Negation in QDM

Two commonly used patterns for negation in quality measurement are:

Absence of evidence for a particular event
Documentation of an event not occurring, together with a reason

For the purposes of quality measurement, when looking for documentation that a particular event did not occur, it must be documented with a reason in order to meet the intent. If a reason is not part of the intent, then the absence of evidence pattern should be used, rather than documentation of an event not occurring. To address the reason an action did not occur (the QDM attribute negation rationale), the eCQM must define the event it expects to occur using appropriate terminology to identify the kind of event (using a value set or direct reference code), and then use additional criteria to indicate that the event did not occur, as well as identifying a reason. The following examples differentiate methods to indicate (a) presence of evidence of an action, (b) absence of evidence of an action, and (c) negation rationale for not performing an action. In each case, the “action” is an administration of medication included within a value set for “Antithrombotic Therapy”.

Presence

Evidence that “Antithrombotic Therapy” (defined by a medication-specific value set) was administered: define "Antithrombotic Administered":

["Medication, Administered": "Antithrombotic Therapy"] AntithromboticTherapy where AntithromboticTherapy.code in “Antithrombotic Therapy”

Absence

No evidence that “Antithrombotic Therapy” medication was administered:

define "No Antithrombotic Administration": not exists ( ["Medication, Administered": "Antithrombotic Therapy"] AntithromboticTherapy where AntithromboticTherapy.code in “Antithrombotic Therapy” )

Negation Rationale

Evidence that “Antithrombotic Therapy” medication administration did not occur for an acceptable medical reason as defined by a value set referenced by the eCQM (i.e., negation rationale): define "Antithrombotic Not Administered":

["Medication, Not Administered": "Antithrombotic Therapy"] NotAdministered where NotAdministered.negationRationale in “Medical Reason” or NotAdministered.negationRationale in "Patient Refusal"

Explanation:

In this example for negation rationale, the logic looks for a member of the value set “Medical Reason” as the rationale for not administering the medication. However, underlying systems might not represent the negated action with a code from the “Antithrombotic Therapy” value set. When justifying the reason for not administering a class of medications, clinicians do not generally specify one of the medications in the class, they most often indicate avoidance of the entire class. In these cases, the value set may be used as a placeholder to indicate the medication class was not administered. Implementations processing data reported in this way should take into account that the reported data may not be returned with a single code, but rather a value set identifier, and should consider data with the appropriate value set identifier as satisfying the criteria for value set membership. Similarly, “Procedure, Not Performed”: “Cardiac Surgery” should not require specification of which cardiac surgery in a value set was not performed, but only reference any member of the class of procedures defined by the value set. The same process works for any application of negation rationale.