A Guide to Meeting Promoting Interoperability Program Requirements
As the healthcare landscape evolves, so do the requirements for quality reporting. One such significant change for hospitals and critical access hospitals (CAHs) in the upcoming year (CY 2024) is the mandatory requirement of the Antimicrobial Use and Resistance (AUR) Surveillance measure under the Public Health and Clinical Data Exchange Objective in the Medicare Promoting Interoperability (PI) Program.
This new requirement not only reflects the growing emphasis on monitoring and controlling antimicrobial resistance but also presents an opportunity for healthcare providers to positively impact the overuse and often unnecessary prescribing of antimicrobial agents. For the 2023 reporting year, reporting AUR data is optional under the PI Public Health and Clinical Data Exchange objective but there is a benefit to voluntarily reporting as it is worth 5 bonus points. In this case, the early bird definitely gets the worm.
However, before delving into AUR reporting, let's first review the Public Health and Clinical Data Exchange Objective requirements. Beginning with 2023 reporting, hospitals must not only attest 'Yes' to active engagement for each required measure, but also report the level of active engagement. Beginning with the 2024 reporting period, a hospital may only spend one EHR reporting period at Option 1 of Active Engagement before progressing to Option 2 for a measure.
In 2024 you must minimally report the Option 1 level of engagement for each required measure under the Public Health and Clinical Data Exchange Objective or qualify for an exclusion. This is the pre-production and validation stage and essentially, this means that you are registered to submit data.
- To be considered as meeting the Active Engagement Option 1 requirement, you must have registered with a PHA or a CDR to submit data and that must have occurred within 60 days after the start of the EHR reporting period.
- Remember that starting in 2024, the EHR reporting period increases from a minimum of 90 continuous days to a minimum of 180 continuous days. This means the last day to begin your 180-day EHR reporting period is July 4, 2024. Your registration with a PHA or CDR must be completed no later than September 2, 2024.
- Once registered, you will await an invitation from the PHA or CDR to begin testing and validating your electronic data submission.
There are steps that should be taken now to get ready for AUR reporting. There are prerequisites for registering with NHSN, fast approaching deadlines and a great deal of mapping that will be required for the measure. Time is of the essence – if you haven't already started, you should begin working on this now.
The AUR Checklist
A very useful source to help prepare you for AUR reporting is MEDITECH's AUR Checklist. It includes the initial requirements for setting up and building the AUR application plus all of the steps that must be completed to implement AUR reporting. This includes registering your intent to submit to NHSN. In the checklist you will note that completing the MEDITECH build should happen prior to registering your intent to submit AUR data with NHSN.
As you move through MEDITECH's AUR checklist, you will note that there are several prerequisites for NHSN that must be met in order to report AUR data. Keep in mind that if your facility is unable to meet these prerequisites, then you may qualify for one of the measure exclusions.
Because NHSN does not allow manual data entry, you must have the ability to package data into Clinical Document Architecture (CDA) standardized format for upload to NHSN. You must also have the ability to obtain data from either an electronic medication administration record (eMAR) or from a bar coding medication administration (BCMA) system. Also, you need a lab information system (LIS) for capturing the antimicrobial susceptibility results and an Admission/Discharge/Transfer (ADT) system to capture patient movement within your facility.
As you continue to progress through the AUR checklist, you'll realize that it will take more than a single person to complete the MT build and configuration and run the SQL reports needed for the monthly submissions to NHSN. Identifying resources at your facility early is recommended. These SQL reports from MT are certified to the 2015 Edition Cures Update and can be used to report your data to NHSN. There is no additional code, interface or priority pack updates required.
The mapping requirements for AUR are fairly significant and working through these will take a good amount of time. There is an spreadsheet located in the CDC toolkit with mapping guidance. The spreadsheet may be daunting at first, but you will get more comfortable as you find your way around it.
We have seen errors upon upload of the CDA files on NHSN and most often, facilities are receiving errors due to facility locations not matching the NHSN location descriptions. Aligning these locations resolves these errors. We have also seen errors due to facility locations being incorrectly mapped to the MEDITECH dictionary map. It is important to note that the monthly reporting plan you submit to NHSN must include each facility location that you plan to submit data for – if one is not included in the plan and data is submitted with that location, an error will result. Lastly, before compiling your AUR files, review your AUR configuration table and make sure that all of your parameters are populated. This will save you time with troubleshooting and hopefully help avoid some of these errors.
There are numerous resources available to assist you in meeting AUR reporting requirements, including from MEDITECH and the CDC.
MEDITECH (requires MT customer login)
If you need assistance with AUR configuration or mapping, please contact us.