Immunization Registry Reporting | MIPS PI Measures

Measure description

The MIPS eligible clinician is in active engagement with a public health agency (PHA) to submit immunization data and receive immunization forecasts and histories from the public health immunization registry/immunization information system (IIS).

*For 2023, the Immunization Registry Reporting measure and the Electronic Case Reporting measure are required. If both measures are attested as YES, then they each are worth 12.5 points. If one of these two measures is excluded, then the other measure will be worth 25 points. If both are excluded, then the Provide Patients Electronic Access to Their Health Information measure (PEA_1) denominator will increase by 25 points. 

Reporting requirements

The MIPS eligible clinician must attest Yes to being in active engagement with a PHA to submit immunization data and receive immunization forecasts and histories from the public health immunization registry/immunization information system (IIS). 

Exclusions

Any MIPS eligible clinician meeting one or more of the following criteria may be excluded from the Immunization Registry Reporting measure if the MIPS eligible clinician:

1. Does not administer any immunizations to any of the populations for which data is collected by its jurisdiction’s immunization registry or immunization information system during the performance period.
2. Operates in a jurisdiction for which no immunization registry or immunization information system is capable of accepting the specific standards required to meet the CEHRT definition at the start of the performance period.
3. Operates in a jurisdiction where no immunization registry or immunization information system has declared readiness to receive immunization data as of 6 months prior to the start of the performance period.

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.

Scoring information

• Required for the Promoting Interoperability Performance Category Score: Yes, must report on Immunization Registry Reporting and Electronic Case Reporting.
• Measure Score: 25 points
• Eligible for Bonus Score: No