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How to Implement the Hospital Harm Opioid-Related Adverse Events eCQM

Opioids have taken national center stage for several years now. Shows like Netflix’s Painkiller or Hulu’s Dopesick have put opioids front and center for many Americans who might not have known about the medication’s addictive qualities or sordid pharmaceutical past.

But in a hospital setting, using an opioid for a patient’s severe pain is effective. There are, however, instances where the mismanagement of the medication leads to what CMS classifies as adverse events. CMS reports that nearly 5% of hospitalized patients experience an adverse drug event, making them one of the most common types of inpatient errors. Patients who experience an opioid-related adverse event can experience delirium and respiratory depression and have associated financial implications with 55% longer length of stay, 47% higher costs, and a 36% higher risk of readmission within 30 days. Worse yet, CMS says in a closed-claims analysis they found 97% of adverse events were judged preventable with better monitoring and response.

Broadly CMS has, in the IQR program, categorically named adverse events in a hospital setting as “Hospital Harm” eCQMs. In other programs you may know these as PSIs or Patient Safety Indicators. So far, CMS has rolled out five hospital harm eCQMs. They are HH-01 and HH-02 (hypo and hyperglycemia), HH-PI and HH-AKI (pressure injury and acute kidney injury), and today’s topic, HH-ORAE or Hospital Harm Opioid-Related Adverse Events.

How is ORAE eCQM calculated?

HH-ORAE is also known as CMS 819. The specification (spec) can be found on the eCQI resource center. The HH-ORAE measure assesses the number of patients who came into your hospital and were given an opioid who were then given an opioid antagonist within 12 hours. Please note, this excludes any patients given an opioid antagonist in the operating room.

It’s an inverse measure so the ideal rate is 0%, though no official CMS threshold exists. You may choose to report this measure as one of your three self-selected eCQMs in the 2024 CMS Inpatient Quality Reporting (IQR) program.

A Review of ORAE eCQM Populations

Let’s start with the Initial Patient Population which in the case of this measures is also the Denominator population.

Initial Patient Population/Denominator

Layman’s description: To get into the Initial Patient Population (IPP) and Denominator the patient must have an inpatient encounter. They must be 18 years of age or older and had at least one opioid medication administered **outside of an OR setting**, during the encounter. 

Simplified logic: Initial Population / Denominator

  • Inpatient Encounter
  • ≥ 18 years of age
  • Opioid medication administration occurs during encounter, but outside of Operating Room (excludes patients who receive an Opioid when in a location of OR)
  • Discharged during the reporting period

Note: the 2023 version of this eCQM spec excludes patients who were administered opioids in an OR setting from the Numerator. The 2024 version excludes them from the IPP.

There are no SPECIFIC POPULATIONS FOR Exclusions or Exceptions.


Layman’s description: A patient gets into the numerator if they received an opioid antagonist within 12 hours following the administration of the opioid medication. Only one numerator event is counted per encounter.

Just like the opioid itself, the opioid antagonist must have been administered outside the operating room.

 Simplified logic: Numerator

  • Opioid antagonist administered within 12 hours after the opioid administration
  • Route of administration of the opioid antagonist is “non-enteral,” defined as intranasal spray, inhalation, intramuscular, subcutaneous, or intravenous injection

Note: the 2023 version of this eCQM spec did not specify how the opioid antagonist was administered (non-enternal). That is added to the 2024 eCQM spec. 

Your performance rate is then calculated using these populations. Remember, a lower number is better.

Setting up the ORAE eCQM Workflow

Once you’ve pulled apart the specification and understand the population requirements, the next step is to do a current state analysis of where (and if!) these items are currently captured in your EHR and compare that to the measure populations and requirements. I find that a workflow graphic like the one I’ve provided below is helpful as you do this process. 

You’ll see (from left to right) I listed the different populations followed by the data elements, then the expected EHR process for capturing the documentation. Lastly, we’ve provided the type of codes you’ll need to map to capture that element. Review this, compare to your current workflow, and identify what you’ll need to adjust and update to align with the measure requirements.


