In testing CMS 146 Version 2 (NQF# 0002) we noticed that in the test data from Cypress the time of certain diagnoses and medication prescriptions is being used as a basis for excluding and including patients. More specifically, the report excludes patients who have a medication for amoxicillin prior to a diagnosis of viral pharyngitis. In the test data, Melinda Sullivan is supposed to show in the denominator of the report and not be excluded. Her medication is prescribed at 12:30 (April 30th) while the diagnosis occurred at 12:05 (April 30th). However, this level of granularity on things like diagnoses and medications is entirely uncommon in practical use of EHRs.

A similar issue was brought forth (http://jira.oncprojectracking.org/browse/CYPRESS-231) and was resolved with the following message:

"This patient is built to exercise the denominator exclusion logic for measure CMS2/NQF0418. This requires the diagnosis of depression to occur before the adult depression screening, therefore, an additional encounter will be added to this patient that occurs before March 1, 2012 and contains the diagnosis of depression. The risk assessment will remain on March 1, 2012 (after the diagnosis). Data criteria will continue to be evaluated to the minute unless otherwise specified. The patient record will be updated the next time a Measure Bundle update is required for Cypress. In the meantime, this should not be a blocking item for certification. ATLs should allow both outcomes for this patient, included in the denominator and excluded from the denominator."

This answer seems to indicate that those involved in the decision agree that the time precision was impractical and that Cypress would update the test data at a later time. Is this stance universal or simply for that particular measure? If measures are calculated using day precision rather than hour/minute, is this incorrect? Are ATLs recommended to allow alternate outcomes based on the discrepancies resulting from differing time precisions for all measures where this becomes an issue?