All EPs attesting for Program Year 2017 must report on a minimum of two Public Health Objective Measure Options. A provider may utilize a combination of measure reporting and measure exclusions to pass the Public Health Objective.
- Immunization Registry Reporting and Exclusions
- Syndromic Surveillance Reporting Exclusions
- Specialized Registry Reporting and Exclusions
Documentation Requirements for PY2017
A tool for documenting a provider's Active Engagement option or exclusion for each Public Health PY2017 Modified MU-2 measure is available at our Documentation Aid webpage.
The 2015-2017 Modified MU-2 rule specifies that an EP the Public Health Objective by being in Active Engagement with a Public Health Agency or clinical data registry to submit electronic public health data. CMS has defined active engagement options as follows:
Active Engagement Option 1 – Completed Registration to Submit Data: The EP is registered to submit data with the public health agency or, where applicable, the clinical data registry to which the information is being submitted; registration was completed within 60 days after the start of the EHR reporting period; and the EP is awaiting an invitation from the public health agency or clinical data registry to begin testing and validation. This option allows providers to meet the measure when the public health agency or the clinical data registry has limited resources to initiate the testing and validation process. Providers that have registered in previous years do not need to submit an additional registration to meet this requirement for each EHR reporting period.
Active Engagement Option 2 – Testing and Validation: The EP is in the process of testing and validation of the electronic submission of data. Providers must respond to requests from the public health agency or, where applicable, the clinical data registry within 30 days; failure to respond twice within an EHR reporting period would result in that provider not meeting the measure.
Active Engagement Option 3 – Production: The EP has completed testing and validation of the electronic submission and is electronically submitting production data to the public health agency or clinical data registry.
Requirement: The EP is in active engagement with a public health agency to submit immunization data.
- The Vermont Department of Health is accepting immunization data from EPs; instructions are available at the VDH website.
- The New Hampshire Department of Health and Human Services has not declared readiness to accept immunization data from EPs.
Immunization Reporting Exclusions
- Vermont EPs who do not administer any immunizations to any of the populations for which data is collected can be excluded from the immunization registry reporting measure.
- New Hampshire EPs may take an exclusion for the immunization registry reporting measure in Program Year 2017.
Requirement: The EP is in active engagement with a syndromic surveillance registry to submit electronic public health data.
- The Vermont Department of Health and the New Hampshire Department of Health and Human Services are not capable of accepting Syndromic Surveillance data from EPs. EPs can be excluded from this measure.
Syndromic Surveillance Reporting Exclusions
- EPs do not need to provide any additional documenation for exclusions to this measure in Program Year 2017.
Requirement: The EP is in active engagement to submit data to a specialized registry.
- The Vermont Department of Health has not declared readiness to accept specialized registry data in Program Year 2017
- The New Hampshire Department of Health and Human Services is accepting the electronic submission of cancer case information.
Specialized Registry Reporting Exclusions
EPs meeting at least one of the following criteria may be excluded from the specialized registry reporting measure if the EP:
- Does not diagnose or treat any disease or condition associated with, or collect relevant data that is collected by, a specialized registry in their jurisdiction during the EHR reporting period;
- Operates in a jurisdiction for which no specialized registry is capable of accepting electronic registry transactions in the specific standards required to meet the CEHRT definition at the start of the EHR reporting period;
- Operates in a jurisdiction where no specialized registry for which the EP is eligible has declared readiness to receive electronic registry transactions at the beginning of the EHR reporting period.
Even though the Vermont Department of Health does not have a Public Health Special Registry available, EPs must ensure they provide the proper documentation in order to take an exclusion. The following is an exceprt from CMS FAQ 13657 that outlines the steps to take for Specialized Registry reporting:
What steps does a provider have to take to determine if there is a specialized registry available for them, or if they should instead claim an exclusion?
The eligible professional (EP) is not required to make an exhaustive search of all potential registries. Instead, they must do a few steps to meet due diligence in determining if there is a registry available for them, or if they meet the exclusion criteria.
- An EP should check with their State to determine if there is an available specialized registry maintained by a public health agency.
- An EP should check with any specialty society with which they are affiliated to determine if the society maintains a specialized registry and for which they have made a public declaration of readiness to receive data for meaningful use no later than the first day of the provider’s EHR reporting period.
If the EP determines no registries are available, they may exclude from the measure, but they must upload the proper documentation to support that the above steps were taken. Examples of Acceptable Documentation for Exclusion:
- A signed EP letter declaring no membership in any specialty or medical societies;
- EP specialty or medical society letter, or screenshot of website statement indicating it does not have a registry;
- A signed letter by the EP stating the specialty or medical society does not have a registry.
What can count as a specialized registry?
A submission to a specialized registry may count if the receiving entity meets the following requirements:
- The receiving entity must declare that they are ready to accept data as a specialized registry and be using the data to improve population health outcomes. Most public health agencies and clinical data registries are declaring readiness via a public online posting. Registries should make this information publicly available for potential registrants.
- The receiving entity must also be able to receive electronic data generated from CEHRT.
- The electronic file can be sent to the receiving entity through any appropriately secure mechanism including, but not limited to, a secure upload function on a web portal or Direct.
- Manual data entry into a web portal would not qualify for submission to a specialized registry.
- The receiving entity should have:
- A registration of intent process,
- A process to take the eligible clinician through test and validation
- A process to move into production.
- The receiving entity should be able to provide appropriate documentation for the sending provider or their current status in Active Engagement.
For qualified clinical data registries, reporting to a QCDR may count for the public health specialized registry measure as long as the submission to the registry is not only for the purposes of meeting CQM requirements of the quality performance category of MIPS in other words, the submission may count if the registry is also using the data for a public health purpose.
Many QCDRs use the data for a public health purpose beyond CQM reporting to CMS. A submission to such a registry would meet the requirement for the measure if the submission data is derived from CEHRT and transmitted electronically.
(From CMQ FAQ 22517)
Centralized Repository for Public Health Agencies and Clinical Data Registries
CMS developed a Centralized Repository for public health agencies (PHA) and clinical data registries (CDR) to provide a centralized source of information for eligible professionals (EPs), eligible hospitals, and critical access hospitals (CAHs) looking for public health, clinical data, or specialized registry electronic reporting options.
The Medicare and Medicaid EHR Incentive Programs include several public health measures that require EPs, eligible hospitals, and CAHs to engage with a PHA or CDR to submit electronic public health data. The repository will assist providers in finding entities that accept electronic public health data.
Please Note: CMS’ Centralized Repository is not the authoritative source of all public health reporting options currently available. For the Medicare or Medicaid EHR Incentive Program, the absence of an entry in the CMS Centralized Repository is not sufficient documentation for claiming an exclusion and should not prevent a provider from reporting to a registry. Providers must check with the jurisdictional public health agencies or specialty societies to which they belong and document that information to satisfy Medicare or Medicaid reporting.
For questions, contact the Vermont EHRIP Team at ahs.dvhaEHRIP@vermont.gov
(Page last updated 12/14/2017)