Public Health Registry Reporting | MIPS PI Measures for 2021 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.

*A MIPS eligible clinician is required to submit at least two of the five measures in the Public Health and Clinical Data Exchange objective for 10 total points.  If the clinician qualifies for an exclusion and can only report one measure, then the point value for that measure will be reweighted to 10 points.

Reporting Requirements

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

Exclusions

Any MIPS eligible clinician meeting one or more of the following criteria may be excluded from the Public Health Reporting measure if the MIPS eligible clinician;

1. Does not diagnose or directly treat any disease or condition associated with a public health registry in the MIPS eligible clinician’s jurisdiction during the performance period.

2. Operates in a jurisdiction for which no public health agency is capable of accepting electronic registry transactions in the specific standards required to meet the CEHRT definition at the start of the performance period.

3. Operates in a jurisdiction where no public health registry for which the MIPS eligible clinician is eligible has declared readiness to receive electronic registry transactions as of 6 months prior to the start of the performance period.

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.