Regulatory Experience
Programs & Measures Supported
Chart Abstracted Measures
Hospital Inpatient Quality Reporting (IQR) Program
Stroke (STK) Measures
STK-1 Venous Thromboembolism Prophylaxis — Introduced 2012
STK-2 Discharged on Antithrombotic Therapy — Introduced 2012
STK-3 Anticoagulation Therapy for AFib/Flutter — Introduced 2012
STK-4 Thrombolytic Therapy — Introduced 2012
STK-5 Antithrombotic Therapy by End of Hospital Day 2 — Introduced 2012
STK-6 Discharged on Statin Medication — Introduced 2012
STK-8 Stroke Education — Introduced 2012
STK-10 Assessed for Rehabilitation — Introduced 2012
Venous Thromboembolism (VTE) Measures
VTE-1 VTE Prophylaxis — Introduced 2011
VTE-2 ICU VTE Prophylaxis — Introduced 2011
VTE-3 VTE Patients with Anticoagulation Overlap Therapy — Introduced 2011
VTE-4 VTE Patients Receiving Unfractionated Heparin — Introduced 2011
VTE-5 VTE Warfarin Therapy Discharge Instructions — Introduced 2011
VTE-6 Hospital Acquired Potentially Preventable VTE — Introduced 2011
Perinatal Care (PC) Measures
PC-01 Elective Delivery — Introduced 2012, Retired 2021
PC-02 Cesarean Birth — Introduced 2012
PC-03 Antenatal Steroids — Introduced 2012
PC-04 Health Care Associated Bloodstream Infections in Newborns — Introduced 2012, Retired 2018
PC-05 Exclusive Breast Milk Feeding — Introduced 2012
Emergency Department (ED) Measures
ED-1 Median Time from ED Arrival to ED Departure for Admitted Patients — Introduced 2012, Retired 2015
ED-2 Admit Decision Time to ED Departure for Admitted Patients — Introduced 2012, Retired 2015
Substance Use (SUB) Measures
SUB-1 Alcohol Use Screening — Introduced 2014
SUB-2 Alcohol Use Brief Intervention — Introduced 2014
SUB-2a Alcohol Use Brief Intervention Provided or Offered — Introduced 2014
SUB-3 Alcohol and Other Drug Use Disorder Treatment Provided or Offered — Introduced 2014
SUB-3a Alcohol and Other Drug Use Disorder Treatment — Introduced 2014
Tobacco Treatment (TOB) Measures
TOB-1 Tobacco Use Screening — Introduced 2014
TOB-2 Tobacco Use Treatment Provided or Offered — Introduced 2014
TOB-2a Tobacco Use Treatment — Introduced 2014
TOB-3 Tobacco Use Treatment Provided or Offered at Discharge — Introduced 2014
TOB-3a Tobacco Use Treatment at Discharge — Introduced 2014
Sepsis Measures
SEP-1 Early Management Bundle Severe Sepsis/Septic Shock — Introduced 2015
Immunization Measures
IMM-2 Influenza Immunization — Introduced 2012, replaced IMM-1 which Retired 2013
Surgical Care Improvement Project (SCIP) Measures
SCIP-Inf-1 Prophylactic Antibiotic Received Within 1 Hour — Retired 2015
SCIP-Inf-2 Prophylactic Antibiotic Selection — Retired 2015
SCIP-Inf-3 Prophylactic Antibiotics Discontinued Within 24 Hours — Retired 2015
SCIP-Inf-4 Cardiac Surgery Patients with Controlled Postoperative Blood Glucose — Retired 2015
SCIP-Inf-9 Urinary Catheter Removed on Postoperative Day 1 or 2 — Retired 2015
SCIP-Card-2 Surgery Patients on Beta-Blocker Therapy — Retired 2015
SCIP-VTE-1 Surgery Patients with Recommended VTE Prophylaxis Ordered — Retired 2015
SCIP-VTE-2 Surgery Patients Who Received Appropriate VTE Prophylaxis — Retired 2015
Heart Failure (HF) Measures
HF-1 Discharge Instructions — Retired 2014
HF-2 Evaluation of LVS Function — Retired 2014
