FAQs: AUR Reporting for the CMS Promoting Interoperability Program

Most acute care hospitals take part in the CMS Medicare Promoting Interoperability (PI) Program. You can reach out to the person(s) in charge of quality reporting for your hospital to confirm. You may need to ask your hospital’s C-Suite (for example, Chief Technology Officer or Chief Informatics Officer) to get connected to the correct individuals within your hospital. Critical access hospitals (CAHs) are also eligible to participate in the Medicare PI Program.

Other types of hospitals that provide inpatient care are not included in the Medicare PI Program. This includes, but is not limited to, Inpatient Rehabilitation Facilities (IRFs), Inpatient Psychiatric Facilities (IPFs), Long Term Care Hospitals (LTCHs/LTACs/LTACHs), PPS-exempt Cancer Hospitals, and Rural Emergency Hospitals (REHs). While these hospital types are not eligible to participate in the Medicare PI Program, any hospital enrolled in the NHSN Patient Safety Component can report AUR data into NHSN.

See Question 5 in the Data Submission Requirements section of the FAQs for clarification on specific units within an eligible hospital or critical access hospital.

Eligible hospitals and CAHs participating in the Medicare PI Program must begin reporting the AUR Surveillance measure within the Public Health and Clinical Data Exchange Objective for Electronic Health Record (EHR) reporting periods in calendar year (CY) 2024. See additional details on the EHR Reporting period in Question 1 in Data Submission Requirements.

Yes. To receive credit beginning in CY 2024, the measure requires eligible hospitals and CAHs attest to being in active engagement to report both AU and AR Option data to NHSN for the EHR reporting period, or else claim an applicable exclusion.

No. As outlined under Question 3 above, eligible hospitals and CAHs must report a ‘‘yes’’ response to being in active engagement with CDC’s NHSN to submit Antimicrobial Use and Resistance (AUR) data for the EHR reporting period to fulfill the measure. Hospitals may also claim an applicable exclusion. In other words, there is no option for eligible hospitals and CAHs to receive “partial credit” if they answer “yes” to only part of the measure (specifically, they meet the requirement for either AU or AR, but not both).

However, hospitals that claim an applicable exclusion for only AU or AR the hospital would claim the exclusion for the measure as a whole. Please note that in these situations, NHSN encourages facilities to report the data they have available. For example, if claiming an exclusion based on the AR Option data, while not required for the Medicare PI Program, the hospital can still submit AU Option data to take advantage of the NHSN AU Standardized Antimicrobial Administration Ratio (SAAR) risk adjusted metric and other analysis reports.

Eligible hospitals and CAHs that report a ‘‘no’’ response or fail to report any response in CY 2024 will not receive credit for reporting the measure. These hospitals would fail to satisfy the Public Health and Clinical Data Exchange Objective and will earn a score of zero for the Medicare PI Program.

The Medicare PI Program requires hospitals be in active engagement with CDC/NHSN to submit AUR data for CY 2024, and to report their level of active engagement. CMS defines active engagement as the eligible hospital or CAH is in process of moving towards sending “production data” to a Public Health Agency, in this case CDC/NHSN, or is sending production data to CDC/NHSN. The measure specification materials are posted in the CMS Promoting Interoperability Resource Library.

Hospitals are required to report their level of active engagement:

Option 1 – Pre-production and Validation

Hospitals first have to register intent to submit AUR data within NHSN. Per the CMS measure specifications, the registration should be completed within 60 days after the start of the EHR reporting period. The registered acute care hospital or CAH will then receive an automated email from NHSN inviting it to begin the Testing and Validation step. Following the instructions in the email, hospitals must work towards submitting one test file for each file type (AU Summary, AR Event, and AR Summary) for validation by the NHSN Team. Per the CMS measure specifications, hospitals should respond to the request for test files within 30 days following the request for test files. The response should include the test files or a summary of the hospital’s progress in setting up AUR Module reporting. As long as the hospital replies within 60 days, no further updates are needed until the test files are ready for validation. Failure to respond twice within an EHR reporting period will result in that eligible hospital not meeting the measure.

