PICY2025HQRUserGuide

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Medicare Promoting Interoperability Program
Hospital Quality Reporting User Guide for
Eligible Hospitals and Critical Access Hospitals
Calendar Year 2025 EHR Reporting Period

CY 2025 HQR User Guide for the Medicare Promoting Interoperability Program

Table of Contents
I. About this User Guide ...................................................................................................................1
II.HQR System Registration Process ...............................................................................................3
III. Logging into the HQR System ....................................................................................................4
IV. Review, Add and/or Modify User Permissions ...........................................................................7
V. Review, Add and/or Modify Vendor Permissions ......................................................................13
VI. Promoting Interoperability Registration ....................................................................................17
A. Registration Information ...........................................................................................................17
B. Business Information................................................................................................................18
C. Registration Disclaimer ............................................................................................................19
VII. Web-Based Measure Data Submissions .................................................................................22
A. Attestation Information/Disclaimer ...........................................................................................22
B. Objectives and Measures Information......................................................................................26
VIII. eCQM Data Submissions .......................................................................................................37
A. Uploading and Reviewing Data Submitted via QRDA Category I Files ...................................37
B. Entering Denominator Declarations (if they apply)...................................................................39
C. Generating the Submission Requirements Report ..................................................................40
D. Program Credit Report (Retired) ..............................................................................................43

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I. About this User Guide
This guide will provide users the necessary tools to register, log in, and navigate within the Hospital
Quality Reporting (HQR) system. It will contain the steps needed to submit data for the Medicare
Promoting Interoperability Program including electronic clinical quality measure (eCQM) data.
Data submission using the HQR Secure Portal is the only Centers for Medicare & Medicaid Services
(CMS)-approved method for secure communications and health care quality data exchange between
healthcare providers/vendors and CMS for the purposes of the Medicare Promoting Interoperability
Program. All files and data exchanged with CMS via the HQR Secure Portal are encrypted during
transmission and are stored in an encrypted format until the recipient downloads the data. The HQR
Secure Portal meets all requirements of the Health Insurance Portability and Accountability Act of 1996.
Eligible hospitals and critical access hospitals (CAHs) can avoid payment reductions under the
Medicare Promoting Interoperability Program by demonstrating their meaningful use of certified
electronic health record technology (CEHRT) to improve patient care. Those participating in the
Medicare Promoting Interoperability Program for calendar year (CY) 2025 must use the Office of the
National Coordinator (ONC) Health Information Technology (IT) certification criteria to meet the CEHRT
requirement. Hospitals wanting to take part in the program and avoid payment reductions under the
Medicare Promoting Interoperability Program will access the HQR system to submit CY 2025 data by
the submission deadline of March 2, 2026, at 11:59 p.m. PT:
•

•

•

Promoting Interoperability Registration (New Hospitals Only)
o Registration Information
o Business Information
o Registration Disclaimer
Web-Based Measure Data
o Attestation Information/Disclaimer
o Objectives and Measures
eCQM Data

For complete information on the CY 2025 Medicare Promoting Interoperability Program requirements,
refer to the Measure/Requirements page on the CMS QualityNet website.
CMS will announce through Listserv communications once the HQR system is open and available to
receive web-based measure data as well as Quality Reporting Document Architecture (QRDA)
Category I file submissions for both test and production eCQM data. Authorized data submitters can
upload, delete, and edit their data submissions until the CMS submission deadline. The HQR Secure
Portal does not allow data to be submitted or corrected after the annual submission deadline.
To ensure you and your staff receive these important notices, sign up for the EHR Notify: EHR and
Medicare Promoting Interoperability/eCQM Listserve.

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Contact Information for further assistance:
Topic
Contact
Phone
HQR System
(user roles, reports,
data upload, and
troubleshooting
file errors)
eCQM specifications,
measure logic,
standards, and tools
QRDA reporting,
development, and
implementation
Medicare Promoting
Interoperability
Program and
Hardship Exception
Process
Hospital IQR Program
and Extraordinary
Circumstances
Exceptions process

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Center for
Clinical
Standards and
Quality (CCSQ)
Service Center

(866) 288-8912

Link/Email
[email protected]

ONC JIRA eCQM
Issue Tracker

https://oncprojectracking.healthit.gov/support/
projects/CQM/summary

ONC Jira QRDA
Issue Tracker

https://oncprojectracking.healthit.gov/support/
projects/QRDA/summary

Inpatient and
Outpatient
Healthcare
Quality Systems
Development and
Program Support.
Inpatient and
Outpatient
Healthcare
Quality Systems
Development and
Program Support

