Denominator 2 section of eMeasure definition for CMS188/nqf0147/PN-6 contains a dilemma/contradiction that cannot be satisfied or tested. The first part refers to "Encounter Inpatient" without an Occurrence, which would then cause Data Elements later inserted for occurence 'B' to fail this earlier part of the logic (See notes below marked with "*******").:
• Denominator 2 =
o AND: "Initial Patient Population 2"
o AND:
 AND:
 AND: "Diagnosis, Active: Hospital Measures-Pneumonia"
 AND: "Medication, Active: IV, IM, PO Antimicrobial Medications (route: 'Hospital measures-Route IV, oral or IM')"
 <= 24 hour(s) starts after start of "Encounter, Performed: Encounter Inpatient" (**** THIS SHOULD BE DESIGNATED AS OCCURRENCE "A" BUT IT IS NOT*****)
 AND NOT: "Encounter, Performed: Emergency Department Visit" <= 1 hour(s) ends before start of "Encounter, Performed: Encounter Inpatient"
 AND NOT: "Encounter, Performed: ICU Admission or Transfer" <= 24 hour(s) starts after start of "Encounter, Performed: Encounter Inpatient"

o AND:
 AND NOT: "Encounter, Performed: ICU Admission or Transfer" <= 24 hour(s) starts after start of "Occurrence B of Encounter, Performed: Encounter Inpatient"
 AND NOT: "Encounter, Performed: ICU Admission or Transfer" <= 24 hour(s) starts after start of "Occurrence A of Encounter, Performed: Emergency Department Visit"
 AND:
 AND: "Diagnosis, Active: Hospital Measures-Pneumonia"
 AND: "Medication, Active: IV, IM, PO Antimicrobial Medications (route: 'Hospital measures-Route IV, oral or IM')"
(****** HER IS WHERE THE DILEMMA BECOMES OBVIOUS. ADDING A 2nd ('B') INPATIENT OCCURRENCE WILL THEN CAUSE THE LOGIC TO FAIL THE EARLIER OCCURRENCE A*****)
 AND: "Occurrence B of Encounter, Performed: Encounter Inpatient"
 <= 24 hour(s) starts after start of "Occurrence A of Encounter, Performed: Emergency Department Visit"

Defect confirmed with Developer Weidong Jin, who stated:
"The Episode-of-Care is marked by occurrences of “Encounter, Performed: Encounter Inpatient”. It should be defined in IPP and used by following rules. In this Denominator rule, random instances of “Encounter, Performed: Encounter Inpatient” are used. This is not a good rule in an Episode-of-Care measure, and returns invalid results."