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

Hospital Quality Reporting 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 HQR
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 multiprovider 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 upto-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
This guide focuses on data entry for the Medicare Promoting Interoperability Program objectives
and CQMs.

Medicare Promoting Interoperability

1

Step 1 – Go to HQR.CMS.Gov to begin

Medicare Promoting Interoperability

2

Step 1, Continued – Two-factor Authentication
Enter your User ID and Password to log in. The system requires two-factor authentication in order
to login.

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.

Medicare Promoting Interoperability

3

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.

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

Medicare Promoting Interoperability

4

Next you will be directed to the below page:

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

Medicare Promoting Interoperability

5

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.

Medicare Promoting Interoperability

6

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

Medicare Promoting Interoperability

7

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.

Medicare Promoting Interoperability

8

Step 5 – Web-based Measures
Select the Web-based Measures tab.
Note: You will only see program selections for programs you have permission to submit data for.

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

Medicare Promoting Interoperability

9

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.

Medicare Promoting Interoperability

10

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

Medicare Promoting Interoperability

11

Medicare Promoting Interoperability

12

Medicare Promoting Interoperability

13

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

Medicare Promoting Interoperability

14

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 nine 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.

Medicare Promoting Interoperability

15

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.

Medicare Promoting Interoperability

16

Appendix A - CQM Measure Titles and Descriptions
Short
Name
STK-3

Title

Description

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

PC-05

Exclusive Breast Milk
Feeding

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

Medicare Promoting Interoperability

17