For healthcare facilities, particularly hospitals, actively participating in antimicrobial use and resistance (AUR) reporting is not just a matter of contributing to a larger cause; it's a compliance requirement that has significant financial implications for most hospitals.
In the ongoing battle against antimicrobial resistance, one of the strongest weapons at our disposal is information. The collection and analysis of data related to the use of antimicrobials and the incidences of resistance are critical for guiding public health strategies and ensuring the effectiveness of treatments.
The CMS Medicare Promoting Interoperability program imposes financial incentives for hospitals to submit data to the NHSN AUR option by making it a required measure for 2024. Hospitals select their electronic health record (EHR) reporting period in the Medicare Promoting Interoperability program, and in 2024 the EHR reporting period is 180 days. In other words, the hospitals may select which 180 continuous days to engage and comply with the reporting requirements for the Medicare Promoting Interoperability program. The selection and definition of the EHR reporting period is usually done by the Quality department of most hospitals, and we encourage early and frequent communications as the EHR reporting period determines the relevant dates and corresponding deadlines for your organization.
It is important to note that even for hospitals that had been submitting AUR data to NHSN prior to the imposed requirements, hospitals must register their intent to participate to obtain credit for the AUR measure.
In this article, we will review how to register your intention to participate in AUR reporting for the Medicare Promoting Interoperability program. Further information and a list of FAQs that’s periodically updated may be found on the NHSN website.
Registering interest for the AUR module
To participate in the AUR module for Medicare Promoting Interoperability Program, hospitals must take proactive steps to register their intent. Here's a simplified breakdown of the process:
Identify your reporting capability and select an ONC-certified partner
Before registering, hospitals should assess their ability to collect and report the necessary data. This might involve coordinating with clinical, IT, and pharmacy departments to ensure the infrastructure and procedures for data collection are in place. Data source requirements such as bar-coded medication administration scanning and electronic posting of microbiology results must be satisfied to participate in the AUR reporting program. Hospitals must use an ONC HIT-certified vendor like—Sentri7 Antimicrobial Stewardship—and its AU and AR-validated software to receive credit for the Medicare Promoting Interoperability program.
Register intent on the NHSN website
Hospitals need to enroll in NHSN (if not already) and complete a specific registration indicating their intent to submit data to the AUR module. It’s important to note:
- Only the NHSN Facility Administrator can view and complete this task.
- All facilities must complete this step regardless of whether they are already sending production AU and AR data to NHSN.
- Read the step-by-step instructions in this NHSN AUR Promoting Interoperability Guide.
Complete training modules
The CDC provides training resources and guidelines to help hospitals understand the data requirements and reporting procedures for the AUR module. Ensuring that relevant staff members are familiar with these guidelines is crucial for accurate and timely data submission.
Respond to NHSN invitation to begin testing
Shortly after registering your intent to submit AUR data, NHSN will email the program administrator to begin testing and data validation.
- If you are new to AUR data submission and will not be able to send 180 continuous days of production data in 2024, you may email NHSN the required three test CDA files to the NHSN CDA Helpdesk at the address provided in the invitation email. The submission of these files will satisfy the “OPTION 1 – pre-production and validation” of the program requirement. This process will count as being in active engagement for the 2024 program year. Due to the number of hospitals participating in this program, it may take NHSN up to 8 weeks to complete validation of the test file. Therefore hospitals should register and submit test files no later than November 1, 2024.
- If you are sending production data already, or planning to send 180 continuous days of production data in 2024, submit the data normally, and when you receive the invitation email to begin testing, you may simply reply that you are submitting production data and will not be sending the test file.
- Deadlines: Once you’ve registered your intent to participate as outlined above, your hospital should respond to the request for test files within 30 days of the request (or notify them you are sending production data). If you are unable to provide NHSN with the test files within 30 days, you may request an extension by providing them a status update within that 30-day window, and follow up with regular status updates at least every 60 days until the test files are sent to NHSN.
Begin data collection and reporting
With registration complete and training in hand, hospitals can start the ongoing process of collecting and submitting data to the AUR module. This involves regular, systematic data reporting of antimicrobial use and resistance within the facility. For hospitals submitting production data for calendar year 2024, the data must be sent to NHSN no later than January 31, 2025, to be included on the February 1, 2025, status report.
Maintain status letters to document compliance
During the AUR PI registration process, the facility NHSN administrator may enter up to 2 additional email addresses for AUR status letters. At the beginning of each month, NHSN will provide the facility with a status report. A final letter will also be sent out on February 1 with the status of the previous year’s data submission.
By participating in AUR reporting, hospitals not only meet regulatory requirements but also contribute to a national effort to monitor and combat antimicrobial resistance. The process may seem daunting initially, but the long-term benefits for public health, hospital compliance, and patient care are undeniable. The fight against antimicrobial resistance is a collective effort, and through diligent reporting, hospitals play a pivotal role in safeguarding the effectiveness of antimicrobial drugs for their patients and communities.