Guidance on this page is for Eligible Professionals attesting to Program Year 2018 Meaningful Use Stage 2 Objectives and Measures. For guidance on PY2018 Stage 3 Public Health reporting requirements, click here.
Specification Sheet
Link to the CMS Specification Sheet for Stage 2:
Objective 10 Public Health Reporting
MU Stage 2 Public Health Objective
All EPs attesting for Program Year 2018 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.
Documentation Requirements for PY2018
Documentation to support both Active Engagement and exclusions for Public Health Objective reporting is required at the time of application submission.
The Vermont Medicaid PIP/EHRIP Team has developed documentation tools to help providers submit accurate and complete documentation for each of the Public Health Objectives they are required to report on:
- Immunization Registry Reporting and Exclusions (.docx, 500 KB)
- Syndromic Surveillance Exclusion (.docx, 430 KB)
- Specialized Registry Reporting and Exclusions (docx., 580 KB)
Active Engagement
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.
Measure Option 1 – Immunization Registry Reporting
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 2018.
For details on how to submit the proper documentation for providers in active engagment, and for providers taking an exclusion, utilize the PY2018 Immunization Registry Reporting Documentation Aid for MU2.
Measure Option 2 – Syndromic Surveillance Reporting
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. EPs do not need to provide any additional documenation for exclusions to this measure in Program Year 2018.
For more information, consult the PY2018 Syndromic Surveillance Registry Reporting Documentation Aid for MU2.
Measure Option 3 - Specialized Registry Reporting
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 2018.
- The New Hampshire Department of Health and Human Services is accepting the electronic submission of cancer case information.
- Providers cannot automatically take an exclusion; they must demonstrate that they qualify to take an exclusion, per the guidance below.
To submit the required documentation, consult the PY2018 Specialized Registry Reporting Documentation Aid for MU2.
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.
Exception for the Blueprint for Health Vermont Clinical Registry
If a provider is in Active Engagement with the Blueprint for Health’s Vermont Clinical Registry, they may attest to the appropriate Active Engagement status in their MAPIR application. The PIP/EHRIP Team will verify the connectivity status using administrative reports from the Vermont Clinical Registry. No further documentation is required at the time of attestation. If additional documentation is required, we will follow up during the application review process.
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.
(From CMS 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 PIP/EHRIP Team at ahs.dvhaEHRIP@vermont.gov
Back to the Vermont Medicaid PIP/EHRIP Home Page
(Page last updated 02/01/2019)