Immunization Registry Reporting | MIPS PI Measures

Measure description

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

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 a public health immunization registry/ IIS.

Level of Active Engagement: Option 1/Option 2
In addition to submitting a response, MIPS eligible clinicians must submit their level of active engagement, either Pre-Production and Validation (PI_PHCDRR_1_PRE) or Validated Data Production (PI_PHCDRR_1_PROD), when reporting this measure.

Exclusions

The MIPS eligible clinician:

1. Doesn’t administer any immunizations to any of the populations for which data is collected by its jurisdiction’s immunization registry or IIS during the performance period.
2. Operates in a jurisdiction for which no immunization registry or IIS 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 IIS 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 PHA or CDR, or is sending production data to a PHA or CDR.

Active engagement may be demonstrated in one of the following ways:

• Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA, or where applicable, the 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 don’t 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.
• 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 MIPS Promoting Interoperability Performance Category Score: Yes
• Measure Score: 25 points total for both PI_PHCDRR_1 and PI_PHCDRR_3
• Eligible for Bonus Score: No