Clinical Data Registry (CDR) Reporting | MIPS ACI Measures for 2018 Reporting

This measure was for 2018 MIPS ACI reporting. View 2019 version ->

For use with CEHRT certified to the 2015 edition. 

Measure Description

The MIPS eligible clinician is in active engagement to submit data to a clinical data registry.

Measure ID Objective Required for Base Score? Percentage of Performance Score
ACI_PHCDRR_5 Public Health and Clinical Data Registry Reporting No 10% for the first registry, 5% bonus for any additional registries

Reporting Requirements

The MIPS eligible clinician must attest YES to being in active engagement to submit data to a clinical data registry.

Definition of Terms & Additional Information

Active engagement – The MIPS eligible clinician is in the process of moving towards sending “production data” to a CDA, or is sending production data to a CDA. There are several options for active engagement.

  • Active Engagement Option 1 – Completed Registration to Submit Data: The MIPS eligible clinician registered to submit data with the CDR 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 CDR to begin testing and validation. This option allows MIPS eligible clinicians to meet the measure when the CDR 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 CDR 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 CDR.

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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