HF-3 ACEI or ARB for LVSD — Retired 2014
Acute Myocardial Infarction (AMI) Measures
AMI-1 Aspirin at Arrival — Retired 2014
AMI-2 Aspirin Prescribed at Discharge — Retired 2014
AMI-3 ACEI or ARB for LVSD — Retired 2014
AMI-4 Adult Smoking Cessation Advice — Retired 2014
AMI-5 Beta-Blocker Prescribed at Discharge — Retired 2014
AMI-7a Fibrinolytic Therapy Received Within 30 Minutes — Retired 2014
AMI-8a Primary PCI Received Within 90 Minutes — Retired 2014
Pneumonia (PN) Measures
PN-3b Blood Cultures Performed Before First Antibiotic — Retired 2013
PN-6 Initial Antibiotic Selection — Retired 2013
Hospital Outpatient Quality Reporting (OQR) Program
OP-1 Median Time to Fibrinolysis — Retired 2017
OP-2 Fibrinolytic Therapy Received Within 30 Minutes — Retired 2017
OP-3 Median Time to Transfer to Another Facility — Retired 2017
OP-4 Aspirin at Arrival — Retired 2015
OP-5 Median Time to ECG — Retired 2017
OP-18 Median Time from ED Arrival to ED Departure — Introduced 2012
OP-19 Transition Record with Specified Elements — Introduced 2012, Retired 2016
OP-20 Door to Diagnostic Evaluation — Introduced 2012
OP-21 ED-Median Time to Pain Management — Introduced 2012, Retired 2018
OP-22 Left Without Being Seen — Introduced 2012, Retired 2018
OP-23 Head CT Scan Results — Introduced 2013, Retired 2018
Inpatient Psychiatric Facility Quality Reporting (IPFQR) Program
HBIPS-1 Physical Restraint Use — Introduced 2013, Retired 2018
HBIPS-2 Hours of Physical Restraint Use — Introduced 2013
HBIPS-3 Hours of Seclusion Use — Introduced 2013
HBIPS-4 Patients Discharged on Multiple Antipsychotic Medications — Introduced 2013, Retired 2018
HBIPS-5 Patients Discharged on Multiple Antipsychotic Medications with Appropriate Justification — Introduced 2013
HBIPS-6 Post Discharge Continuing Care Plan Created — Introduced 2013, Retired 2018
HBIPS-7 Post Discharge Continuing Care Plan Transmitted — Introduced 2013, Retired 2018
TOB-1 Tobacco Use Screening — Introduced 2014
TOB-2 Tobacco Use Treatment — Introduced 2014
TOB-3 Tobacco Use Treatment at Discharge — Introduced 2014
SUB-1 Alcohol Use Screening — Introduced 2014
SUB-2 Alcohol Use Brief Intervention — Introduced 2014
SUB-3 Alcohol and Other Drug Use Disorder Treatment — Introduced 2014
FUH Follow-Up After Hospitalization for Mental Illness — Introduced 2016
IMM-2 Influenza Immunization — Introduced 2016
ORYX Performance Measurement Program
Acute Myocardial Infarction (AMI) Measures
AMI-1 Aspirin at Arrival — Retired 2014
AMI-2 Aspirin Prescribed at Discharge — Retired 2014
AMI-3 ACEI or ARB for LVSD — Retired 2014
AMI-4 Adult Smoking Cessation Advice — Retired 2014
AMI-5 Beta-Blocker Prescribed at Discharge — Retired 2014
AMI-7a Fibrinolytic Therapy Received Within 30 Minutes — Retired 2014
AMI-8a Primary PCI Received Within 90 Minutes — Retired 2014
Heart Failure (HF) Measures
HF-1 Discharge Instructions — Retired 2014
HF-2 Evaluation of LVS Function — Retired 2014
HF-3 ACEI or ARB for LVSD — Retired 2014
HF-4 Adult Smoking Cessation Advice — Retired 2014
Pneumonia (PN) Measures
PN-3b Blood Cultures Performed Before First Antibiotic — Retired 2013
PN-6 Initial Antibiotic Selection — Retired 2013
Surgical Care Improvement Project (SCIP) Measures
