Clinical Data Registry (CDR) Reporting

Measure description

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

* Any of the three PHCDRR measures of Syndromic Surveillance Reporting, Public Health Registry Reporting, Clinical Data Registry (CDR) Reporting can be reported as a bonus measure for 2023. None of them are required to be reported. If one or more are reported with an attestation of Yes, a total of 5 points will be awarded regardless of how many of the three measures are reported. 

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 and 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 (PHA) or clinical data registry (CDR). Active engagement may be demonstrated in one of the following ways:

• Active Engagement option 1 – Pre-production and validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. MIPS eligible clinicians that have registered in previous years do not need to submit an additional registration for subsequent performance periods. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.
• Active engagement option 2 – validated data production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or 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.