2022 Hospital PI and eCQM Requirements

CMS finalized several updates that raise the level of performance hospitals must meet to demonstrate meaningful use in the PI program. The minimum score necessary to avoid the PI penalty increased and, over the next few years, CMS will establish a longer EHR reporting period and require CEHRT upgrades.

Minimum PI score increases in 2022

Hospitals must earn at least 60 points to avoid the PI penalty starting 2022. In addition to earning points through performance on required measures, hospitals can earn up to 15 bonus points through reporting certain optional measures. See the section on 2022 hospital PI measures for more details.

CEHRT upgrade required for 2023

For 2022, hospitals can use either 2015 Edition and/or the 2015 Edition Cures Update CEHRT. Starting 2023, hospitals must use 2015 Edition Cures Update CEHRT. This timeline is consistent with the ONC Cures Act rule, which requires EHR vendors to roll out these updates to their customers by Dec. 31, 2022.

Reporting period doubles in 2024

The EHR reporting period remains at a minimum continuous 90 days for program years 2022 and 2023, but this is set to increase to an any continuous minimum 180 days starting 2024. Many hospitals have relied on the flexibility offered by a 90-day reporting period to address issues that would otherwise prevent hospitals from reporting PI.

2022 hospital PI measures

CMS added a new measure to the Protect Patient Health Information objective. Starting 2022, hospitals must attest to whether they completed an annual self assessment of all nine Safety Assurance Factors for EHR Resilience (SAFER) Guides. The new SAFER Guides measure requirement comes in addition to the existing requirement to complete an annual security risk analysis.

SAFER Guides required, but not scored in 2022

While the SAFER Guides measure is required in 2022, it will not be scored. This means reporting either “yes” or “no” will not affect your PI score for 2022. This policy could change across the next few years, subject to future rulemaking.

Assess potential EHR safety risks annually

The SAFER Guides aim to prepare hospitals for planned and unplanned events that may lead to EHR unavailability and safety risks, such as system disruption, failure, or natural disasters. The self assessments help hospitals raise awareness of potential risks and learn about practices to mitigate these risks. Completing the assessments does not require an organization to confirm that it has fully implemented each practice described in the guides.

Hospitals should engage a multidisciplinary team to conduct the self assessments that includes stakeholders from clinical, nursing, health information management, and IT departments. Broadly, the team should consist of staff responsible for implementing and maintaining internal technology systems and external data connections, such as a health information exchange.

CMS wants to use the PI program to better equip public health agencies (PHAs) with data that could help them tackle current and future public health emergencies. As in previous years, the Public Health and Clinical Data Reporting objective includes six measures. But starting 2022, hospitals must report a specific set of four required measures.

Increasing the public health reporting requirement

Hospitals must work with their EHR vendors and state PHAs to report the Immunization Registry, Syndromic Surveillance, Electronic Reportable Laboratory Results, and Electronic Case Reporting (eCR) measures to meet PI program requirements. In contrast, hospitals previously were required to report any two measures out of the six measures available.

Active Engagement required, with limited exclusions

Hospitals must either report “yes” to Active Engagement with their PHA or claim an exclusion across all four required measures. Each measure allows certain exclusion criteria, for example, if the state PHA is not ready to receive data. But lacking the necessary EHR functionality does not qualify for an exclusion.

Optional measures offer bonus points

Hospitals may also choose to report either the Public Health Registry or Clinical Data Registry measure for 5 bonus points. Reporting both of these optional measures would not earn additional bonus points compared to reporting one of these optional measures.

CMS is incentivizing hospitals to report optional measures in two main ways, either through earning bonus points in addition to reporting required measures or as a reporting option in place of certain existing required measures.

Up to 15 bonus points available

Under the Electronic Prescribing objective, CMS will award 10 bonus points for reporting the optional Query of PDMP measure, which is double the number of bonus points previously available through this measure. Additionally, starting 2022, hospitals can earn 5 bonus points under the Public Health and Clinical Data Reporting objective for reporting either one of the two optional measures.

Alternate HIE reporting option

Reporting the new bi-directional exchange measure earns the full 40 points available under the HIE objective. This optional measure replaces the two existing percentage-based HIE measures for sending and receiving/reconciling health information. Hospitals must confirm they meet the rigorous conditions outlined for the new measure in these three attestation statements:

• I participate in an HIE in order to enable secure, bi-directional exchange to occur for every patient encounter, transition or referral, and record stored or maintained in the EHR during the performance period in accordance with applicable law and policy.
• The HIE that I participate in is capable of exchanging information across a broad network of unaffiliated exchange partners including those using disparate EHRs, and does not engage in exclusionary behavior when determining exchange partners.
• I use the functions of CEHRT to support bi-directional exchange with an HIE.

For 2022, CMS finalized the same eCQM options compared to the previous year —there are nine eCQMs available for reporting. But CMS added two new eCQMs in 2023 and removed four existing eCQMs in 2024. The following table lists the eCQM options from 2022 through 2024.

2022 eCQM reporting requirement

The 2021 IPPS final rule updated several eCQM policies for 2022. Hospitals must submit three calendar quarters of eCQM data, an increase of one quarter from the prior year. Starting 2022, hospitals must report the Safe Use of Opioids eCQM as one of the four required eCQMs.