatientPerformed

Clinical Focus: This set of values identify the most common inpatient encounter types.

Data Element Scope: The intent of this data element is to identify patients who have had an inpatient encounter. Using the Quality Data Model, this particular element will map to the 'encounter' category.

Inclusion Criteria: Only SNOMED CT codes representing inpatient encounter should be included.

Exclusion Criteria: None.

Subject constrained to the Encounter Inpatient

EncounterPerformed: Data elements that meet criteria using this datatype should document that the encounter indicated by the QDM category and its corresponding value set is in progress or has been completed. Timing: The Relevant Period addresses: startTime – The time the encounter began (admission time) stopTime – The time the encounter ended (discharge time). The Author dateTime addresses when an Encounter is documented. Documentation can occur at the beginning, during, at the end or subsequent to the end of an Encounter. The Author dateTime should be used only if the Relevant Period cannot be obtained. The Location Period is an attribute of the attribute facility location addresses: startTime = the time the patient arrived at the location; stopTime = the time the patient departed from the location

DataType

Cardinality

EncounterInpatientPerformed

0..*

OfficeVisit1Performed

Clinical Focus: This value set identifies patients who have had an office or other outpatient visit.

Data Element Scope: This value set was intended to map to the QDM data type of encounter.

Inclusion Criteria: Includes comprehensive history, evaluation, and management of a patient in an office or outpatient facility. Patient can be presenting with problems that are minor to high severity.

Exclusion Criteria: Excludes non-office visits, including telehealth services.

Subject constrained to the Office Visit1

EncounterPerformed: Data elements that meet criteria using this datatype should document that the encounter indicated by the QDM category and its corresponding value set is in progress or has been completed. Timing: The Relevant Period addresses: startTime – The time the encounter began (admission time) stopTime – The time the encounter ended (discharge time). The Author dateTime addresses when an Encounter is documented. Documentation can occur at the beginning, during, at the end or subsequent to the end of an Encounter. The Author dateTime should be used only if the Relevant Period cannot be obtained. The Location Period is an attribute of the attribute facility location addresses: startTime = the time the patient arrived at the location; stopTime = the time the patient departed from the location

DataType

Cardinality

OfficeVisit1Performed

0..*

HomeHealthcareServicesPerformed

Clinical Focus: This value set identifies patients who have had a home health visit by a provider for the evaluation or management of a new or existing patient.

Data Element Scope: This value set was intended to map to the QDM data type of encounter.

Inclusion Criteria: Include all home visits for the evaluation and management of a new or established patient.

Exclusion Criteria: None

Subject constrained to the Home Healthcare Services

EncounterPerformed: Data elements that meet criteria using this datatype should document that the encounter indicated by the QDM category and its corresponding value set is in progress or has been completed. Timing: The Relevant Period addresses: startTime – The time the encounter began (admission time) stopTime – The time the encounter ended (discharge time). The Author dateTime addresses when an Encounter is documented. Documentation can occur at the beginning, during, at the end or subsequent to the end of an Encounter. The Author dateTime should be used only if the Relevant Period cannot be obtained. The Location Period is an attribute of the attribute facility location addresses: startTime = the time the patient arrived at the location; stopTime = the time the patient departed from the location

DataType

Cardinality

HomeHealthcareServicesPerformed

0..*

PreventiveCareServicesInitialOfficeVisit0To17Performed

Clinical Focus: Initial comprehensive preventive medical evaluation, including regular preventive care or care of small problem or preexisting condition that requires no extra work, for a patient that has no prior outpatient professional services from the physician practice in the last 3 years.

Data Element Scope: This value set was intended to map to the QDM data type of encounter.

Inclusion Criteria: Include only codes that indicate initial comprehensive preventive medical evaluation, including regular preventive care or care of small problem or preexisting condition that requires no extra work, for a patient that has no prior outpatient professional services from the physician practice in the last 3 years.

Exclusion Criteria: Exclude codes that are not for comprehensive preventive medical evaluations and codes that are for patients who have been seen in the last 3 years.

Subject constrained to the Preventive Care Services, Initial Office Visit, 0 to 17

EncounterPerformed: Data elements that meet criteria using this datatype should document that the encounter indicated by the QDM category and its corresponding value set is in progress or has been completed. Timing: The Relevant Period addresses: startTime – The time the encounter began (admission time) stopTime – The time the encounter ended (discharge time). The Author dateTime addresses when an Encounter is documented. Documentation can occur at the beginning, during, at the end or subsequent to the end of an Encounter. The Author dateTime should be used only if the Relevant Period cannot be obtained. The Location Period is an attribute of the attribute facility location addresses: startTime = the time the patient arrived at the location; stopTime = the time the patient departed from the location

DataType

Cardinality

PreventiveCareServicesInitialOfficeVisit0To17Performed

0..*

PreventiveCareEstablishedOfficeVisit0To17Performed

Clinical Focus: Initial comprehensive preventive medical evaluation, including regular preventive care or care of small problem or preexisting condition that requires no extra work, for a patient that received prior outpatient professional services from the physician practice in the last 3 years.