SCIP-Inf-1 Prophylactic Antibiotic Received Within 1 Hour — Retired 2015
SCIP-Inf-2 Prophylactic Antibiotic Selection — Retired 2015
SCIP-Inf-3 Prophylactic Antibiotics Discontinued Within 24 Hours — Retired 2015
SCIP-Inf-4 Cardiac Surgery Patients with Controlled Postoperative Blood Glucose — Retired 2015
SCIP-Inf-9 Urinary Catheter Removed on Postoperative Day 1 or 2 — Retired 2015
SCIP-Card-2 Surgery Patients on Beta-Blocker Therapy — Retired 2015
SCIP-VTE-1 Surgery Patients with Recommended VTE Prophylaxis Ordered — Retired 2015
SCIP-VTE-2 Surgery Patients Who Received Appropriate VTE Prophylaxis — Retired 2015
Stroke (STK) Measures
STK-1 Venous Thromboembolism Prophylaxis — Introduced 2012
STK-2 Discharged on Antithrombotic Therapy — Introduced 2012
STK-3 Anticoagulation Therapy for AFib/Flutter — Introduced 2012
STK-4 Thrombolytic Therapy — Introduced 2012
STK-5 Antithrombotic Therapy by End of Hospital Day 2 — Introduced 2012
STK-6 Discharged on Statin Medication — Introduced 2012
STK-8 Stroke Education — Introduced 2012
STK-10 Assessed for Rehabilitation — Introduced 2012
Venous Thromboembolism (VTE) Measures
VTE-1 VTE Prophylaxis — Introduced 2011
VTE-2 ICU VTE Prophylaxis — Introduced 2011
VTE-3 VTE Patients with Anticoagulation Overlap Therapy — Introduced 2011
VTE-4 VTE Patients Receiving Unfractionated Heparin — Introduced 2011
VTE-5 VTE Warfarin Therapy Discharge Instructions — Introduced 2011
VTE-6 Hospital Acquired Potentially Preventable VTE — Introduced 2011
Perinatal Care (PC) Measures
PC-01 Elective Delivery — Introduced 2012, Retired 2021
PC-02 Cesarean Birth — Introduced 2012
PC-03 Antenatal Steroids — Introduced 2012
PC-04 Health Care Associated Bloodstream Infections in Newborns — Introduced 2012, Retired 2018
PC-05 Exclusive Breast Milk Feeding — Introduced 2012
PC-06 Unexpected Complications in Term Newborns — Introduced 2014
Substance Use (SUB) Measures
SUB-1 Alcohol Use Screening — Introduced 2014
SUB-2 Alcohol Use Brief Intervention — Introduced 2014
SUB-2a Alcohol Use Brief Intervention Provided or Offered — Introduced 2014
SUB-3 Alcohol and Other Drug Use Disorder Treatment Provided or Offered — Introduced 2014
SUB-3a Alcohol and Other Drug Use Disorder Treatment — Introduced 2014
Tobacco Treatment (TOB) Measures
TOB-1 Tobacco Use Screening — Introduced 2014
TOB-2 Tobacco Use Treatment Provided or Offered — Introduced 2014
TOB-2a Tobacco Use Treatment — Introduced 2014
TOB-3 Tobacco Use Treatment Provided or Offered at Discharge — Introduced 2014
TOB-3a Tobacco Use Treatment at Discharge — Introduced 2014
Immunization Measures
IMM-1 Influenza Immunization — Retired 2013
IMM-2 Pneumococcal Vaccination — Introduced 2012
Sepsis Measures
SEP-1 Early Management Bundle Severe Sepsis/Septic Shock — Introduced 2015
Behavioral Health Care (BHC) Measures
HBIPS-1 Physical Restraint Use — Introduced 2013, Retired 2018
HBIPS-2 Hours of Physical Restraint Use — Introduced 2013
HBIPS-3 Hours of Seclusion Use — Introduced 2013
HBIPS-4 Patients Discharged on Multiple Antipsychotic Medications — Introduced 2013, Retired 2018
HBIPS-5 Patients Discharged on Multiple Antipsychotic Medications with Appropriate Justification — Introduced 2013
