?495.24(e) Objectives/Measures (hospitals/CAHs)

QualityNet User Guide for Medicare
Promoting Interoperability Program Eligible
Hospitals and Critical Access Hospitals
Getting Started
This guide will assist in navigation throughout the Hospital Quality Reporting (HQR) Web-Based Data
Collection Tool application. It will contain the steps needed to use this application in the QualityNet
Secure Portal to submit data for the Medicare Promoting Interoperability Program objectives and clinical
quality measures (CQMs).
Single provider and multi-provider users will use this HQR web-based application. Users with
administrator privileges are generally the multi-provider users. The principal difference is multi-provider
users will have to select the providers they want to view; they will also be able to move between these
providers when viewing data.
The summary screens presented in this user guide is from the point of view of the single-provider user.
No public health information or personally identifiable information will be displayed within this
document.
Eligible hospitals and critical access hospitals (CAHs) can avoid penalties through the Medicare
Promoting Interoperability Program by demonstrating their meaningful use of certified electronic health
record technology (CEHRT) to improve patient care.
The Centers for Medicare & Medicaid Services (CMS) and the Office of the National Coordinator for
Health Information Technology established standards that hospitals must meet in order to qualify for the
Medicare Promoting Interoperability Program. The CEHRT is a fifteen-character, alpha-numeric value
that documents the standard against which your EHR technology was certified. For those participating in
the Medicare Promoting Interoperability Program, participants may use (1) existing 2015 Edition
certification criteria, (2) the 2015 Edition Cures Update criteria, or (3) a combination of the two in
order to meet the CEHRT definition. The more up-to-date standards and functions in 2015 Edition
CEHRT better support interoperable exchange of health information and improve clinical workflows.
Hospitals wanting to take part in the program will use this HQR web-based system to register and
demonstrate effective and meaningful use of CEHRT by providing the following information:
• Registration Information
• Business Information
• Registration Disclaimer
• Objectives
• CQMs
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This guide focuses on data entry for the Medicare Promoting Interoperability Program objectives and
CQMs.

Step 1 – Go to QualityNet.org to Begin
Go to QualityNet.org and select Log into Secure Portal.

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Step 1, Continued – HARP Sign In
Enter your User ID and Password to log in. The system requires two-factor authentication in order to
login. Note, you will need to have migrated your QualityNet account to a HARP account to continue
utilizing the system.

Step 1, Continued – Terms and Conditions
After you have submitted your log in details and completed the two-factor authentication, you will need
to Agree to the Terms & Conditions in order to proceed. Once this step has been completed, you will be
directed to the main dashboard.

Step 2 – Select Organization
On the main dashboard, you will have the option to select or change the organization for which you are
submitting data for.

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Step 3 – Complete Administrative Tasks
Listed in the left-hand navigation bar, select Administration, then select Promoting Interoperability
Registration.

Next you will be directed to the below page:

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Step 3, continued – Complete Registration Information
Select Start Registration Information and enter required information. Once complete, select Save &
Return.

Step 3, continued – Complete Business Information
Select Start Business information and enter required information. You will be required to submit address,
phone number, and email information. Once complete, select Save & Return.

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Step 3, continued – Complete Registration Disclaimer
Select Start Registration Disclaimer and enter required information. Select Yes, I Acknowledge. Once
complete, select Sign.

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Step 3, Complete
Once you have signed the Disclaimer, you will be notified that you have successfully submitted your
registration information.

Step 4 – Begin Data Submission
After you have completed your registration information, select Data Submissions in the left-hand
navigation.

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Step 5, Continued – Web-based Measures
Select the Web-based Measures tab.

Step 6 – Begin Attestation
After advancing to the Web-based Measures tab, you will be directed to the Promoting Interoperability
webpage.

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Press Start and enter your attestation information.

Once you have completed the attestation/disclaimer information, click Yes, I Acknowledge then select
Save & Close Attestation Information.

Step 7 – Begin Objective Data Submission

Data for the Medicare Promoting Interoperability Program objectives can be submitted anytime and in
any order during the submission period. Likewise, answer values can be changed and resubmitted as
many times as necessary during the submission period.
There are a total of five objectives and one additional requirement, the Security Risk Analysis measure,
that are required to be reported on. Each objective is made up of one or more measures consisting of one
or more required questions. Some of these questions are part of a question hierarchy, meaning additional
questions may appear depending on how the previous question was answered.
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A question hierarchy exists when the leading question is an Exclusion question. You will see the word
Exclusion at the beginning of these questions.
Answers are required for all displayed questions. You cannot calculate or submit an objective unless all
its measures required questions are answered. Select the Save & Close button for each objective.
The following screen shots will walk through examples of how the objectives will be displayed and the
order in which they will appear.

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After you have completed each objective, the dashboard will show the following:

Step 8 – Begin Clinical Quality Measure Data Submission
Data for the Medicare Promoting Interoperability Program CQMs can be submitted anytime and in any
order during the submission period. Likewise, answer values can be changed and resubmitted as many
times as necessary during the submission period. You are required to submit data for a minimum of four
of the eight measures.
Note: The directions included in this step and the following screenshots are an example of how to submit
your CQM data via a QRDA file. You may also submit your CQM data through a Web Form, if
preferred.

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Step 9 – Submit Data
Once you have completed each section for Promoting Interoperability, select I’m Ready to Submit. You
will then receive the following message notifying you that you have successfully submitted your data.
This completes the data submission process.

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Appendix A - CQM Measure Titles and Descriptions
STK-3

Anticoagulation Therapy for
Atrial Fibrillation/Flutter

Ischemic stroke patients with atrial fibrillation/flutter who
are prescribed or continuing to take anticoagulation
therapy at hospital discharge.

STK-5

Antithrombotic Therapy By
End of Hospital Day 2

Ischemic stroke patients administered antithrombotic
therapy by the end of hospital day 2.

STK-2

Discharged on Antithrombotic
Therapy

Ischemic stroke patients prescribed or continuing to take
antithrombotic therapy at hospital discharge.

STK-6

Discharged on Statin
Medication

Ischemic stroke patients who are prescribed or continuing
to take statin medication at hospital discharge.

PC-05

Exclusive Breast Milk Feeding

During the newborn’s entire hospitalization. This measure
is reported as an overall rate which includes all newborns
that were exclusively fed breast milk during the entire
hospitalization.

VTE-2

Intensive Care Unit Venous
Thromboembolism (VTE)
Prophylaxis

This measure assesses the number of patients who
received VTE prophylaxis or have documentation why no
VTE prophylaxis was given the day of or the day after the
initial admission (or transfer) to the Intensive Care Unit
(ICU) or surgery end date for surgeries that start the day
of or the day after ICU admission (or transfer).

ED-2

Median Admit Decision Time
to ED Departure Time for
Admitted Patients

Median time (in minutes) from admit decision time to
time of departure from the emergency department for
emergency department patients admitted to inpatient
status.

VTE-1

Venous Thromboembolism
Prophylaxis

This measure assesses the number of patients who
received VTE prophylaxis or have documentation why no
VTE prophylaxis was given the day of or the day after
hospital admission or surgery end date for surgeries that
start the day of or the day after hospital admission.

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