Public Health Reporting Using Trusted Exchange Framework and Common Agreement™ (TEFCA™)

Measure description

The MIPS eligible clinician is (1) participating as a signatory to a Framework Agreement (as that term is defined by the Common Agreement for Nationwide Health Information Interoperability as published in the Federal Register and on the Assistant Secretary for Technology Policy/Office of the National Coordinator for Health Information Technology (ASTP/ONC’s) website); (2) isn’t suspended from participating in TEFCA Exchange; (3) submits health information using TEFCA to a PHA consistent with one or more of the measures under the Public Health and Clinical Data Exchange objective; (4) is in active engagement Option 2 (validated data production) with a PHA to transfer health information for one or more of the measures under the Public Health and Clinical Data Exchange objective; and (5) uses the functions of CEHRT to exchange with the PHA.

Reporting requirements

The MIPS eligible clinician must attest “Yes” to the following statements:

• I participate as a signatory to a Framework Agreement.
• I haven’t been suspended from participating in TEFCA Exchange.
• I submit health information using TEFCA to a PHA consistent with one or more of the measures under the Public Health and Clinical Data Exchange objective.
• I am in active engagement Option 2 (Validated Data Production) with a PHA to transfer health information for one or more of the measures under the Public Health and Clinical Data Exchange objective.
• I use the functions of CEHRT to exchange with the PHA.

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.

Signatory to a TEFCA Framework Agreement – Either the Common Agreement or an agreement that includes the Participant/Sub-participant Terms of Participation and isn’t suspended under the respective agreement.

Scoring Information

• Required for MIPS Promoting Interoperability Performance Category Score: No
• Measure Score: N/A
• Eligible for Bonus Score: Yes, 5 points