KENTUCKY REGIONAL EXTENSION CENTER

The Hospital Quality Reporting (HQR) System is now open and accepting calendar year 2024 Medicare Promoting Interoperability Program data submissions and attestations from eligible hospitals and critical access hospitals.

The data submission deadline for the CY 2024 requirements, including eCQM data, has been changed from February 28, 2025 to Friday, March 14, 2025.

As a reminder, hospitals are required to:

  • Report data using the ONC Health Information Technology certification criteria to meet the certified electronic health record technology (CEHRT) requirement. Get your ID # from the Certified Health IT Product List (CHPL).
  • Successfully submit four calendar quarters of data for six eCQMs:
    • Three self-selected eCQMs from the CY 2024 Available eCQMs Table
    • Three CMS-selected eCQMs: Safe Use of Opioids-Concurrent Prescribing, Cesarean Birth (PC-02), and Severe Obstetric Complications (PC-07)
  • Submit web-based measure data for any continuous, self-selected 180-day EHR period within the calendar year.

Note: Failure to report at least a “1” for all required measures with a numerator or reporting a “No” for a Yes/No response measure will result in a total score of 0 points for the Medicare Promoting Interoperability Program.

  • Earn a minimum total score of 60 points
  • Complete the following requirements by attesting “Yes” to both
    • Acting to Limit or Restrict the Compatibility or Interoperability of CEHRT
    • ONC Direct Review
  • Complete the following measures under the Protect Patient Health Information Objective by attesting “Yes” to both
    • SAFER Guides
    • Security Risk Analysis
  • Submit data for the following measures under each objective below:
    • Electronic Prescribing Objective
      • e-Prescribing
      • Query of Prescription Drug Monitoring Program (PDMP)
    • Health Information Exchange Objective (Participants must select one of the three reporting options below)
      • Report on both the Support Electronic Referral Loops by Sending Health Information measure and the Support Electronic Referral Loops by Receiving and Reconciling Health Information OR Report on the Health Information Exchange (HIE) Bi-Directional Exchange OR Report on the Enabling Exchange Under the Trusted Exchange Framework and Common Agreement (TEFCA)
    • Provider to Patient Exchange Objective
      • Provide Patients Electronic Access to Their Health Information
    • Public Health and Clinical Data Exchange (A level of active engagement is required for each measure below)
      • Syndromic Surveillance Reporting
      • Immunization Registry Reporting
      • Electronic Case Reporting
      • Electronic Reportable Laboratory Result Reporting
      • Antimicrobial Use and Resistance (AUR) Surveillance
    • Voluntarily submit data for the following optional measures/requirements  (Select One):
      • Clinical Data Registry Reporting
      • Public Health Registry Reporting

Contact YOUR experts at KY***@uk*.edu“>Kentucky REC with all your QPP, MIPS/MVP, and APM Track questions. We’re here to help: 859-323-3090.