(844) 472-4477

https://cmsqualitysupport.servicenowservices.
com/qnet_qa

(844) 472-4477

https://cmsqualitysupport.servicenowservices.
com/qnet_qa

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II.HQR System Registration Process
To participate and submit data for reporting in the Medicare Promoting Interoperability Program, eligible
hospitals and CAHs must register for access to the HQR System. To log into HQR, users must already
have or create a Health Care Quality Information Systems (HCQIS) Access Roles and Profile (HARP)
account. Creating a HARP account provides you with a User ID and password that can be used to sign
into the HQR Secure Portal and access the necessary user interfaces (applications) for data
submission. More information regarding this process can be found on the Getting Started with
QualityNet page.
All users requesting access to the HQR System must complete identify proofing to verify their identity.
This mandatory registration process is used to maintain the confidentiality and security of healthcare
information and data transmitted via the HQR System.
The HQR Secure Portal is the only CMS-approved website for secure healthcare quality data exchange to
enable facility reporting. HARP is a secure identity management portal for users of the HQR System, and
it streamlines the login process by allowing access to all CMS Quality organizations with one login.
These HARP resources are available on the QualityNet Registration page:
•
•
•
•

HARP User Guide
HARP Frequently Asked Questions (FAQ)
HARP Registration Training Video
HARP Manual Proofing Training Video

For additional help on navigating the HQR system, view the video tutorials on YouTube:
https://www.youtube.com/playlist?list=PLaV7m2-zFKpjctAKzszs_jNbXmhvADgcy.
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III. Logging into the HQR System
Step 1: Access and log into the HQR Secure Portal with your Health Care Quality Information Systems
Access Roles and Profile (HARP) User ID and password. (Link: https://hqr.cms.gov/hqrng/login)
Note: The screens displayed may vary depending on the user’s permissions.
Important: If you do not have a HARP account, then click on the Sign-Up button and follow
instructions to create one. For assistance, contact the CCSQ Service Center at
[email protected].

Step 2: Select an option for two-factor authentication to verify your account. Then, click Next.

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Step 3: Enter the code received. Then, click Next.

Step 4: From the landing page, select or change the organization submitting data.

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Step 5: Review the left-hand Navigation menu, to perform actions in the HQR system.

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IV. Review, Add and/or Modify User Permissions
Basic users will need to add/edit both the Web-Based Measures and eCQM permissions to view or
upload/edit data for the Medicare Promoting Interoperability Program.
Step 1: From landing page, click on Username in the top-right corner. Then, select My Profile.

Step 2: Under Organization, click on the three vertical dots and select Request Change in Access.

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Step 3: Under each Permission Type, click Add next to Web-based Measures and eCQM.

Step 4: Next to the Promoting Interoperability Program (PI), select your permission level for
Web-Based Measures and eCQM. Then, click Apply & Close.

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Step 5: Scroll to the bottom of the page and click Review.

Step 6: Review your Access Request for accuracy. Then, click Submit.

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Step 7: Under Authorizations, click Add to view or upload/edit PI Registration.

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Step 8: Select your permission level. Then, click Apply & Close.

Step 9: Scroll to the bottom of the page and click Review.

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Step 10: Review your Access Request for accuracy. Then, click Submit.

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V. Review, Add and/or Modify Vendor Permissions
Vendor(s) must be authorized to submit eCQM data on the hospital’s behalf.
Step 1: From the landing page, click Administration and select Vendor Management.

Step 2: Search for a new vendor and click Add Vendor.
Important: The HQR system will only display vendor(s) assigned with the eCQM role. If you are unable
to add your vendor, contact the CCSQ Service Center for assistance.
Tip: Visit the HQR YouTube playlist for additional assistance on adding a new vendor.

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Step 3: Click the three vertical dots menu to allow the vendor to submit eCQM data on the hospital’s
behalf. Then, select Edit Access.

Step 4: Under each Permission Type, click Add next to eCQM.

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Step 5: Select the permission level. Complete the Discharge Quarters and Submission Date fields.
Then, click Confirm.

Step 6: Click Apply & Close. For additional changes, click edit and then click Apply & Close.

Promoting Interoperability

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Step 7: Scroll to the bottom of the page and click Review.

Promoting Interoperability

Step 8: Click Save & Close.