Note: Beginning in CY 2024, eligible hospitals and CAHs can only spend one calendar year in Option 1 – Pre-production and Validation.

Option 2 – Validated Data Production

Hospitals first have to register intent to submit AUR data within NHSN if they did not complete Option 1 – Pre-production and Validation. CMS defines production data as data generated through clinical processes involving patient care, and it is used to distinguish between data and “test data,” which is submitted for the purpose of testing and validation. For CY 2024, hospitals must submit 180 continuous days of AUR data to NHSN. Keep in mind that you must report the same 180 days of AU and AR data as they are considered a single measure for the Medicare PI Program. Additionally, those 180 days must be the same for some other Medicare PI Program measures for your hospital (also known as the EHR reporting period). Please reach out to your Quality Department and/or C-Suite team to determine your hospital’s designated EHR reporting period.

As outlined in the CMS Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Policy Changes and Fiscal Year 2023 Rates; Quality Programs and Medicare Promoting Interoperability Program Requirements for Eligible Hospitals and Critical Access Hospitals; Costs Incurred for Qualified and Non-Qualified Deferred Compensation Plans; and Changes to Hospital and Critical Access Hospital Conditions of Participation (IPPS) FY 2023 final rule, any eligible hospital or CAH meeting one or more of the following criteria may be excluded from the AUR Surveillance measure if the eligible hospital or CAH:

1. Does not have any patients in any patient care location for which data are collected by NHSN during the EHR reporting period; or
2. Does not have electronic medication administration records (eMAR)/bar coding medication administration (BCMA) records or an electronic admission discharge transfer (ADT) system during the EHR reporting period; or
3. Does not have an electronic laboratory information system (LIS) or electronic ADT system during the EHR reporting period.

Eligible hospitals and CAHs should claim the exclusion that is closest to their situation. While NHSN can provide guidance to hospitals in determining whether they meet the criteria for an exclusion, ultimately CMS must decide whether a certain scenario meets the exclusion criteria. These questions should be directed to the CMS CCSQ Help Desk at QnetSupport@cms.hhs.gov or 1-866-288-8912.

Hospitals should reach out to the CMS CCSQ Help Desk to determine what documentation is needed when claiming an exclusion. They can be reached at QnetSupport@cms.hhs.gov or 1-866-288-8912.

The measure requires that eligible hospitals and CAHs are in active engagement with CDC to report both AU and AR data—or claim an applicable exclusion. There is no “partial credit” for being in active engagement to report AU or AR data, but not both.

If an eligible hospital or CAH can report AU or AR data, but not both, it must either claim an applicable exclusion for the data it can’t report or attest “No” to the measure.

However, hospitals that claim an applicable exclusion for only AU or AR the hospital would claim the exclusion for the measure as a whole. Please note that in these situations, NHSN encourages facilities to report the data they have available. For example, if claiming an exclusion based on the AR Option data, the hospital can still submit AU Option data to take advantage of the NHSN AU Standardized Antimicrobial Administration Ratio (SAAR) risk adjusted metric and other analysis reports.

Beginning in CY 2024, reporting a “No” for the measure will result in a total score of 0 points for the Public Health and Clinical Data Exchange objective. As a reminder, eligible hospitals or CAHs who fail to achieve a minimum total score of 60 points are not considered meaningful users and may be subject to a downward payment adjustment. Required measures earn a score, but if a required measure is not fulfilled, the eligible hospital or CAH will earn a score of zero for the PI Program.

Example for CY 2024

If an eligible hospital or CAH was in active engagement to report AU data but could not report AR data due to absence of an electronic Laboratory Information System (LIS) (one of the approved exclusions), the hospital would claim the exclusion for the measure as a whole.

