In the following measures:

ED: 0495, 0496, 0497
VTE: 0371, 0372, 0373, 0374, 0375, 0376
Stroke: 0435, 0436, 0437, 0438, 0439, 0440, 0441

We have many statements like:

AND: "Occurrence A of Encounter, Performed: Emergency Department Visit" <= 1 hour(s) ends before start of "Occurrence A of Encounter, Performed: Encounter Inpatient"

AND: "Occurrence A of Encounter, Performed: Inpatient Encounter (admission datetime)" <= 1 hour(s) starts after end of "Occurrence A of Encounter, Performed: Emergency Department Visit (facility location departure datetime)"

AND: "Occurrence A of Encounter, Performed: Non-Elective Inpatient Encounter (admission datetime)" <= 1 hour(s) starts after end of "Occurrence A of Encounter, Performed: Emergency Department Visit (facility location departure datetime)"

These statements basically mean that the ED visit needs to have ended at least 1 minute, but not more than 1 hour before the patient was admitted to inpatient.

To determine this you would state the logic like:

edDepartureDateTime < admitDateTime <= edDepartureDateTime + 1 hour

The problem with this is that in many hospitals we are seeing that a patient will be admitted as an inpatient shortly after the physician decides they need to be, but they might not leave the ED department for some period of time after that because an inpatient bed is not yet available. What this causes is an admitDateTime that is before the edDepartureDateTime.

Due to the way the logic is written we cannot include that patient (or certain aspects of the patients ED stay) because they violate the logic as it is written above. Is it the intention of the logic to exclude any pairs of encounters where the end of the ED encounter is later than the admitDateTime of the subsequent inpatient encounter? This would exclude a number of cases that would seem desirable to include in these measures. Do we have to advise hospitals to change their data recording practices?