Promoting Interoperability

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VI. Promoting Interoperability Registration
New eligible hospitals and CAHs participating in the Medicare Promoting Interoperability Program are
required to initially complete the following three sections: Registration Information, Business
Information, and Registration Disclaimer on the Promoting Interoperability Registration page to begin
submitting data for the Medicare Promoting Interoperability Program. Existing users can review and/or
edit these fields, as necessary.

A. Registration Information
Step 1: From the landing page, select Administration. Then, select Promoting Interoperability (PI)
Registration.

Step 2: On the next page, click the green Start button to complete the Registration Information.

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Step 3: Complete the required fields. Then, click Save & Return.

Step 4: Confirm and/or Edit the Registration Information.

B. Business Information
Step 1: Click the green Start button to complete the Business Information.

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Step 2: Complete the required fields. Then, click Save & Return.

Step 3: Confirm and/or Edit the Business Information.

C. Registration Disclaimer
Step 1: Click the green Sign button to complete the Registration Disclaimer.

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Step 2: Read and acknowledge the disclaimer. Complete the position field and click Sign.

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Step 3: Verify the Promoting Interoperability Registration information is complete. A green banner will
display noting that registration has been successfully submitted.

Step 4: Click the Export Data button to view the Promoting Interoperability Registration Summary
as a PDF.

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VII. Web-Based Measure Data Submissions
A. Attestation Information/Disclaimer
The tabs displayed may vary depending on the user’s permissions.
Step 1: From the landing page under Data Submissions, click on the Web-based Measures tab and
select Data Form.

Step 2: Launch the PI Data Form.

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Step 3: Click on the green Start button to complete the Attestation Information and Attestation
Disclaimer. A blue banner will continually display reminding users to upload eCQM data as any
combination of QRDA Category I files with patients meeting the initial patient population of the
applicable measure(s), zero denominator declarations and case threshold exemptions. For detailed
eCQM submission instructions, refer to the CY 2025 QRDA I Submission Checklist.
Note: The Program Year will default to the current reporting period.
Important: If the required registration fields are incomplete, a banner will display indicating the
Promoting Interoperability (PI) Registration is required prior to beginning the Attestation/Disclaimer
information.

Step 4: Complete the Attestation Information fields and click Submit.
Important: To generate the CMS EHR Certification Identification Number, visit the ONC Certified
Health Information Technology Product List website. For CY 2025 reporting, the CMS EHR
Certification ID must start with “2025C”.

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Step 5: Read and acknowledge the disclaimer. Complete the position field and click Submit.

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B. Objectives and Measures Information
Each objective is made up of one or more measures consisting of one or more required questions.
Some questions are part of a question hierarchy, meaning additional questions may appear depending
on how the previous question was answered. 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. The HQR system will not allow users to submit an
objective unless all required measures have been completed.
The following screen shots will walk through examples of how the objectives will be displayed and the
order in which they will appear.
Step 1: Click the green Start button to submit measure data for the required objectives.
Important: Users are required to complete the Attestation Information/Disclaimer prior to completing
the Objectives.

Step 2: Complete the Security Risk Analysis measure and click Submit.
*Indicates Required Measure

Step 3: Complete the SAFER Guides measure and click Submit.
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Step 4: Complete the eRx (electronic prescribing) Objective and exclusions, if applicable.
Then, click Submit.

Step 4a: If an exclusion applies to your facility, select an exclusion option under the Query of
PDMP measure.

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Step 4b: If an exclusion does not apply to your facility, enter the numerator and denominator for the ePrescribing measure.
Important: A response is required for the Query of PDMP measure.

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If you select No under PDMP, select an exclusion option:

Step 5: Select one of the three reporting options to complete the Health Information Exchange (HIE)
Objective. Then, click Submit.

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Step 5a: If the user selects option one, enter the numerator and denominator for the Support
Electronic Referral Loops by Sending Health Information measure and the Support Electronic
Referral Loops by Receiving and Reconciling Health Information measure. Then, click Submit.

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Step 5b: If the user selects option two, select Yes or No from the drop-down box.
Then, click Submit.

Step 5c: If the user selects option three, select a Yes or No response from the drop-down box.
Then, click Submit.

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Step 6: Complete the numerator and denominator for the Provider to Patient Exchange Objective.
Then, click Submit.