Under the same scenario above, if an eligible hospital or CAH was in active engagement to report AU data, but not AR data and did not have a valid exclusion for reporting AR data, the hospital would be required to answer “No” to the measure and thus fail to successfully demonstrate meaningful use and thus be subject to a negative payment adjustment.

No, data suppression does not count as an eligible exclusion. Please see the exclusions listed above in Question 6 of the Requirement Details section.

Data suppression prevents complete antimicrobial susceptibility data from being reported to the AR Option. We have observed that there are two types of suppression. The first is that the testing instrument suppresses the results for organism-drug combinations that are not supposed to be reported for microbiology purposes, such as ampicillin for Pseudomonas aeruginosa. The second is data suppression for the purpose of antimicrobial stewardship; for example, suppressing carbapenems for E. coli isolates that are susceptible to first, second, or third generation cephalosporins in order to reduce the use of carbapenems.

For purpose #1, we would recommend keeping those results suppressed and not submitting them to NHSN. For the organism-drug combinations that are suppressed for purpose #2, generally we would recommend that, if feasible, allow labs to release complete antimicrobial susceptibility testing (AST) results to the EHR and perform data suppression at the EHR level (as opposed to suppression at the susceptibility testing instrument or laboratory information system level). This way, complete data will still be available in the EHR and theoretically should be available for data extraction and submission for surveillance purposes. You might need to work with your microbiology lab to identify which combinations belong to which purpose.

However, if your hospital cannot obtain and/or send suppressed data to the NHSN AR Option, NHSN will accept the data your hospital is able to provide. Please be sure that your AUR reporting software vendor is using ‘Not Tested’ for the unavailable tests/drugs. The NHSN application will not accept AR Event CDA files that do not contain all the required drugs for a given organism.

Many hospitals use outside labs for some, most, or even all of their susceptibility testing. We also know that, in some cases, those results might not make it into the hospital LIS.

At the same time, NHSN has some minimum results requirements. A hospital may qualify for an exclusion in rare instances where the following conditions are met:

• They have an LIS for non-microbiology data (e.g., hematology or chemistry results), but don’t have an LIS for microbiology data.
• The AR data required for submission to NHSN are not available as discrete fields in the LIS. For example, results for Candida species identification and/or susceptibility testing are faxed and scanned into the patient record as a PDF.

In such cases, the hospital would functionally qualify for an exclusion based on lack of an electronic LIS. Hospitals should not employ manual means of data collection for the AUR Module. Eligible hospitals and CAHs should claim the AUR reporting measure exclusion that is closest to their situation.

If the eligible hospital does not have access to results of all eligible organisms as outlined in the AUR Module Protocol, the hospital may claim an exclusion to the AUR Measure. For example, a hospital may claim an exclusion if results for Candida species were not available or only available in the form of images (e.g., fax or PDF). Please note it would not qualify as an exclusion if isolate identifications were available but antimicrobial susceptibility results were conditionally available depending on individual isolate or patient’s profile due to facility’s reporting algorithm for antimicrobial stewardship (selective/cascade reporting).

If an eligible hospital or CAH is producing and reporting validated production data to NHSN for one of the two—say, AU data—but is still in the pre-production and validation stage for the other—in this example, AR data—the hospital would attest “yes” to the measure and report “Option 1– Pre-production and Validation” as its overall level of engagement for the measure. In this case, the hospital should work towards sending test files for validation for both AU and AR despite being able to successfully submit AU data into NHSN.

An eligible hospital or CAH would only select “yes” for the measure and report their level of engagement as “Option 2 – Validated Data Production” if it is successfully reporting both AU and AR data to NHSN for their EHR reporting period in CY 2024, which is a minimum of any continuous 180-days.

No. Hospitals are encouraged to proceed to validated data production as soon as they are ready to do so.

Many eligible hospitals/CAHs already report Antimicrobial Use (AU) Option and/or Antimicrobial Resistance (AR) Option data to CDC’s NHSN. We expect they will attest to “Option 2 – Validated Data Production” for EHR reporting periods in the CY 2024 if they are reporting both AU and AR data.

