The intent of this measure is to track patients who were dispensed ADHD medication and calculate if they had a follow up encounter within a certain number of days. The requirements regarding the encounters in this measure simply state the value set and the temporal relations. The encounter required in the denominator is restricted to occurring during the measurement period. The encounter required in the numerator is restricted to ending less than or equal to 30 days after the medication dispensed ends. There is no explicit relationship defined between the medication dispensed and the encounter required by the denominator.

As a result of this relative manner of defining requirements (rather than absolute/explicit), the test data we are using can be interpreted in a manner that it is not intended to be. Two patients in the test data should not appear in the numerator according to Cypress. They both have two encounters and one medication dispensed, with the first encounter ending at the exact moment the medication is dispensed. The second encounter for both of these patients is well after the 30 day mark and so the patients should indeed be excluded from the numerator. However, the first encounter can qualify for both requirements (the denominator encounter requirement and the numerator encounter requirement). The encounter occurs during the measurement period as the denominator requires. It also ends less than or equal to the end of the medication dispensed. If you're calculating each requirement blindly (as a computer would be doing – it unfortunately doesn't understand the intent of the measure as we do), it would say that this first encounter meets the numerator requirements and then include that patient in the numerator.

As this report is implemented currently, I believe that Cypress should be including all four patients in the numerator of the report because they all technically do have encounters that end less than or equal to 30 days after the medication dispensed ends.

If the numerator count is to remain as it currently is, I think there needs to be more explicit requirement definition. If the encounter referenced in the denominator is to be a different encounter than the encounter referenced in the numerator, using the specific occurrence methodology would be preferred, with the denominator encounter being Occurrence A and the numerator encounter being Occurrence B. Defining a relationship between the medication dispensed and the denominator encounter (if the denominator encounter is indeed intended to be a different encounter than the numerator encounter) would also be helpful.

If the denominator encounter and the numerator encounter are meant to be the same encounter, then I believe the numerator temporal relationship should be adjusted to not be inclusive (>, rather than the current >=). If it was not inclusive, the first encounter for these test patients would not qualify for the numerator encounter requirements, nor would the second encounter and both patients would be excluded properly.

Could you please advise?