Data Element

Data Capture Workflow

Code Type

Inpatient Encounter



Opioid Administration



Operating Room





Data Element

Data Capture Workflow

Code Type

Opioid Administration



Opioid Antagonist Administration



Route of Administration




Helpful Tips to Succeed with ORAE

The key to a successful implementation, is to first ensure those medications are properly mapped. Then carefully review where your medications are administered and make sure the OR location is properly mapped as well. 

Tracking how the opioid antagonist is administered is also important. It must be delivered either by intranasal spray, inhalation, intramuscular, subcutaneous, or intravenous injection, so you will need to make sure the route of administration is also being tracked in your data.

Be advised: your hospital quality team is going to have to work closely with your OR team to establish new methods of tracking opioid administration within the OR setting. Just because patients who are administered an opioid in the OR setting are excluded from this measure, doesn’t mean we don’t have to keep track of those patients. To get accurate results for the initial patient population, we must know where patients were administered an opioid in the first place. So, it’s important to start establishing tracking methods now to ensure your data will be correct.

Should you select and submit the ORAE eCQM?

As far as eCQM implementations go this one is relatively easy with a few critical elements that will make or break your measure performance.

Remember that all eCQMs you submit to CMS will be publicly reported on Care Compare. Assuming you don’t have major problems with opioid-related adverse events, this measure could be a good one from a public reputation perspective. The general public has a higher awareness of opioids as compared to VTE. No one is talking about VTE around the dinner table. And if your hospital can point to careful care of patients and opioids that’s a plus.

I’ve done these eCQM reviews for a long time now and I can assure you that no matter how much time you spend with the specifications, it doesn’t really click until you’ve set it up and worked through an actual patient who qualifies for the population(s). Only then can the validation and improvement work begin.

So, I suggest getting started on this measure right away. The sooner you understand the measure logic and its components, the sooner you understand how to implement requirements at your hospital, the sooner you can do the real work of improving performance.

Don’t go it alone! Reach out to us today to talk about how we can help your team. Leave all this measure deciphering to us. We guide you as you set up the measure, troubleshoot technical errors and come up with strategies for improvement like clinician adherence. Schedule a 1:1 call with us today to see our ENCOR for Electronic Hospital Measures software.



Medisolv Can Help

This is a big year for Quality. Medisolv can help you along the way. Along with award-winning software you receive a Clinical Quality Advisor that helps you with all of your technical and clinical needs.

We consistently hear from our clients that the biggest differentiator between Medisolv and other vendors is the level of one-of-one support. Especially if you use an EHR vendor right now, you’ll notice a huge difference.

  • We help troubleshoot technical and clinical issues to improve your measures.
  • We keep you on track for your submission deadlines and ensure you don’t miss critical dates
  • We help you select and set up measures that make sense based on your hospital’s situation.
  • You receive one Clinical Quality Advisor that you can call anytime with questions or concerns. 

Contact us today.



Kristen Beatson, RN

Kristen Beatson is a Registered Nurse and the Vice President of Electronic Measures at Medisolv. With over 15 years of experience in digital health quality measurement, Kristen is a leading expert in electronic measurement logic, nomenclature requirements, and best practices for data capture and validation. Her exceptional contributions to the healthcare IT landscape include spearheading the validation of Core Clinical Data Elements for the Hospital-wide Readmission and Mortality hybrid measures, as well as developing eCQM specifications for the CMS Social Drivers of Health (SDOH) measures. Kristen's expertise and accomplishments make her a sought-after public speaker, and she has shared her insights at prestigious conferences like HIMSS, keeping quality leaders informed about the ever-changing landscape of healthcare measures. Kristen Beatson began her career in Nursing in 1994, working in various pediatric positions before transitioning to informatics. She spent several years supporting advanced clinical application implementations at a community hospital where she developed an interest in improving quality through electronic documentation. She began her career at Medisolv in 2011. Kristen now leads Medisolv’s team of Quality Advisors who help hospitals and other healthcare providers prepare for digital measurement. Kristen and her team work closely with healthcare quality leaders to assess and analyze workflows, evaluate data for the purpose of validation and compliance, and submit Electronic Clinical Quality Measures (eCQMs) data on behalf of hundreds of hospitals each year to regulatory bodies, including the Centers for Medicare and Medicaid Services (CMS) and The Joint Commission (TJC).

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