Similarly, some hospitals may move through registration, testing and validation and begin submitting production data all within CY 2024. If their selected EHR reporting period begins after they’ve reached the point of submitting validated production data for both AU and AR, they can and should attest to reaching that stage.

Yes. If the eligible hospital completes registration of intent and validation of test files in CY 2023, the hospital can use that documentation to attest to Option 1 – Pre-production and Validation for CY 2024. However, hospitals are encouraged to proceed to Option 2 – Validated Data Production as soon as they are ready to do so.

Note: Beginning in CY 2024, eligible hospitals and CAHs can only spend one calendar year in Option 1 – Pre-production and Validation.

For CY 2024, eligible hospitals and CAHs should complete the registration of intent to submit AUR data within NHSN. Once registration is complete, hospitals should work towards sending AUR files to the NHSN AUR Team for validation. Files sent to the NHSN AUR Team prior to November 1, 2024, will be processed in time for the facility to receive feedback prior to December 31, 2024. However, hospitals and CAHs are not required to submit files for validation during CY 2024. Hospitals can attest “Yes” to “Option 1 – Pre-production and validation” as long as they are working towards the creation of AUR files within CY 2024. See question 15 in Logistics for more information on attestations.

Per the CMS measure specifications, hospitals should respond to the request for test files within 30 days following the request for test files. The response should include the test files or a summary of the hospital’s progress in setting up AUR Module reporting. As long as the hospital replies within 60 days of the initial request from NHSN, no further updates are needed until the test files are ready for validation. Failure to respond twice within an EHR reporting period will result in that eligible hospital not meeting the measure.

If a hospital is already reporting AUR data to CDC, it does not need to complete the validation process of sending test files to the NHSN Team. However, all hospitals must complete the registration step within NHSN regardless of where they are in the submission process. In this case, hospitals can ignore the automated emails requesting test files sent by NHSN after the facility registers intent. If the hospital is sending production AU and AR data to NHSN, they will be able to attest to being in active engagement and report their level of engagement as “Option 2 – Validated Data Production” in CY 2024. Hospitals attesting to “Option 2 – Validated Data Production” do not need official proof from NHSN of completing the validation process.

Hospitals submit their attestations directly to CMS. CDC/NHSN has no role in the attestation process for the AUR measure.

NHSN automatically sends out letters showing the registered hospital’s reporting status on the 1st of every month. A final letter is sent out on February 1 with the previous year’s submissions. Eligible hospitals and CAHs can use these reports to support their active engagement status for the required measures under the Public Health and Clinical Data Exchange Objective (e.g., being in active engagement with a CDC/NHSN to report AUR data) in case of an audit by CMS. Registered hospitals can also generate ad hoc letters within NHSN following the process outlined in Step 3 of our guidance document.  The letters should be retained but do not get submitted to CMS, unless requested.

No, the AUR Measure of the Medicare PI Program is attestation based. Hospitals attest Yes/No to being in active engagement with the AUR measure within the CMS hospital quality reporting (HQR) system. The NHSN application provides hospitals with documentation to use as proof in the event of a CMS audit (see previous FAQ). NHSN does not provide any AUR data to CMS nor does CMS request them, as this program is aimed at increasing interoperable healthcare data exchange.

No.

Under the definition of ‘‘EHR reporting period for a payment adjustment year’’ at 42 CFR 495.4, for eligible hospitals and CAHs that are new or returning participants in the Medicare PI Program, the EHR reporting period in CY 2024 is a minimum of any continuous 180-day period within CY 2024. This is an increase from 90 continuous days in CY 2023.

Eligible hospitals and CAHs must report both AU and AR data during the same EHR reporting period, which is a minimum of any continuous 180-days, self-selected by individual hospitals, within the calendar year. Please note the same EHR reporting period is used for all measures required by the Medicare Promoting Interoperability Program. Please reach out to your Quality Department and/or C-Suite team to determine an EHR reporting period that works best for your hospital.

