NOTE - comment is on the to-be-published version of QI-Core representing FHIR R4 (the Jira ticket did not allow selection of that version since only 3.02 is published

The MedicationNotDispensed.status is fixed to "declined" which is defined as "The dispense was declined and not performed."  Considering the clinical workflow, the "declined" only the pharmacist likely performs the "decline" status - based on medication interaction or on failure of insurance authorization (perhaps due to patient declining when the cost/co-pay is identified).  But the patient would not enter the status, only the pharmacist would do so.  The use case likely still works for the measure developer intent (that a valid reason exists for not dispensing the medication). However, if the measure developer wants to address patient's decisions to avoid dispensing, the patient will likely not show up at the pharmacy to as for the medication to be dispensed - hence, there will be no dispensing event.  The best way to capture that scenario may to to assure the MedicationNotRequested includes a Patient reason.

The issue is informational and intended to help drive clarification of the descriptions in the Pattern and QDM-to-QI-Core mapping sections of QI-Core R4 version. The existing structure likely remains correct.