Data Element Scope: This value set was intended to map to the QDM data type of encounter.

Inclusion Criteria: Include only codes that indicate initial comprehensive preventive medical evaluation, including regular preventive care or care of small problem or preexisting condition that requires no extra work, for a patient that received prior outpatient professional services from the physician practice in the last 3 years.

Exclusion Criteria: Exclude codes that are not for comprehensive preventive medical evaluations and codes that are for patients who have not been seen in the last 3 years.

Subject constrained to the Preventive Care, Established Office Visit, 0 to 17

EncounterPerformed: Data elements that meet criteria using this datatype should document that the encounter indicated by the QDM category and its corresponding value set is in progress or has been completed. Timing: The Relevant Period addresses: startTime – The time the encounter began (admission time) stopTime – The time the encounter ended (discharge time). The Author dateTime addresses when an Encounter is documented. Documentation can occur at the beginning, during, at the end or subsequent to the end of an Encounter. The Author dateTime should be used only if the Relevant Period cannot be obtained. The Location Period is an attribute of the attribute facility location addresses: startTime = the time the patient arrived at the location; stopTime = the time the patient departed from the location

DataType

Cardinality

PreventiveCareEstablishedOfficeVisit0To17Performed

0..*

RotavirusLiveMonovalentVaccineAdministered

ImmunizationAdministered: Data elements that meet criteria using this datatype should document that the vaccine indicated by the QDM category and its corresponding value set was actually administered to the patient. Timing: The time the immunization is administered, i.e., a single point in time, or Author dateTime.

DataType

Cardinality

RotavirusLiveMonovalentVaccineAdministered

0..*

VaricellaZosterVaccineVzvAdministered

Clinical Focus:

Data Element Scope:

Inclusion Criteria:

Exclusion Criteria:

ObservableCode constrained to codes in the Varicella Zoster Vaccine (VZV) Administered valueset (2.16.840.1.113883.3.464.1003.110.12.1040).

Procedure: Procedure is derived directly from HL7 and Canada Health Infoway: “An Act whose immediate and primary outcome (post-condition) is the alteration of the physical condition of the subject. ... Procedure is but one among several types of clinical activities such as observation, substance- administrations, and communicative interactions ... Procedure does not comprise all acts of [sic] whose intent is intervention or treatment.”17 A procedure may be a surgery or other type of physical manipulation of a person’s body in whole or in part for purposes of making observations and diagnoses or providing treatment

DataType

Cardinality

VaricellaZosterVaccineVzvAdministered

0..*

DTaPVaccineAdministered

Clinical Focus:

Data Element Scope:

Inclusion Criteria:

Exclusion Criteria:

ObservableCode constrained to codes in the DTaP Vaccine Administered valueset (2.16.840.1.113883.3.464.1003.110.12.1022).

Procedure: Procedure is derived directly from HL7 and Canada Health Infoway: “An Act whose immediate and primary outcome (post-condition) is the alteration of the physical condition of the subject. ... Procedure is but one among several types of clinical activities such as observation, substance- administrations, and communicative interactions ... Procedure does not comprise all acts of [sic] whose intent is intervention or treatment.”17 A procedure may be a surgery or other type of physical manipulation of a person’s body in whole or in part for purposes of making observations and diagnoses or providing treatment

DataType

Cardinality

DTaPVaccineAdministered

0..*

HepatitisAVaccineAdministered

Clinical Focus:

Data Element Scope:

Inclusion Criteria:

Exclusion Criteria:

ObservableCode constrained to codes in the Hepatitis A Vaccine Administered valueset (2.16.840.1.113883.3.464.1003.110.12.1041).

Procedure: Procedure is derived directly from HL7 and Canada Health Infoway: “An Act whose immediate and primary outcome (post-condition) is the alteration of the physical condition of the subject. ... Procedure is but one among several types of clinical activities such as observation, substance- administrations, and communicative interactions ... Procedure does not comprise all acts of [sic] whose intent is intervention or treatment.”17 A procedure may be a surgery or other type of physical manipulation of a person’s body in whole or in part for purposes of making observations and diagnoses or providing treatment

DataType

Cardinality

HepatitisAVaccineAdministered

0..*

HepatitisBVaccineAdministered

Clinical Focus:

Data Element Scope:

Inclusion Criteria:

Exclusion Criteria:

ObservableCode constrained to codes in the Hepatitis B Vaccine Administered valueset (2.16.840.1.113883.3.464.1003.110.12.1042).