Hospitals that attest to “Option 2 – Validated Data Production” for the AUR measure must report on an ongoing basis during their selected EHR reporting period. Please see question 16 in Logistics for more information on submitting attestations.

Hospitals submitting data through NHSN’s AU and AR Options are required to complete a Monthly Reporting Plan for every month that they plan to submit AU and AR data prior to uploading data to NHSN.

For additional information on reporting AUR data, see:

• NHSN AUR Module Protocol [PDF – 3 MB]
• FAQs: Antimicrobial Use (AU) Option
• FAQs: Antimicrobial Resistance (AR) Option

For the Medicare PI Program, hospitals attesting to Option 2 – Validated data production are expected to report 180 continuous days during their designated EHR reporting period. The NHSN Team encourages facilities to report continuously once the EHR reporting period is complete to be able to take full advantage of the available risk adjustment metrics within NHSN.

The AUR reporting measure for the Medicare PI Program is a hospital-level attestation as identified by CCN. The measure requires the eligible hospital or CAH to submit data for the inpatient or emergency department (Place of Service [POS] 21 or 23).

NHSN strongly encourages the submission of data from all NHSN-defined inpatient locations (including procedural areas like operating rooms), facility-wide inpatient (FacWideIN), and select outpatient acute care settings (specifically, outpatient emergency department [ED], pediatric ED, and 24-hour observation area) from which the numerator and denominator data can be accurately captured. Hospitals would attest “Yes” if AU Summary, AR Event [numerator], and AR Summary [denominator] data were submitted for all locations meeting the above criteria for each month for the required time frame (e.g., 180 continuous days in CY 2024). A comprehensive submission will enable a hospital to optimize inter- and/or intra-facility comparisons among specific wards, combined wards, and facility-wide data.

As described in the preceding FAQ, NHSN encourages facilities to submit AUR data from all inpatient locations and select outpatient locations where numerator and denominator data can be accurately captured. This includes:

• Inpatient rehabilitation units (IRF) that are mapped as a location within the eligible NHSN hospital or critical access hospital (regardless of IRF unit CCN)
• Inpatient psychiatric units (IPF) that are mapped as a location within the eligible NHSN hospital or critical access hospital (regardless of IPF unit CCN)
• Skilled nursing/long term care units that are mapped as a location within the eligible NHSN hospital or critical access hospital
• Swing beds that are mapped as a location within the eligible NHSN hospital or critical access hospital

This excludes:

• IRF units that are enrolled in NHSN as a separate NHSN facility using the HOSP-REHAB facility type. However, AUR data can be reported within this separately enrolled NHSN facility.
• IPF units that are enrolled in NHSN as a separate NHSN facility using the HOSP-PSYCH facility type. However, AUR data can be reported within this separately enrolled NHSN facility.
• Skilled nursing/long term care units that are enrolled in the NHSN Long Term Care Facility Component as a separate NHSN facility
• All outpatient clinic locations

While attestation/reporting for the Medicare Promoting Interoperability Program is completed at the CCN level, the NHSN Team encourages all NHSN facilities enrolled as hospitals or CAHs to complete the steps for AUR reporting separately. This means each NHSN facility should complete the registration of intent and work towards sending test files. If the hospital wants to receive official documentation of completing the testing and validation step, each NHSN facility must send AUR files for validation. Each hospital should plan to submit their own production AUR data. After completing the registration of intent, each hospital will receive their own monthly AUR submission status report from NHSN.

Per Medicare PI Program requirements, hospitals must use Certified EHR Technology (CEHRT) that has been updated to meet the ONC Certification Criteria for Health IT. Hospitals can confirm whether their vendor has been certified by reviewing the Certified HealthIT Product List maintained by the Office of the National Coordinator for Health Information Technology (ONC). When searching, filter by Certification Criteria then click the box for “170.315 (f)(6): Transmission to Public Health Agencies – Antimicrobial Use and Resistance Reporting” as shown in the screenshot below.