Step 7: Complete all six measures under the Public Health and Clinical Data Exchange Objective.
Users are required to answer Yes or provide an exclusion for each measure.
Note: For CY 2025, CMS excluded the eCR measure from scoring. Eligible hospitals and CAHs will
receive full credit for the measure by attesting a Yes/No response or by claiming an applicable
exclusion. All fields must be complete. A blank response will result in non-compliance.
Important: For each Yes response, a level of active engagement is required for each measure. Eligible
hospitals and CAHs may spend only one EHR reporting period in Option 1 (Pre-production and
validation) before progressing to Option 2 (Validated data production).

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Step 7a: (Optional) Complete one bonus question under the Public Health and Clinical Data Exchange
Objective. Select a Yes or No response from the drop-down box. Then, click Submit.
Important: For a Yes response, a level of active engagement is required.

Step 8: After you have completed each objective, the dashboard will display the final score.
Green indicates a passing score; Red indicates a “failed” or non-passing score.
Note: The screenshots below are examples and do not reflect the actual scores achieved.

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A. Passing Score

B. Failed Score

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Step 9: Export the report for your records.

VIII. eCQM Data Submissions
Eligible hospitals and CAHs participating in the Medicare Promoting Interoperability Program are
required to successfully submit eCQM data per the calendar year reporting requirements. The eCQM
reporting requirement is an aligned requirement for hospitals participating in the Hospital Inpatient
Quality Reporting (IQR) Program and the Medicare Promoting Interoperability Program. The
successful submission of eCQM data will meet the eCQM reporting requirement for both programs.
For complete information on the CY 2025 eCQM reporting requirements, please visit the eCQM
pages on QualityNet.
Users can upload eCQM data as any combination of QRDA Category I files with patients meeting the
initial patient population of the applicable measure(s), zero denominator declarations, and case
threshold exemptions. For detailed eCQM submission instructions, refer to the CY 2025 Preparation
Checklist for eCQM Reporting.

A. Uploading and Reviewing Data Submitted via QRDA Category I Files
Step 1: From the landing page, select Data Submissions. Click on the eCQM tab located at the top.
Click on File Upload. Select Submission Type as Test or Production.

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Step 2: Once your files have been uploaded, click on Data Results from the left-side menu. Then,
click on eCQM. Located at the top, the user can select one of the three tabs displayed (Files,
Accuracy, and Outcomes) and complete the applicable fields below. Then, click Select.

Step 3: To view a CSV file, click on Export Results.

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B. Entering Denominator Declarations (if they apply)
Step 1: From the landing page, select Data Submissions. Click on the eCQM tab located at the top.
Click on the Data Form box and Launch the IQR/PI Denominator Declaration Data Form.

Step 2: Enter the declarations for case threshold and/or zero denominator for each applicable measure
and quarter. Then, click I’m Ready to Submit.
Note: File submissions will overwrite denominator declarations. The HQR system will validate
successfully submitted eCQM(s) via QRDA Category I files even if the user has already submitted a
zero denominator and/or case threshold exemption.

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C. Generating the Submission Requirements Report
Beginning with CY 2025 reporting, users must generate the submission requirements report to confirm
their eCQM submission status.
Note: CMS retired the Program Credit Report, but historical data remain available. (Refer to Section D.)
Step 1: From the landing page, click on Program Reporting. Then, click on Submission requirements.

Step 2: Click on the Submission Requirements dashboard box. Then, select IQR or PI.

Step 3: Verify the Program Year [2025]. The HQR system will default to the current fiscal or program
year. Click on the arrow to review, by quarter, the measures successfully submitted and date of the last
submission update.

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Step 4: Confirm your eCQM submission status. A box displays the requirements.
A. The green check indicates the eCQM submission requirement was met for the
reporting year.

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B. The yellow triangle indicates the eCQM submission requirement was not met for the
reporting year.

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Step 5: Export a PDF report for your records.

D. Program Credit Report (Retired)
CMS retired the Program Credit Report, but you can still access historical data.
Note: Beginning with CY 2025 reporting, users must generate the submission requirements report to
confirm their eCQM submission status.
Step 1: From the landing page, click on Program Reporting. Then, click on Program Credit. Select the
PI Program and Quarter from the drop-down boxes. Then, click Select.

Step 2: The user interface will show which measures were submitted, the submission status, and the
date of the last submission update. Export the report for your records.
Important: A green banner indicates successful submission was achieved for the reporting year; A
yellow banner indicates successful submission was not achieved for the reporting year.

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A.

Submission Requirements Met

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B.

Submission Requirements Not Met

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