Procedure: Procedure is derived directly from HL7 and Canada Health Infoway: “An Act whose immediate and primary outcome (post-condition) is the alteration of the physical condition of the subject. ... Procedure is but one among several types of clinical activities such as observation, substance- administrations, and communicative interactions ... Procedure does not comprise all acts of [sic] whose intent is intervention or treatment.”17 A procedure may be a surgery or other type of physical manipulation of a person’s body in whole or in part for purposes of making observations and diagnoses or providing treatment

DataType

Cardinality

HepatitisBVaccineAdministered

0..*

HaemophilusInfluenzaeTypeBHiBVaccineAdministered

Clinical Focus:

Data Element Scope:

Inclusion Criteria:

Exclusion Criteria:

ObservableCode constrained to codes in the Haemophilus Influenzae Type B (HiB) Vaccine Administered valueset (2.16.840.1.113883.3.464.1003.110.12.1043).

Procedure: Procedure is derived directly from HL7 and Canada Health Infoway: “An Act whose immediate and primary outcome (post-condition) is the alteration of the physical condition of the subject. ... Procedure is but one among several types of clinical activities such as observation, substance- administrations, and communicative interactions ... Procedure does not comprise all acts of [sic] whose intent is intervention or treatment.”17 A procedure may be a surgery or other type of physical manipulation of a person’s body in whole or in part for purposes of making observations and diagnoses or providing treatment

DataType

Cardinality

HaemophilusInfluenzaeTypeBHiBVaccineAdministered

0..*

InfluenzaVaccine1Administered

Clinical Focus:

Data Element Scope:

Inclusion Criteria:

Exclusion Criteria:

Subject constrained to the Influenza Vaccine1

ImmunizationAdministered: Data elements that meet criteria using this datatype should document that the vaccine indicated by the QDM category and its corresponding value set was actually administered to the patient. Timing: The time the immunization is administered, i.e., a single point in time, or Author dateTime.

DataType

Cardinality

InfluenzaVaccine1Administered

0..*

InactivatedPolioVaccineIpvAdministered

Clinical Focus:

Data Element Scope:

Inclusion Criteria:

Exclusion Criteria:

ObservableCode constrained to codes in the Inactivated Polio Vaccine (IPV) Administered valueset (2.16.840.1.113883.3.464.1003.110.12.1045).

Procedure: Procedure is derived directly from HL7 and Canada Health Infoway: “An Act whose immediate and primary outcome (post-condition) is the alteration of the physical condition of the subject. ... Procedure is but one among several types of clinical activities such as observation, substance- administrations, and communicative interactions ... Procedure does not comprise all acts of [sic] whose intent is intervention or treatment.”17 A procedure may be a surgery or other type of physical manipulation of a person’s body in whole or in part for purposes of making observations and diagnoses or providing treatment

DataType

Cardinality

InactivatedPolioVaccineIpvAdministered

0..*

PneumococcalConjugateVaccineAdministered

Clinical Focus:

Data Element Scope:

Inclusion Criteria:

Exclusion Criteria:

ObservableCode constrained to codes in the Pneumococcal Conjugate Vaccine Administered valueset (2.16.840.1.113883.3.464.1003.110.12.1046).

Procedure: Procedure is derived directly from HL7 and Canada Health Infoway: “An Act whose immediate and primary outcome (post-condition) is the alteration of the physical condition of the subject. ... Procedure is but one among several types of clinical activities such as observation, substance- administrations, and communicative interactions ... Procedure does not comprise all acts of [sic] whose intent is intervention or treatment.”17 A procedure may be a surgery or other type of physical manipulation of a person’s body in whole or in part for purposes of making observations and diagnoses or providing treatment

DataType

Cardinality

PneumococcalConjugateVaccineAdministered

0..*

RotavirusVaccine3DoseScheduleAdministered

Clinical Focus:

Data Element Scope:

Inclusion Criteria:

Exclusion Criteria:

Subject constrained to the Rotavirus Vaccine (3 dose schedule)

ImmunizationAdministered: Data elements that meet criteria using this datatype should document that the vaccine indicated by the QDM category and its corresponding value set was actually administered to the patient. Timing: The time the immunization is administered, i.e., a single point in time, or Author dateTime.

DataType

Cardinality

RotavirusVaccine3DoseScheduleAdministered

0..*

MeaslesMumpsAndRubellaMmrVaccineAdministered

Clinical Focus:

Data Element Scope:

Inclusion Criteria:

Exclusion Criteria:

ObservableCode constrained to codes in the Measles, Mumps and Rubella (MMR) Vaccine Administered valueset (2.16.840.1.113883.3.464.1003.110.12.1031).

Procedure: Procedure is derived directly from HL7 and Canada Health Infoway: “An Act whose immediate and primary outcome (post-condition) is the alteration of the physical condition of the subject. ... Procedure is but one among several types of clinical activities such as observation, substance- administrations, and communicative interactions ... Procedure does not comprise all acts of [sic] whose intent is intervention or treatment.”17 A procedure may be a surgery or other type of physical manipulation of a person’s body in whole or in part for purposes of making observations and diagnoses or providing treatment

DataType

Cardinality

MeaslesMumpsAndRubellaMmrVaccineAdministered

0..*

HospiceCareAmbulatoryOrder

Clinical Focus: Patients receiving hospice care outside of hospital or long term care facility.