Additionally, per NHSN requirements, hospitals must use vendors that have completed the NHSN AU and AR Synthetic Data Set Validation requirements. Hospitals can find the list of vendors that have passed AU validation and AR validation on NHSN’s website.

Participants must submit their attestation through the CMS Hospital Quality Reporting (HQR) system, ensuring they’ve met all the program requirements for the EHR reporting period and their electronic clinical quality measures (eCQMs) for the required EHR reporting period. Participants have until the last day in February of each year to attest for the previous year. Exclusions are also submitted at this time. An HQR User Guide can be found in the CMS Resource Library: Resource Library | CMS.

Note: This date is subject to change due to weekends, federal holidays, or other changes proposed and finalized in CMS regulations. Date changes are communicated by CMS.

Per Medicare Promoting Interoperability Program measure specifications, hospitals must register intent to submit AUR data within 60 days of the start of their designated EHR reporting period. Once the hospital completes registration, it will receive an automated email from NHSN to send test files for validation. Per the CMS measure specifications, hospitals should respond to the request for test files within 30 days following the request for test files. The response should include the test files or a summary of the hospital’s progress in setting up AUR Module reporting. As long as the hospital replies within 60 days, no further updates are needed until the test files are ready for validation. Failure to respond twice within an EHR reporting period results in the eligible hospital or CAH not meeting the measure.

Please allow up to 8 weeks from receipt of test files for the NHSN Team to complete the validation of your test files.

Hospitals can attest “Yes” to “Option 1 – Pre-production and validation” as long as they are working towards the creation of AUR files within CY 2024. However, if your hospital wants a letter from NHSN denoting the validation stage is complete, you must have three passing test files: AU Summary, AR Event (numerator) and AR Summary (denominator). We ask hospitals and CAHs that would like official record of completing the test file process to submit test files no later than November 1, 2024, to allow the NSHN AUR Team time to process the test files.

Please go ahead and complete the registration of intent within NHSN as soon as possible.

Per CMS specifications, hospitals that attest to “Option 2 – Validated Data Production” for the AUR measure must report on an ongoing basis during their selected 180-day EHR reporting period. NHSN automatically sends out letters to the NHSN Facility Administrator and PI Program contacts designated in the NHSN application showing the registered hospital’s status with reporting on the 1st of every month. A final letter is sent out on February 1 with the previous year’s submissions. Therefore, CY 2024 AUR data must be submitted to NHSN no later than January 31, 2025, in order to be included on the February 1, 2025, status report.

No. The CMS Quality Reporting Program and the Medicare Promoting Interoperability (PI) Program are two separate programs. The AUR Measure within the Medicare PI Program does not have quarterly deadlines. Hospitals and CAHs planning to attest to “Option 2 – Validated data production” should report their AUR data into NHSN on an ongoing basis during their 180-day EHR reporting period. Hospitals complete the PI Program attestation/reporting in the CMS Hospital Quality Reporting (HQR) system once a year during the HQR open period from January-February.

If your hospital meets the criteria for an exclusion for the AUR reporting measure within the Medicare PI Program and selects the applicable exclusion when they attest, then you do not need to complete the registration of intent within NHSN.

If you’ve already completed the registration of intent within NHSN but plan to claim an exclusion, you do not need to provide NHSN with test files for the calendar year in which your facility is claiming an exclusion.

Only the NHSN Facility Administrator can complete this task. They will log into NHSN, click “Facility” then “AUR PI Registration” on the left-hand navigation bar.

On the AUR Promoting Interoperability (PI) Program Registration page, read the text and check the box to automatically add your name and the hospital name to the form:

Add up to two optional email addresses for individuals, aside from the NHSN Facility Administrator, who will be involved in the PI Program process and who will receive copies of submission documentation. These people do not need to have NHSN credentials. Adding the email address on this screen ensures they will receive the automated emails regarding your hospital’s AUR submission status. Of note, adding the optional PI Program contact email address on the registration screen will not kick off the process to become an NHSN User. If they are not NHSN users, they will not be able to log into NHSN.