HBIPS-6 Post Discharge Continuing Care Plan Created — Introduced 2013, Retired 2018
HBIPS-7 Post Discharge Continuing Care Plan Transmitted — Introduced 2013, Retired 2018
TOB-1 Tobacco Use Screening — Introduced 2014
TOB-2 Tobacco Use Treatment — Introduced 2014
TOB-3 Tobacco Use Treatment at Discharge — Introduced 2014
SUB-1 Alcohol Use Screening — Introduced 2014
SUB-2 Alcohol Use Brief Intervention — Introduced 2014
SUB-3 Alcohol and Other Drug Use Disorder Treatment — Introduced 2014
FUH Follow-Up After Hospitalization for Mental Illness — Introduced 2016
IMM-2 Influenza Immunization — Introduced 2016
CMS Critical Access Hospital Quality Reporting (CAHQR) Program
Outpatient Measures (OP)
OP-1 Median Time to Fibrinolysis — Retired 2017
OP-2 Fibrinolytic Therapy Received Within 30 Minutes — Retired 2017
OP-3 Median Time to Transfer to Another Facility — Retired 2017
OP-4 Aspirin at Arrival — Retired 2015
OP-5 Median Time to ECG — Retired 2017
OP-18 Median Time from ED Arrival to ED Departure — Introduced 2012
OP-20 Door to Diagnostic Evaluation — Introduced 2012
OP-21 ED Median Time to Pain Management — Introduced 2012, Retired 2018
OP-22 Left Without Being Seen — Introduced 2012, Retired 2018
OP-23 Head CT Scan Results — Introduced 2013, Retired 2018
Inpatient Measures
Acute Myocardial Infarction (AMI) Measures
AMI-1 Aspirin at Arrival — Retired 2014
AMI-2 Aspirin Prescribed at Discharge — Retired 2014
AMI-3 ACEI or ARB for LVSD — Retired 2014
AMI-4 Adult Smoking Cessation Advice — Retired 2014
AMI-5 Beta-Blocker Prescribed at Discharge — Retired 2014
AMI-7a Fibrinolytic Therapy Received Within 30 Minutes — Retired 2014
AMI-8a Primary PCI Received Within 90 Minutes — Retired 2014
Heart Failure (HF) Measures
HF-1 Discharge Instructions — Retired 2014
HF-2 Evaluation of LVS Function — Retired 2014
HF-3 ACEI or ARB for LVSD — Retired 2014
HF-4 Adult Smoking Cessation Advice — Retired 2014
Pneumonia (PN) Measures
PN-3b Blood Cultures Performed Before First Antibiotic — Retired 2013
PN-6 Initial Antibiotic Selection — Retired 2013
Surgical Care Improvement Project (SCIP) Measures
SCIP-Inf-1 Prophylactic Antibiotic Received Within 1 Hour — Retired 2015
SCIP-Inf-2 Prophylactic Antibiotic Selection — Retired 2015
SCIP-Inf-3 Prophylactic Antibiotics Discontinued Within 24 Hours — Retired 2015
SCIP-Inf-4 Cardiac Surgery Patients with Controlled Postoperative Blood Glucose — Retired 2015
SCIP-Inf-9 Urinary Catheter Removed on Postoperative Day 1 or 2 — Retired 2015
SCIP-Card-2 Surgery Patients on Beta-Blocker Therapy — Retired 2015
SCIP-VTE-1 Surgery Patients with Recommended VTE Prophylaxis Ordered — Retired 2015
SCIP-VTE-2 Surgery Patients Who Received Appropriate VTE Prophylaxis — Retired 2015
Stroke (STK) Measures
STK-1 Venous Thromboembolism Prophylaxis — Introduced 2012
STK-2 Discharged on Antithrombotic Therapy — Introduced 2012
STK-3 Anticoagulation Therapy for AFib/Flutter — Introduced 2012
STK-4 Thrombolytic Therapy — Introduced 2012
STK-5 Antithrombotic Therapy by End of Hospital Day 2 — Introduced 2012
STK-6 Discharged on Statin Medication — Introduced 2012
STK-8 Stroke Education — Introduced 2012
STK-10 Assessed for Rehabilitation — Introduced 2012
Venous Thromboembolism (VTE) Measures
