Public Health Registry Reporting | MIPS ACI Measures for 2018 Reporting

For use with CEHRT certified to the 2015 edition.

Measure Description

The MIPS eligible clinician is in active engagement with a public health agency (PHA) to submit data to public health registries.

Measure ID Objective Required for Base Score? Percentage of Performance Score
ACI_PHCDRR_4 Patient Electronic Access No 10%

Reporting Requirements

The MIPS eligible clinician must attest YES to being in active engagement with a PHA to submit data to public health registries.

Definition of Terms & Additional Information

Active engagement – The MIPS eligible clinician is in the process of moving towards sending “production data” to a public health agency or clinical data registry, or is sending production data to a public health agency or clinical data registry. There are several options to achieve active engagement as follows.

  • Active Engagement Option 1 – Completed Registration to Submit Data: The MIPS eligible clinician registered to submit data with the PHA to which the information is being submitted; registration was completed within 60 days after the start of the performance period; and the MIPS eligible clinician is awaiting an invitation from the PHA to begin testing and validation. This option allows MIPS eligible clinicians to meet the measure when the PHA has limited resources to initiate the testing and validation process. MIPS eligible clinicians that have registered in previous years do not need to submit an additional registration to meet this requirement for each performance period.
  • Active Engagement Option 2 – Testing and Validation: The MIPS eligible clinician is in the process of testing and validation of the electronic submission of data. MIPS eligible clinicians must respond to requests from the PHA within 30 days; failure to respond twice within a performance period would result in that MIPS eligible clinician not meeting the measure.
  • Active Engagement Option 3 – Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA.

Production data – Refers to data generated through clinical processes involving patient care, and it is used to distinguish between data and “test data” which may be submitted for the purposes of enrolling in and testing electronic data transfers.

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