Data Element Scope: The intent of this value set is to identify all patients receiving hospice care outside of hospital or long term care facility . Using the quality data model this maps to 'Intervention, Order' and 'Procedure, Order'.

Inclusion Criteria: All hospice care concepts should be included.

Exclusion Criteria: Do not include concepts for palliative care or comfort measures.

Subject constrained to the Hospice care ambulatory

InterventionOrder: Data elements that meet criteria using this datatype should document a request to perform the intervention indicated by the QDM category and its corresponding value set. Timing: The time the order is signed; Author dateTime

DataType

Cardinality

HospiceCareAmbulatoryOrder

0..*

HospiceCareAmbulatoryPerformed

Clinical Focus: Patients receiving hospice care outside of hospital or long term care facility.

Data Element Scope: The intent of this value set is to identify all patients receiving hospice care outside of hospital or long term care facility . Using the quality data model this maps to 'Intervention, Order' and 'Procedure, Order'.

Inclusion Criteria: All hospice care concepts should be included.

Exclusion Criteria: Do not include concepts for palliative care or comfort measures.

Subject constrained to the Hospice care ambulatory

InterventionPerformed: Data elements that meet criteria using this datatype should document the completion of the intervention indicated by the QDM category and its corresponding value set. Timing: The Relevant Period addresses: startTime – The time the intervention begins stopTime – The time the intervention ends NOTE - timing refers to a single instance of an intervention. If a measure seeks to evaluate multiple interventions over a period of time, the measure developer should use CQL logic to represent the query request.

DataType

Cardinality

HospiceCareAmbulatoryPerformed

0..*

AntiHepatitisAIgGAntigenTestPerformed

Clinical Focus:

Data Element Scope:

Inclusion Criteria:

Exclusion Criteria:

Subject constrained to the Anti Hepatitis A IgG Antigen Test

LaboratoryTestPerformed: Data elements that meet criteria using this datatype should document the laboratory test indicated by the QDM category and its corresponding value set was performed. Timing: The Relevant Period addresses: startTime – When the laboratory test is initiated (i.e., the time the specimen collection begins). stopTime – when the laboratory test is completed (i.e., the time the specimen collection ends). Examples: 1) Initiation of a venipuncture for a fasting blood glucose to the time venipuncture for the fasting blood glucose is completed – basically a single point in time for many specimen collections. 2) Initiation of a 24-hour urine collection for measured creatinine clearance until completion of the 24-hour urine collection Note – the time that the result report is available is a separate attribute than the time of the study (specimen collection)

DataType

Cardinality

AntiHepatitisAIgGAntigenTestPerformed

0..*

VaricellaZosterAntibodyTestIgGAntibodyTiterPerformed

Clinical Focus:

Data Element Scope:

Inclusion Criteria:

Exclusion Criteria:

Subject constrained to the Varicella Zoster Antibody Test (IgG Antibody Titer)

LaboratoryTestPerformed: Data elements that meet criteria using this datatype should document the laboratory test indicated by the QDM category and its corresponding value set was performed. Timing: The Relevant Period addresses: startTime – When the laboratory test is initiated (i.e., the time the specimen collection begins). stopTime – when the laboratory test is completed (i.e., the time the specimen collection ends). Examples: 1) Initiation of a venipuncture for a fasting blood glucose to the time venipuncture for the fasting blood glucose is completed – basically a single point in time for many specimen collections. 2) Initiation of a 24-hour urine collection for measured creatinine clearance until completion of the 24-hour urine collection Note – the time that the result report is available is a separate attribute than the time of the study (specimen collection)

DataType

Cardinality

VaricellaZosterAntibodyTestIgGAntibodyTiterPerformed

0..*

VaricellaZosterAntibodyTestIgGAntibodyPresencePerformed

Clinical Focus:

Data Element Scope:

Inclusion Criteria:

Exclusion Criteria:

Subject constrained to the Varicella Zoster Antibody Test (IgG Antibody Presence)

LaboratoryTestPerformed: Data elements that meet criteria using this datatype should document the laboratory test indicated by the QDM category and its corresponding value set was performed. Timing: The Relevant Period addresses: startTime – When the laboratory test is initiated (i.e., the time the specimen collection begins). stopTime – when the laboratory test is completed (i.e., the time the specimen collection ends). Examples: 1) Initiation of a venipuncture for a fasting blood glucose to the time venipuncture for the fasting blood glucose is completed – basically a single point in time for many specimen collections. 2) Initiation of a 24-hour urine collection for measured creatinine clearance until completion of the 24-hour urine collection Note – the time that the result report is available is a separate attribute than the time of the study (specimen collection)

DataType

Cardinality

VaricellaZosterAntibodyTestIgGAntibodyPresencePerformed

0..*

AntiHepatitisBVirusSurfaceAbPerformed

Clinical Focus:

Data Element Scope:

Inclusion Criteria:

Exclusion Criteria:

Subject constrained to the Anti Hepatitis B Virus Surface Ab

LaboratoryTestPerformed: Data elements that meet criteria using this datatype should document the laboratory test indicated by the QDM category and its corresponding value set was performed. Timing: The Relevant Period addresses: startTime – When the laboratory test is initiated (i.e., the time the specimen collection begins). stopTime – when the laboratory test is completed (i.e., the time the specimen collection ends). Examples: 1) Initiation of a venipuncture for a fasting blood glucose to the time venipuncture for the fasting blood glucose is completed – basically a single point in time for many specimen collections. 2) Initiation of a 24-hour urine collection for measured creatinine clearance until completion of the 24-hour urine collection Note – the time that the result report is available is a separate attribute than the time of the study (specimen collection)

DataType

Cardinality

AntiHepatitisBVirusSurfaceAbPerformed

0..*

PositiveFindingResult

Clinical Focus:

Data Element Scope:

Inclusion Criteria:

Exclusion Criteria:

Result: The final consequences or data collected from the datatype. Results can be used in five ways, to express: That a result is present in the electronic record but any entry is acceptable. A numerical result is reported directly as a value. Values may be integers or decimal numbers without units, or as a quantity with a value and units – examples: 100 mg/dL for a lab test, 140 mmHg for blood pressure, as a percentage (actually a quantity with % as units), as a ratio (e.g., 1:4, 1:80). Beginning with QDM 5.3 measures use CQL logic to express the mathematical operators to constrain desired results to those above or below a certain threshold. A result that matches one of a specific set of coded concepts in a value set or a code that matches a direct referenced code. A result as a dateTime (Assessment, Performed and components).

DataType

Cardinality

PositiveFindingResult

0..*

MeaslesAntibodyTestIgGAntibodyPresencePerformed

Clinical Focus:

Data Element Scope:

Inclusion Criteria:

Exclusion Criteria:

Subject constrained to the Measles Antibody Test (IgG Antibody presence)

LaboratoryTestPerformed: Data elements that meet criteria using this datatype should document the laboratory test indicated by the QDM category and its corresponding value set was performed. Timing: The Relevant Period addresses: startTime – When the laboratory test is initiated (i.e., the time the specimen collection begins). stopTime – when the laboratory test is completed (i.e., the time the specimen collection ends). Examples: 1) Initiation of a venipuncture for a fasting blood glucose to the time venipuncture for the fasting blood glucose is completed – basically a single point in time for many specimen collections. 2) Initiation of a 24-hour urine collection for measured creatinine clearance until completion of the 24-hour urine collection Note – the time that the result report is available is a separate attribute than the time of the study (specimen collection)

DataType

Cardinality

MeaslesAntibodyTestIgGAntibodyPresencePerformed

0..*

MumpsAntibodyTestIgGAntibodyPresencePerformed

Clinical Focus:

Data Element Scope:

Inclusion Criteria:

Exclusion Criteria:

Subject constrained to the Mumps Antibody Test (IgG Antibody presence)

LaboratoryTestPerformed: Data elements that meet criteria using this datatype should document the laboratory test indicated by the QDM category and its corresponding value set was performed. Timing: The Relevant Period addresses: startTime – When the laboratory test is initiated (i.e., the time the specimen collection begins). stopTime – when the laboratory test is completed (i.e., the time the specimen collection ends). Examples: 1) Initiation of a venipuncture for a fasting blood glucose to the time venipuncture for the fasting blood glucose is completed – basically a single point in time for many specimen collections. 2) Initiation of a 24-hour urine collection for measured creatinine clearance until completion of the 24-hour urine collection Note – the time that the result report is available is a separate attribute than the time of the study (specimen collection)

DataType

Cardinality

MumpsAntibodyTestIgGAntibodyPresencePerformed

0..*

RubellaAntibodyTestIgGAntibodyPresencePerformed

Clinical Focus:

Data Element Scope:

Inclusion Criteria:

Exclusion Criteria:

Subject constrained to the Rubella Antibody Test (IgG Antibody presence)

LaboratoryTestPerformed: Data elements that meet criteria using this datatype should document the laboratory test indicated by the QDM category and its corresponding value set was performed. Timing: The Relevant Period addresses: startTime – When the laboratory test is initiated (i.e., the time the specimen collection begins). stopTime – when the laboratory test is completed (i.e., the time the specimen collection ends). Examples: 1) Initiation of a venipuncture for a fasting blood glucose to the time venipuncture for the fasting blood glucose is completed – basically a single point in time for many specimen collections. 2) Initiation of a 24-hour urine collection for measured creatinine clearance until completion of the 24-hour urine collection Note – the time that the result report is available is a separate attribute than the time of the study (specimen collection)

DataType

Cardinality

RubellaAntibodyTestIgGAntibodyPresencePerformed

0..*

MeaslesAntibodyTestIgGAntibodyTiterPerformed

Clinical Focus:

