Many QMs contain "Starts After Start of" logic that, would make more clinical sense if they were "Starts At or After Start of". Similarly for "Starts After End of", etc. Here are three examples:

1) This example is taken from the Numerator logic of VTE 3:

OR: Bla...
OR: "Medication, Administered: Unfractionated Heparin (route: 'Intravenous route')" <= 1 day(s) starts after start of "Occurrence A of Encounter, Performed: ICU Admission or Transfer"
OR: Bla...
etc.

If the Unfractionated Heparin is given at the time of ICU Admission, then the patient is not included in the Numerator. If the nurse hangs an IV bag of Unfractionated Heparin as the patient is wheeled through the door of the ICU, surely they should get credit for it.

2) This example is taken from the Denominator logic of Stroke 6:

OR: "Occurrence A of Encounter, Performed: Non-Elective Inpatient Encounter (admission datetime)" <= 30 day(s) starts after end of "Laboratory Test, Result: LDL-c (result >= 100 mg/dL)"
OR: "Laboratory Test, Result: LDL-c (result >= 100 mg/dL)" <= 48 hour(s) starts after start of "Occurrence A of Encounter, Performed: Non-Elective Inpatient Encounter (admission datetime)"

The clear intent here is to include all patients that have had an "LDL-c >= 100" performed between 30 days before the start of the inpatient encounter and 48 hours after the start of the inpatient encounter. However, as the logic stands, the patient will not be included if the LDL was performed exactly at the point of inpatient admission. This is clearly not the intent and is counter-intuitive.

3) This appears in multiple EH QMs:

"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)"

If the equal condition is excluded here, the result would be False if the inpatient admission occurred at the exact time as the emergency department discharge. In the real world, this is not an uncommon event. In fact, it is common for the inpatient encounter to begin before the end of the emergency department encounter. Patients are frequently "held" in the ED for hours waiting for an inpatient bed to open up; during which time they are technically "Admitted", but are still physically in the ED and largely under the care of the ED staff. In this particular case, I would argue that the logic should include any time during the ED visit up to one hour after the ED visit.

There are numerous other examples.
Thanks for looking at this.

• John