"Reusing QuestionnaireResponses may save time and effort. In the case of a QuestionnaireResponse being reused. The data in the QuestionnaireResponse should be refreshed where possible with the latest data from the EHR system when being reused."

The term "reuse" is vague and the scenarios in which a QuestionnaireResponse should be reused are not specified. Is it considered "reusing" a QuestionnaireResponse if it is sent during the PAS process, or is that just a standard usage of the resource? Is it considered "reusing" the resource when relaunching DTR to continue filing out answers to an incomplete questionnaire? If not, when would we consider a QuestionnaireResponse to be reused? Can the specification provide examples of scenarios for reuse?

Similarly, this statement needs more detail regarding the scope of refreshing a QuestionnaireResponse resource. Should the system re-execute all of the CQL rules every time? How should conflicts be resolved? Who is responsible for refreshing the data? If the QuestionnaireResponse was transmitted to the Payer IT system, does it need to be synched to the payer every time it is refreshed? Should we introduce some way of marking a QuestionnaireResponse as being 'complete' and therefore shouldn't be refreshed again?

The QuestionnaireResponse does not have item-level timestamps or any indication from where a given answer was pulled when not answered manually by a user, which makes it difficult to determine whether or not an answer should be updated. Should a refresh always overwrite existing answers? Should manually-answered questions be overwritten if the execution of the CQL rules on refresh finds an answer to that question?

As an example: In the case where the ordering provider and servicing provider systems are different, the ordering provider may have more up-to-date patient data and have populated the QuestionnaireResponse before passing it to the servicing provider system for use with PAS. The servicing provider system cannot know, when refreshing the QuestionnaireResponse, whether or not the answers currently present in the QuestionnaireResponse are more or less accurate than the result of running the questionnaire CQL rules on this second system.