The MIPS eligible clinician is in active engagement to submit data to a clinical data registry.
Measure Overview
Objective: Public Health and Clinical Data Exchange
Bonus Measure: The MIPS eligible clinician is in active engagement to submit data to a clinical data registry.
Measure ID: PI_PHCDRR_5
Definition of Terms
Active engagement may be demonstrated in one of the following ways:
Option 1 – Completed Registration to Submit Data: The MIPS eligible clinician registered to submit data with the PHA or, where applicable, the CDR to which the information is being submitted; registration was completed within 60 days after the start of the MIPS performance period; and the MIPS eligible clinician is awaiting an invitation from the PHA or CDR to begin testing and validation. This option allows MIPS eligible clinicians to meet the measure when the PHA or the CDR 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 MIPS performance period.
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 or, where applicable, the CDR within 30 days; failure to respond twice within a MIPS performance period would result in that MIPS eligible clinician not meeting the measure.
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 or CDR.
Measure Reporting
YES/NO
The MIPS eligible clinician must attest YES to being in active engagement to submit data to a clinical data registry.
Measure Scoring
- Required for Promoting Interoperability Performance Category Score: No
- Measure Score: N/A
- Eligible for Bonus Score: Yes, 5 points
Note: The following measures are included in the Public Health and Clinical Data Exchange objective: Immunization Registry Reporting (required), Electronic Case Reporting (required), Public Health Registry Reporting (optional), Clinical Data Registry Reporting (optional), and Syndromic Surveillance Reporting (optional).
In order to earn a score greater than zero for the Promoting Interoperability performance category, MIPS eligible clinicians must:
- Complete the activities required by the Security Risk Analysis and High Priority Practices SAFER Guide, submit their complete numerator and denominator or Yes/No data for all required measures, and attest to the Actions to limit or restrict compatibility or interoperability of CEHRT statement.
- Failure to report at least a “1” in all required measures with a numerator or reporting a “No” for a Yes/No response measure (except for the SAFER Guides measure2) will result in a total score of 0 points for the Promoting Interoperability performance category
Freedom | EHR Workflow
MIPS Conformance Calculation
To meet this measure, MIPS eligible clinicians must attest YES to being in active engagement to submit data to a clinical data registry.
After completing the requirements for this objective, you can manually attest to the objective and its associated measure from the MIPS Conformance > Attestation tab.
Attention
In order to attest to the Clinical Data Registry (CDR) Reporting objective and measure, your database must be configured to have an interface with the Clinical Data Registry. Please contact EHR Support at (402) 905-3169 in advance of the performance period if you are interested in reporting to a Clinical Data Registry. Please note that interface configuration and setup can take up to 120 days depending on the registries interface and data validation requirements. One-time interface setup and configuration fees may apply.
Data Validation
CMS will publish guidance to help clinicians better understand the supporting documentation they should retain when attesting to the MIPS requirements. CMS calls this guidance “MIPS Data Validation Criteria” as it outlines the types of documentation that should be retained to validate the data the provider submits to CMS at the end of the performance period. You must keep documentation for six years subsequent to submission. We suggest reviewing this validation document to ensure you document your work appropriately.