Verify all information is correct and click the “Save” button. Click “Yes” on the pop-up alert to confirm your hospital’s registration of intent to submit AU and AR data.

Note: If the person listed as your NHSN Facility Administrator no longer works at your hospital, please submit a request for that role to be reassigned.

Per the CMS measure specifications, hospitals should respond to the request for test files within 30 days. Failure to respond twice within an EHR reporting period will result in that eligible hospital not meeting the measure. If the hospital registers intent to submit AUR data within NHSN prior to having test files ready, the hospital should reply to the request for test files with their current status.

However, hospitals and CAHs are not required to submit files for validation during CY 2024. Hospitals can attest “Yes” to “Option 1 – Pre-production and validation” as long as they are working towards the creation of AUR files within CY 2024.

Per Medicare PI Program requirements, hospitals must use Certified EHR Technology (CEHRT) that has been updated to meet the ONC Certification Criteria for Health IT. Additionally, per NHSN requirements, hospitals must use a software vendor that has completed the NHSN AU and AR Synthetic Data Set (SDS) Validation requirements.

See more on vendor requirements in question 7 of the Data Submission Requirements section.

These files should be regular CDA files but contain test data without protected health information (PHI) or personally identifiable information (PII). This step requires you to send one CDA file of each type: AU Summary, AR Event (numerator) and AR Summary (denominator). First, check with your AUR reporting software vendor as many have created test files to use for this purpose. If your vendor is unable to provide files with test data, you can send production files for validation. However, please be sure to send these via secure email to NHSNCDA@cdc.gov. If possible, please only include one CDA file for each file type: AU Summary, AR Event (numerator) and AR Summary (denominator).

No. There is no penalty for submitting test files that do not pass the initial round(s) of validation by the NHSN Team. However, hospitals should make every attempt to submit what they believe to be valid AUR CDA files. Please only send CDA files with the extension .xml. Facilities should send all three files at the same time since a passing letter cannot be generated until all three file types have been validated.

As a reminder, hospitals and CAHs are not required to submit files for validation during CY 2024. Hospitals can attest “Yes” to “Option 1 – Pre-production and validation” as long as they are working towards the creation of AUR files within CY 2024.

If the hospital would like an official letter from NHSN showing that the testing and validation step is complete then yes, the hospital should email one file for each type: AU, AR Event and AR Summary. The hospital should include an AU test file regardless of the fact they are already submitting production AU data to NHSN.

Guidance on how to add a new NHSN Monthly Reporting Plan or edit an existing plan to include AUR data can be found in our AU and AR FAQs:

AU FAQs

AR FAQs

The NHSN Facility Administrator and up to two additional email addresses specified on the AUR PI Registration page can receive the automated compliance emails. The Facility Administrator can add the additional emails within NHSN on the Facility > AUR PI Registration page. These emails can be updated at any time on the same page.

Yes, the NHSN Facility Administrator can generate an ad hoc compliance report at any time. After logging into the NHSN facility, click “Facility” then “AUR PI Registration” on the left-hand navigation bar.

On the AUR Promoting Interoperability (PI) Program Registration page, click “Reports”:

On the Request for AUR PI Program Status Report page, select the year of report desired then click “View Report”:

Once generated, the report can be emailed, printed, or downloaded.

We recommend at least two people be educated users for AUR Module reporting. It’s most common for either the pharmacist or the infection preventionist to update the monthly reporting plans within NHSN and submit the AUR data, though any NHSN user with appropriate rights can fulfill these responsibilities. It’s also important for hospitals to designate who will review and validate submitted data and who will run reports and analyze the data. You can divide these tasks the way that works best for your hospital. Assuming you will need to add new user(s) to your NHSN hospital, please follow the steps to ensure the new user(s) has the necessary rights to perform relevant tasks: User Rights in NHSN AUR Module (cdc.gov) [PDF – 491 KB].

