Promoting Interoperability Program
The NHSN Antimicrobial Use (AU) and Antimicrobial Resistance (AR) (AUR) Module reporting was identified as one option to meet the Public Health Registry reporting element within the Centers for Medicare and Medicaid Services (CMS) Medicare Promoting Interoperability (PI) Program for eligible hospitals and critical access hospitals (CAHs) in 2017. This option continues to be available in calendar year (CY) 2023, and facilities reporting to the NHSN AUR Module will receive 5 bonus points. For measure details, please see the applicable Medicare Promoting Interoperability Program Specification Sheets.
Beginning in CY 2024, CMS finalized changes to the Medicare Promoting Interoperability Program for eligible hospitals and critical access hospitals (CAHs) that include a new AUR Surveillance measure under the Public Health and Clinical Data Exchange Objective. To obtain credit for calendar year 2024, eligible hospitals and CAHs must attest to being in active engagement with CDC’s NHSN to submit AUR data for the EHR reporting period, or else claim an applicable exclusion. Further, to meet the CMS PI Program requirement, facilities must use CEHRT updated to meet 2015 Edition Cures Update criteria, including criteria at 45 CFR 170.315 (f)(6).
Refer to the CMS Promoting Interoperability Program webpages for additional information, including CY-specific submission requirements.
- Promoting Interoperability – Guidance for NHSN Facilities – March 2023 [PDF – 356 KB]
- The NHSN user interface includes an AUR Promoting Interoperability (PI) Program registration of intent page.
- Only the NHSN Facility Administrator has access to register the facility’s AUR PI Program intent.
- Perquisites for registering intent and sending electronic AUR Clinical Document Architecture (CDA) data:
- Facility is enrolled in NHSN
- If the facility is not enrolled, review information on enrolling your facility
- Facility locations are mapped within NHSN
- Monthly reporting plans exist for month/year of data to be transmitted
- Assigned NHSN Object Identifier (OID) has been entered into NHSN
- If facility does not have an OID, view the Object Identifier (OID) assignment procedure to request a unique OID
- Software requirements
- For the NHSN application, facilities are required to use vendor/homegrown software that has been validated by NHSN to submit data to the AUR Module. See the lists of AU and AR validated vendor software. Note: vendor software is not required to be validated for AR submission until May 2023.
- For the CMS PI Program, facilities are required to use vendor software that has been certified by the Office of the National Coordinator for Health Information Technology (ONC) Health IT Certification Program for NHSN Antimicrobial Use and Resistance reporting. Use this site to check if your vendor has been certified.
- Facility is enrolled in NHSN
- Facilities that have registered their intent shall receive a data submission status report monthly regarding whether AUR data are successfully uploaded to NHSN. An email shall be sent to the Facility Administrator and two optional emails as designated on the AUR PI Program registration page. Registered facilities will receive an emailed annual report detailing the previous year’s submissions of AUR data on February 1 of each year.
- For more detailed information on NHSN CDA files, view the NHSN CDA Submission Support Portal (CSSP) site.
- Download AU and AR CDA Toolkits
- Toolkits include Extensible Markup Language (XML) samples, helpful hints, vocabulary, business rule information, important links, etc.
Facilities are required to use vendor software that has been validated by NHSN. The NHSN vendor validation process involves using NHSN-provided synthetic data to confirm vendor software can accurately compile and aggregate AU and AR data according the NHSN AUR Module protocol. Vendors, please see the AUR SDS webpage for details on this initiative.
To be considered a meaningful user and avoid a downward payment adjustment, eligible hospitals and CAHs attesting to the Medicare Promoting Interoperability Program will be required to use CEHRT that has been updated to meet 2015 Edition Cures Update criteria.
As part of this certification, an Electronic Health Record (EHR) or EHR Module must be capable of creating CDA documents for AUR conformant to the CDA Implementation Guides below. (You must log into the HL7 site to download an Implementation Guide)
The following CDA files must all be successfully generated.
- Antimicrobial Resistance Option (ARO) Report (Numerator): Use the SVAP-approved standard: R2 Implementation Guide: Healthcare Associated Infection (HAI) Reports, Release 3 – US Realm (Volume 3)
- Antimicrobial Resistance Option (ARO) Summary Report (Denominator): Use the SVAP-approved standard: R2 Implementation Guide: Healthcare Associated Infection (HAI) Reports, Release 3 – US Realm (Volume 3)
- Antimicrobial Use (AUP) Summary Report (Numerator and Denominator): Continue to use the base standard adopted at 170.205(r)(1): Release 2: Healthcare Associated Infection Reports, Release 1 – August 2013, specific document template in Section 220.127.116.11 (pages 56-58)
Vendors may self-check their XML files for compliance to the Implementation Guides prior to sending them to the ONC Health IT Certification Program. View the instructions for using the Lantana Consulting Group Schematron Validator on the NHSN Validation Tools & Test Sites webpage.
To learn more about the ONC Health IT Certification Program and the “Transmission to public health agencies – antimicrobial use and resistance reporting” criterion at 170.315(f)(6), please refer to the Certification Companion Guide for (f)(6) published by ONC. For more information about ONC Certification generally, please refer to the ONC Certification homepage.