VTE-1 VTE Prophylaxis — Introduced 2011
VTE-2 ICU VTE Prophylaxis — Introduced 2011
VTE-3 VTE Patients with Anticoagulation Overlap Therapy — Introduced 2011
VTE-4 VTE Patients Receiving Unfractionated Heparin — Introduced 2011
VTE-5 VTE Warfarin Therapy Discharge Instructions — Introduced 2011
VTE-6 Hospital Acquired Potentially Preventable VTE — Introduced 2011
Perinatal Care (PC) Measures
PC-01 Elective Delivery — Introduced 2012, Retired 2021
PC-02 Cesarean Birth — Introduced 2012
PC-03 Antenatal Steroids — Introduced 2012
PC-04 Health Care Associated Bloodstream Infections in Newborns — Introduced 2012, Retired 2018
PC-05 Exclusive Breast Milk Feeding — Introduced 2012
Substance Use (SUB) Measures
SUB-1 Alcohol Use Screening — Introduced 2014
SUB-2 Alcohol Use Brief Intervention — Introduced 2014
SUB-2a Alcohol Use Brief Intervention Provided or Offered — Introduced 2014
SUB-3 Alcohol and Other Drug Use Disorder Treatment Provided or Offered — Introduced 2014
SUB-3a Alcohol and Other Drug Use Disorder Treatment — Introduced 2014
Tobacco Treatment (TOB) Measures
TOB-1 Tobacco Use Screening — Introduced 2014
TOB-2 Tobacco Use Treatment Provided or Offered — Introduced 2014
TOB-2a Tobacco Use Treatment — Introduced 2014
TOB-3 Tobacco Use Treatment Provided or Offered at Discharge — Introduced 2014
TOB-3a Tobacco Use Treatment at Discharge — Introduced 2014
Sepsis Measures
SEP-1 Early Management Bundle Severe Sepsis/Septic Shock — Introduced 2015
Immunization Measures
IMM-1 Influenza Immunization — Retired 2013
IMM-2 Influenza Immunization — Introduced 2012
Software Used
eQualityCheck to abstract patients data
SAP Business Objects to view reports
Submission in portals to reporting agencies via browser or CSV
Agencies
CMS
TJC
State Agencies
Electronic Measures
Programs
Meaningful Use (MU)
Stage 1 (2011-2012) — Data Capture and Sharing
CQMs- Clinical Quality Measures
Stage 2 (2014) — Advance Clinical Processes
Electronic submission of clinical quality measures (eCQMs)
Stage 3 (2016 forward) — Improved Outcomes
Clinical decision support for high-priority conditions
Computerized provider order entry (CPOE)
Electronic submission of clinical quality measures (eCQMs)
Promoting Interoperability (PI)
Submit data based on the CMS required reporting period.
Report data using the ONC Health IT certification criteria to meet the CEHRT requirement.
Report data using CMS approved CY 2025 measure specifications.
Successfully submit data to the HQR Secure Portal by the submission deadline:
EHR Incentive Programs
Medicare EHR Incentive Program — incentive payments to eligible professionals and hospitals for demonstrating meaningful use
Medicaid EHR Incentive Program — separately administered by states, offered incentives for adoption and meaningful use
Eligible Professionals (EPs) — physicians and other qualified clinicians
Eligible Hospitals (EHs) — acute care hospitals and critical access hospitals
Critical Access Hospitals (CAHs) — separate reporting requirements and payment methodology
Software Used
Cerner Millennium Suite for Data Capture
SAP Business Objects to View Reports
Submission in portals to reporting agencies via browser or CSV
Agencies
CMS
TJC
State Agencies