HQR System Now Accepting CY 2024 Medicare PI Program Data

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Posted By: HHS/ONC/CMS Communications January 15, 2025

The Hospital Quality Reporting (HQR) System is now open and accepting calendar year (CY) 2024 Medicare Promoting Interoperability Program data submissions and attestations from eligible hospitals and critical access hospitals (CAHs). The data submission deadline for the CY 2024 requirements, including electronic clinical quality measure (eCQM) data, has been changed from February 28, 2025, to Friday, March 14, 2025, at 11:59 p.m. Pacific Time (PT).

Submission Details

By March 14, 2025, at 11:59 p.m. PT, Medicare Promoting Interoperability Program participants are required to:

  • Report data using the Office of the National Coordinator Health Information Technology certification criteria to meet the certified electronic health record (EHR) technology (CEHRT) requirement.
  • Successfully submit four calendar quarters of data for the following 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 Measure
  • 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 measure

OR

  • Report on the Health Information Exchange (HIE) Bi-Directional Exchange measure

OR

  • Report on the Enabling Exchange Under the Trusted Exchange Framework and Common Agreement (TEFCA) measure
  • Provider to Patient Exchange Objective
  • Provide Patients Electronic Access to Their Health Information measure
  • Public Health and Clinical Data Exchange

(A level of active engagement is required for each measure below.)

  • Syndromic Surveillance Reporting measure
  • Immunization Registry Reporting measure
  • Electronic Case Reporting measure
  • Electronic Reportable Laboratory Result Reporting measure
  • Antimicrobial Use and Resistance (AUR) Surveillance measure
  • Voluntarily submit data for the following optional measures/requirements:
    • Provider to Patient Exchange Objective (Select One)
      • Clinical Data Registry Reporting
      • Public Health Registry Reporting
  • ONC-Authorized Certification Body (ACB) Surveillance

Where can I find help with the data submission process?

The CY 2024 HQR User Guide provides the necessary tools to register, log in, and navigate within the HQR system. It contains the steps needed to submit data for the Medicare Promoting Interoperability Program, including eCQM data. Refer to the CY 2024 QRDA I Submission Checklist for more help on submitting eCQM data.

Hardship Exceptions

CMS understands that there may be circumstances out of your control that make it difficult for you to successfully meet the Medicare Promoting Interoperability Program requirements. CMS provides eligible hospitals and critical access hospitals (CAHs) the opportunity to apply for a Hardship Exception. A granted Hardship Exception avoids a downward payment adjustment for the Medicare Promoting Interoperability Program.

To be considered for an exception (to avoid a downward payment adjustment), eligible hospitals and CAHs must complete and submit a Hardship Exception application. If approved, the Hardship Exception is valid for only one payment adjustment year. Eligible hospitals and CAHs would need to submit a new application for subsequent years and no eligible hospital or CAH can receive more than five exceptions in a lifetime.

For more information regarding Hardship Exceptions, please review the CY 2024 Hardship Exception Fact Sheet.

For More Information

For more information on CY 2024 Medicare Promoting Interoperability Program Requirements, reference the resources below:

Help and Support

  • For information regarding the Medicare Promoting Interoperability Program and Hardship Exception Process, please submit questions to Inpatient and Outpatient Healthcare Quality Systems Development and Program Support at the QualityNet Question and Answer Tool at QualityNet Question and Answer Site or by phone at (844) 472-4477
  • For information about the HQR System, including user roles, reports, data upload, and troubleshooting error messages, please submit questions to the Center for Clinical Standards and Quality (CCSQ) Service Center at QnetSupport@cms.hhs.gov or (866) 288-8912.