For NHSN purposes, we encourage facilities to submit the validated AUR data they have available. If the switch happens in the middle of the month, submit from the vendor system that’s captured the larger portion of the month. Please also make a note for analysis and presentation purposes that for the given month, only a partial month of data was submitted to NHSN.

For the Medicare PI Program, if a hospital switches vendors they still need to submit data for their chosen 180-day EHR reporting period.

The Missing Data Alerts appear in NHSN for any location in your Monthly Reporting Plan for which you haven’t yet submitted data for, but the month has passed. For example, if you listed FacWideIN, MedWard1, and MedWard2 in your January reporting plan to report AU data but then only uploaded one AU file for FacWideIN, you’ll see Missing Summary data alerts for the January AU data for MedWard1 and MedWard2. In this case, your monthly AUR submission status report would show “Yes” for AU for January because you uploaded FacWideIN data, but you should still work with your software vendor to find AU files for all eligible locations.

Similarly, if you’re seeing an alert for Missing AR Event data, first determine if you had any isolates that met eligibility criteria for the month (see General Submission Requirements AR FAQs). If so, work with your software vendor to find those AR Event files. If your facility did not have any isolates that met eligibility criteria for a given month, follow the steps to report No AR Events.

Hospitals do not designate an EHR reporting period within NHSN. That information is entered into the CMS Hospital Quality Reporting (HQR) system. Within NHSN, hospitals should add AUR reporting to their Monthly Reporting Plans prior to uploading AUR data.

Hospitals do not attest to Option 1 or Option 2 within NHSN. The attestations for the AUR reporting measure are completed in the CMS Hospital Quality Reporting (HQR) system once a year for the previous year during the HQR open period. For example, hospitals will attest “Yes” to being in active engagement for CY 2024 then designate either Option 1 or Option 2 within the CMS HQR system at some point during January – February 2025. Refer to the CMS Promoting Interoperability Program Resource Library for more information.

Exclusions are not reported within the NHSN application. Hospitals report measure exclusions at the same time they are reporting/attesting to other Medicare PI Program measures within the CMS Hospital Quality Reporting (HQR) system. Hospitals should reach out to the CMS CCSQ Help Desk for assistance on claiming an exclusion. They can be reached at QnetSupport@cms.hhs.gov or 1-866-288-8912.

Eligible hospitals and CAHs must report a “yes” response or claim an applicable exclusion* for each of the required measures under the Public Health and Clinical Data Exchange objective to receive the full 25 points for that objective.

The scores for each of the individual measures are added together to calculate the total score of up to 105 possible points for each eligible hospital or CAH. For the CY 2024 reporting period, a total score of 60 points or more is one of the requirements for an eligible hospital or CAH to be considered a meaningful EHR user and avoid a downward payment adjustment. Failure to fulfill any of the required measures, including the AUR measure, will result in a score of zero for the Promoting Interoperability Program.

Eligible hospitals or CAHs scoring below 60 points will not be considered meaningful EHR users and could be subject to a downward payment adjustment.

*If an eligible hospital or CAH claims exclusions for all required measures, the entire point value for the Public Health and Clinical Data Exchange Objective would be redistributed to the Provide Patients Electronic Access to Their Health Information measure under the Provider to Patient Exchange objective.

You can find more information, including measure specifications, FAQs and recorded webinars on the CMS Promoting Interoperability Programs page.

If you have SAMS credentials you can submit a ticket to the NHSN Helpdesk using this link: https://servicedesk.cdc.gov/epp. If you do not have SAMS credentials you can email us at NHSN@cdc.gov.

Medicare eligible hospitals and critical access hospitals participating in the Medicare Promoting Interoperability Program may contact the CMS CCSQ help desk for assistance at QnetSupport@cms.hhs.gov or 1-866-288-8912. Hospitals can also submit a question to the CMS Questions & Answers tool: https://cmsqualitysupport.servicenowservices.com/qnet_qa?id=ask_a_question.