Data Element Scope:

Inclusion Criteria:

Exclusion Criteria:

Subject constrained to the Measles Antibody Test (IgG Antibody Titer)

LaboratoryTestPerformed: Data elements that meet criteria using this datatype should document the laboratory test indicated by the QDM category and its corresponding value set was performed. Timing: The Relevant Period addresses: startTime – When the laboratory test is initiated (i.e., the time the specimen collection begins). stopTime – when the laboratory test is completed (i.e., the time the specimen collection ends). Examples: 1) Initiation of a venipuncture for a fasting blood glucose to the time venipuncture for the fasting blood glucose is completed – basically a single point in time for many specimen collections. 2) Initiation of a 24-hour urine collection for measured creatinine clearance until completion of the 24-hour urine collection Note – the time that the result report is available is a separate attribute than the time of the study (specimen collection)

DataType

Cardinality

MeaslesAntibodyTestIgGAntibodyTiterPerformed

0..*

MumpsAntibodyTestIgGAntibodyTiterPerformed

Clinical Focus:

Data Element Scope:

Inclusion Criteria:

Exclusion Criteria:

Subject constrained to the Mumps Antibody Test (IgG Antibody Titer)

LaboratoryTestPerformed: Data elements that meet criteria using this datatype should document the laboratory test indicated by the QDM category and its corresponding value set was performed. Timing: The Relevant Period addresses: startTime – When the laboratory test is initiated (i.e., the time the specimen collection begins). stopTime – when the laboratory test is completed (i.e., the time the specimen collection ends). Examples: 1) Initiation of a venipuncture for a fasting blood glucose to the time venipuncture for the fasting blood glucose is completed – basically a single point in time for many specimen collections. 2) Initiation of a 24-hour urine collection for measured creatinine clearance until completion of the 24-hour urine collection Note – the time that the result report is available is a separate attribute than the time of the study (specimen collection)

DataType

Cardinality

MumpsAntibodyTestIgGAntibodyTiterPerformed

0..*

RubellaAntibodyTestIgGAntibodyTiterPerformed

Clinical Focus:

Data Element Scope:

Inclusion Criteria:

Exclusion Criteria:

Subject constrained to the Rubella Antibody Test (IgG Antibody Titer)

LaboratoryTestPerformed: Data elements that meet criteria using this datatype should document the laboratory test indicated by the QDM category and its corresponding value set was performed. Timing: The Relevant Period addresses: startTime – When the laboratory test is initiated (i.e., the time the specimen collection begins). stopTime – when the laboratory test is completed (i.e., the time the specimen collection ends). Examples: 1) Initiation of a venipuncture for a fasting blood glucose to the time venipuncture for the fasting blood glucose is completed – basically a single point in time for many specimen collections. 2) Initiation of a 24-hour urine collection for measured creatinine clearance until completion of the 24-hour urine collection Note – the time that the result report is available is a separate attribute than the time of the study (specimen collection)

DataType

Cardinality

RubellaAntibodyTestIgGAntibodyTiterPerformed

0..*

EthnicityPatientCharacteristicEthnicity

Clinical Focus:

Data Element Scope:

Inclusion Criteria:

Exclusion Criteria:

ResultValue constrained to codes in the Ethnicity valueset (2.16.840.1.114222.4.11.837)

PatientCharacteristicEthnicity: Data elements that meet criteria using this datatype should document that the patient has one or more of the ethnicities indicated by the QDM category and its corresponding value set. Timing: Ethnicity does not have a specific timing. Measures using Patient Characteristic, Ethnicity should address the most recent entry in the clinical record.

DataType

Cardinality

EthnicityPatientCharacteristicEthnicity

0..*

OncAdministrativeSexPatientCharacteristicGender

Clinical Focus: Gender identity restricted to only Male and Female used in administrative situations requiring a restriction to these two categories.

Data Element Scope: Gender

Inclusion Criteria: Male and Female only.

Exclusion Criteria: Any gender identity that is not male or female.

ResultValue constrained to codes in the ONC Administrative Sex valueset (2.16.840.1.113762.1.4.1)

PatientCharacteristicGender: Data elements that meet criteria using this datatype should document that the patient's sex matches the QDM category and its corresponding value set. Timing: Birth (administrative) sex does not have a specific timing.

