Thank you for your feedback regarding CMS1264v1: Emergency Care Access and Timeliness (REHQR). As you are aware, this measure assesses the variation in access and timeliness of emergency care to support rural emergency hospital (REH) quality improvement for patients requiring emergency care in an emergency department (ED). The numerator is comprised of ED visits meeting the denominator criteria and where the patient experiences any of the following quality gaps in access: (i) The patient waited longer than 60 minutes (1 hour) after arrival to ED to be placed in a treatment room or dedicated treatment area that allows for audiovisual privacy during history-taking and physical examination, or (ii) The patient left the ED without being evaluated, or (iii) The patient, if transferred, boarded for longer than 240 minutes (4 hours), or (iv) The patient had an ED length of stay (LOS) (time from ED arrival to ED departure as defined by the ED departure timestamp indicating when the patient physically left the ED) of longer than 480 minutes (8 hours). ED encounters with ED observation stays are excluded from numerator criteria #3 (boarded) and #4 (ED LOS). CMS and the measure developer greatly appreciate EDBA’s thoughtful feedback. We address each of your key recommendations below. Boarding Time Thank you for your suggestion to use the earliest evidence of an admission decision to calculate boarding time. We want to note that CMS1264v1 was developed for use in the Rural Emergency Hospital Quality Reporting (REHQR) and evaluates ED visits at REHs. Since REHs do not provide inpatient services, numerator 3 for CMS 1264v1 defines boarding as the practice of holding transfer patients in the ED after a decision to transfer has been made. Therefore, our understanding is that your suggestion regarding the inpatient boarding numerator component applies to CMS1244v1: Emergency Care Access & Timeliness (HOQR), which evaluates all emergency departments required to submit data for the Hospital Outpatient Quality Reporting (OQR) program. With that said, CMS and the measure developer will consider updating numerator 3 in both measures to use the earliest evidence of a decision to transfer (CMS1264) and the earliest evidence of an admission decision (CMS1244) to calculate boarding time in a future annual update cycle. Regarding the suggestion to report boarding time in total minutes, the purpose of CMS1244v1 and CMS1264v1 is to assess the proportion of patients impacted by access and timeliness gaps of ED care. As a result, we do not believe that reporting boarding time in total minutes would align with the measure’s intent. However, the measure developer will consider leveraging the data elements submitted by hospitals for monitoring purposes and consider potential changes in the boarding time threshold in the future, as needed. Door to Treatment Space Thank you for supporting the privacy criterion for numerator 1: “the patient waited longer than 60 minutes (1 hour) after arrival to ED to be placed in a treatment room or dedicated treatment area that allows for audiovisual privacy during history-taking and physical examination”. Left Before Treatment Complete (LBTC) Thank you for your suggestion. CMS and the measure developer will consider the “Left Before Treatment Complete” metric for numerator 2: “the patient left the ED without being evaluated” (i.e., “Left without being seen”) in a future annual update cycle to include all forms of incomplete visits. Include Inpatient Capacity Metrics We appreciate your suggestion to include hospital‑based metrics (e.g., occupancy, beds opened and staffed, inpatient LOS, discharge timing) to address the true drivers of lengthy boarding and ED crowding. We agree that ED efficiency and patient throughput are closely tied to a broad collection of hospital-wide operational processes beyond those just occurring in the ED. However, since CMS’s quality reporting programs are divided to separately monitor inpatient and outpatient settings, we do not believe that including inpatient capacity metrics aligns with the measure intent. With that said, CMS is actively considering how to best measure care access and timeliness among hospitals participating in its quality reporting and value-based purchasing programs. As such, CMS has issued a Request for Information (RFI) in the FY 2027 Hospital Inpatient Prospective Payment System (IPPS) proposed rule and for the adoption of the Emergency Care Access & Timeliness (ECAT) measure into the Hospital Inpatient Quality Reporting Program (IQR). The proposed rule is currently available in the Federal Register website for public comment: https://www.federalregister.gov/documents/2026/04/14/2026-07203/medicare-program-hospital-inpatient-prospective-payment-systems-for-acute-care-hospitals-ipps-and . We encourage you to share your feedback on the inclusion of inpatient capacity metrics in the ECAT measure for inclusion in the IQR.