Reporting And Data

Promoting Interoperability Programs (PIP) & Electronic Health Records - Meaningful Use (EHR-MU)

Latest Update: August 11, 2020

Reporting Information

In 2011, CMS established the Medicare and Medicaid EHR Incentive Programs (now known as the Promoting Interoperability Programs) to encourage eligible professionals (EPs), eligible hospitals, and CAHs to adopt, implement, upgrade (AIU), and demonstrate meaningful use of certified electronic health record technology (CEHRT). The program consisted of three stages and by using certified EHR technology, the provider must submit to the Secretary of Health & Human Services (HHS) information on the quality of care and other measures.

Responsible Party

Who Must Report?

The following hospitals are eligible to participate in the Medicare Promoting Interoperability Program:

  • Subsection (d) hospitals in the 50 states, DC, and Puerto Rico that are paid under the Inpatient Prospective Payment System (IPPS)
  • CAHs
  • Medicare Advantage (MA-Affiliated) Hospitals


When Do I Report?

A minimum of any continuous 90-day period within calendar (CY) 2020 or 2021, respectively. Please contact your State Medicaid Agency for information on the attestation period and deadline. (Contact information below)

*November 30, 2020: Deadline for critical access hospitals (CAHs) to submit a hardship exception application*


How Do I Report?

Medicare eligible hospitals and CAHs must attest through the QualityNet Secure Portal. (Visit Portal Site button above)

Objectives Measures Points
e-Prescribing e-Prescribing* 10 Points
Query of PDMP 5 Points (Bonus)
Health Information Exchange Support Electronic Referral Loops by Sending Health Information 20 Points
Support Electronic Referral Loops by Receiving and Incorporating Health Information 20 Points
Provider to Patient Exchange Provides Patients Electronic Access to their Health Information 40 Points
Public Health and Clinical Data Exchange Report to two different public health agencies or clinical data registries.** 10 Points

*Exclusion available

**Public Health Objective included in the programs: Public Health Registry and Clinical Data Registry Reporting. The specific measures included under the above objective are-

  1. Immunization Registry Reporting. See "WebIZ (Immunization Information System)(IIS)"
  2. Syndromic Surveillance Reporting. See "Syndromic Surveillance"
  3. Electronic Case Reporting.
  4. Public Health Registries Reporting*** See "Cancer Registry (Nevada Central Cancer Registry)(NCCR)"
  5. Clinical Data Registries Reporting
  6. Electronic Reportable Laboratory Test Reporting (for Hospitals only).

***includes- a) Cancer Reporting by Eligible Practitioners (EPs) only to State Cancer Registries. b) Reporting data by EPs and Eligible Hospitals (EHs)/CAHs to CDC/NCHS and CDC/NHSN programs for Health Care Surveys and Antibiotic Use (AU) & Antibiotic Resistance (AR). EHs and CAHs must attest to at least two measures from 1 through 6 above.

Contact Information



Electronic Health Record Incentive Payment Program Webpage: http://dhcfp.nv.gov/Providers/PI/EHRMain/

Nevada HIT - NevadaHIT@dhcfp.nv.gov

EHR Incentive Program Support - NV_Support@NVEHRSupport.com


Why Should I Report?

Starting in 2016, eligible professionals and hospitals having failed to adopt and demonstrate meaningful use of certified EHR technology (and related health IT) in the preceding year were hit with Medicare payment reductions. If a CAH does not demonstrate meaningful use, its Medicare reimbursement will be reduced from 101 percent of its reasonable costs to a specified percent for each year.


The legal mandate requiring reporting


Any other pertinent information

Originating Legislation: H.R.1 (2009)

Although many of these requirements apply to individual medical professionals and other types of hospitals and health care facilities, the information is presented solely to support Critical Access Hospitals. The reporting requirements and legal mandates on this site are not an exhaustive list and Nevada Rural Hospital Partners, Inc. bears no responsibility or liability for any hospitals' or providers' failure to comply with Federal or State laws or regulations.