I needed clarification in handling a particular scenario,

• The patient has two referrals (e.g., dermatologist and cardiologist).
• Both referrals share the same authoredon timestamp
• Only one referral (cardiologist) has a consultant report tied to it.

Under such cases if the referral without consultant report is picked as FIRST it results in measure dissatisfaction.
Which referral is to be considered? And how is the cql handling this for the measure?

As per our understanding:
The image below is the CQL which tells us about the logic to choose the FIRST referral

According to the CQL HL7 authors guide when there are duplicates in sorting value (in our example multiple referrals with same referral having dateintervention ascending) the order of duplicate is unspecified.

Ref: https://cql.hl7.org/STU4/02-authorsguide.html#sorting
Hence there is a 1/2 probability of choosing a referral with consult note in case of 2 referrals being performed at same time.

Could you further give us clarification to handle this scenario.