DataType

Cardinality

OncAdministrativeSexPatientCharacteristicGender

0..*

PayerPatientCharacteristicPayer

Clinical Focus: Categories of types of health care payor entities as defined by the US Public Health Data Consortium SOP code system

Data Element Scope: @code in CCDA r2.1 template Planned Coverage [act: identifier urn:oid:2.16.840.1.113883.10.20.22.4.129 (open)] DYNAMIC

Inclusion Criteria: All codes in the code system

Exclusion Criteria: none

ResultValue constrained to codes in the Payer valueset (2.16.840.1.114222.4.11.3591)

PatientCharacteristicPayer: Data elements that meet criteria using this datatype should document that the patient has one or more of the payers indicated by the QDM category and its corresponding value set. Timing: The Relevant Period addresses: startTime – The first day of insurance coverage with the referenced payer stopTime – The last day of insurance coverage with the referenced payer

DataType

Cardinality

PayerPatientCharacteristicPayer

0..*

RacePatientCharacteristicRace

Clinical Focus:

Data Element Scope:

Inclusion Criteria:

Exclusion Criteria:

ResultValue constrained to codes in the Race valueset (2.16.840.1.114222.4.11.836)

PatientCharacteristicRace: Data elements that meet criteria using this datatype should document the patient’s race. Timing: Race does not have a specific timing. Measures using Patient Characteristic, Race should address the most recent entry in the clinical record.

DataType

Cardinality

RacePatientCharacteristicRace

0..*

RotavirusVaccinePentavalentRv53DoseScheduleLiveForOralUsePerformed

ProcedurePerformed: Data elements that meet criteria using this datatype should document the completion of the procedure indicated by the QDM category and its corresponding value set. Timing: The Relevant Period addresses: StartTime = the time the procedure begins; StopTime = the time the procedure is completed NOTE: 1) Timing refers to a single instance of a procedure. If a measure seeks to evaluate multiple procedures over a period of time, the measure developer should use CQL logic to represent the query request. 2) The Incision dateTime is a single point in time available from the Operating Room and/or Anesthesia Record.

DataType

Cardinality

RotavirusVaccinePentavalentRv53DoseScheduleLiveForOralUsePerformed

0..*

RotavirusVaccineHumanAttenuatedRv12DoseScheduleLiveForOralUsePerformed

ProcedurePerformed: Data elements that meet criteria using this datatype should document the completion of the procedure indicated by the QDM category and its corresponding value set. Timing: The Relevant Period addresses: StartTime = the time the procedure begins; StopTime = the time the procedure is completed NOTE: 1) Timing refers to a single instance of a procedure. If a measure seeks to evaluate multiple procedures over a period of time, the measure developer should use CQL logic to represent the query request. 2) The Incision dateTime is a single point in time available from the Operating Room and/or Anesthesia Record.

DataType

Cardinality

RotavirusVaccineHumanAttenuatedRv12DoseScheduleLiveForOralUsePerformed

0..*

DTaPVaccineAdministeredPerformed

Clinical Focus:

Data Element Scope:

Inclusion Criteria:

Exclusion Criteria:

Subject constrained to the DTaP Vaccine Administered

ProcedurePerformed: Data elements that meet criteria using this datatype should document the completion of the procedure indicated by the QDM category and its corresponding value set. Timing: The Relevant Period addresses: StartTime = the time the procedure begins; StopTime = the time the procedure is completed NOTE: 1) Timing refers to a single instance of a procedure. If a measure seeks to evaluate multiple procedures over a period of time, the measure developer should use CQL logic to represent the query request. 2) The Incision dateTime is a single point in time available from the Operating Room and/or Anesthesia Record.

DataType

Cardinality

DTaPVaccineAdministeredPerformed

0..*

MeaslesMumpsAndRubellaMmrVaccineAdministeredPerformed

Clinical Focus:

Data Element Scope:

Inclusion Criteria:

Exclusion Criteria:

Subject constrained to the Measles, Mumps and Rubella (MMR) Vaccine Administered

ProcedurePerformed: Data elements that meet criteria using this datatype should document the completion of the procedure indicated by the QDM category and its corresponding value set. Timing: The Relevant Period addresses: StartTime = the time the procedure begins; StopTime = the time the procedure is completed NOTE: 1) Timing refers to a single instance of a procedure. If a measure seeks to evaluate multiple procedures over a period of time, the measure developer should use CQL logic to represent the query request. 2) The Incision dateTime is a single point in time available from the Operating Room and/or Anesthesia Record.

DataType

Cardinality

MeaslesMumpsAndRubellaMmrVaccineAdministeredPerformed

0..*

VaricellaZosterVaccineVzvAdministeredPerformed

Clinical Focus:

Data Element Scope:

Inclusion Criteria:

Exclusion Criteria:

Subject constrained to the Varicella Zoster Vaccine (VZV) Administered

ProcedurePerformed: Data elements that meet criteria using this datatype should document the completion of the procedure indicated by the QDM category and its corresponding value set. Timing: The Relevant Period addresses: StartTime = the time the procedure begins; StopTime = the time the procedure is completed NOTE: 1) Timing refers to a single instance of a procedure. If a measure seeks to evaluate multiple procedures over a period of time, the measure developer should use CQL logic to represent the query request. 2) The Incision dateTime is a single point in time available from the Operating Room and/or Anesthesia Record.

DataType

Cardinality

VaricellaZosterVaccineVzvAdministeredPerformed

0..*

HepatitisAVaccineAdministeredPerformed

Clinical Focus:

Data Element Scope:

Inclusion Criteria:

Exclusion Criteria:

Subject constrained to the Hepatitis A Vaccine Administered

ProcedurePerformed: Data elements that meet criteria using this datatype should document the completion of the procedure indicated by the QDM category and its corresponding value set. Timing: The Relevant Period addresses: StartTime = the time the procedure begins; StopTime = the time the procedure is completed NOTE: 1) Timing refers to a single instance of a procedure. If a measure seeks to evaluate multiple procedures over a period of time, the measure developer should use CQL logic to represent the query request. 2) The Incision dateTime is a single point in time available from the Operating Room and/or Anesthesia Record.

DataType

Cardinality

HepatitisAVaccineAdministeredPerformed

0..*

HepatitisBVaccineAdministeredPerformed

Clinical Focus:

Data Element Scope:

Inclusion Criteria:

Exclusion Criteria:

Subject constrained to the Hepatitis B Vaccine Administered

ProcedurePerformed: Data elements that meet criteria using this datatype should document the completion of the procedure indicated by the QDM category and its corresponding value set. Timing: The Relevant Period addresses: StartTime = the time the procedure begins; StopTime = the time the procedure is completed NOTE: 1) Timing refers to a single instance of a procedure. If a measure seeks to evaluate multiple procedures over a period of time, the measure developer should use CQL logic to represent the query request. 2) The Incision dateTime is a single point in time available from the Operating Room and/or Anesthesia Record.

DataType

Cardinality

HepatitisBVaccineAdministeredPerformed

0..*

HaemophilusInfluenzaeTypeBHiBVaccineAdministeredPerformed

Clinical Focus:

Data Element Scope:

Inclusion Criteria:

Exclusion Criteria:

Subject constrained to the Haemophilus Influenzae Type B (HiB) Vaccine Administered

ProcedurePerformed: Data elements that meet criteria using this datatype should document the completion of the procedure indicated by the QDM category and its corresponding value set. Timing: The Relevant Period addresses: StartTime = the time the procedure begins; StopTime = the time the procedure is completed NOTE: 1) Timing refers to a single instance of a procedure. If a measure seeks to evaluate multiple procedures over a period of time, the measure developer should use CQL logic to represent the query request. 2) The Incision dateTime is a single point in time available from the Operating Room and/or Anesthesia Record.

DataType

Cardinality

HaemophilusInfluenzaeTypeBHiBVaccineAdministeredPerformed

0..*

InfluenzaVaccineAdministeredPerformed

Clinical Focus:

Data Element Scope:

Inclusion Criteria:

Exclusion Criteria:

Subject constrained to the Influenza Vaccine Administered

ProcedurePerformed: Data elements that meet criteria using this datatype should document the completion of the procedure indicated by the QDM category and its corresponding value set. Timing: The Relevant Period addresses: StartTime = the time the procedure begins; StopTime = the time the procedure is completed NOTE: 1) Timing refers to a single instance of a procedure. If a measure seeks to evaluate multiple procedures over a period of time, the measure developer should use CQL logic to represent the query request. 2) The Incision dateTime is a single point in time available from the Operating Room and/or Anesthesia Record.

DataType

Cardinality

InfluenzaVaccineAdministeredPerformed

0..*

InactivatedPolioVaccineIpvAdministeredPerformed

Clinical Focus:

Data Element Scope:

Inclusion Criteria:

Exclusion Criteria:

Subject constrained to the Inactivated Polio Vaccine (IPV) Administered

ProcedurePerformed: Data elements that meet criteria using this datatype should document the completion of the procedure indicated by the QDM category and its corresponding value set. Timing: The Relevant Period addresses: StartTime = the time the procedure begins; StopTime = the time the procedure is completed NOTE: 1) Timing refers to a single instance of a procedure. If a measure seeks to evaluate multiple procedures over a period of time, the measure developer should use CQL logic to represent the query request. 2) The Incision dateTime is a single point in time available from the Operating Room and/or Anesthesia Record.

DataType

Cardinality

InactivatedPolioVaccineIpvAdministeredPerformed

0..*

PneumococcalConjugateVaccineAdministeredPerformed

Clinical Focus:

Data Element Scope:

Inclusion Criteria:

Exclusion Criteria:

Subject constrained to the Pneumococcal Conjugate Vaccine Administered

ProcedurePerformed: Data elements that meet criteria using this datatype should document the completion of the procedure indicated by the QDM category and its corresponding value set. Timing: The Relevant Period addresses: StartTime = the time the procedure begins; StopTime = the time the procedure is completed NOTE: 1) Timing refers to a single instance of a procedure. If a measure seeks to evaluate multiple procedures over a period of time, the measure developer should use CQL logic to represent the query request. 2) The Incision dateTime is a single point in time available from the Operating Room and/or Anesthesia Record.

DataType

Cardinality

PneumococcalConjugateVaccineAdministeredPerformed

0..*