Public Health and Clinical Data Exchange
MEASURE DESCRIPTION
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 (PHA) or clinical data registry (CDR).
Active engagement in:
Immunization Registry and Electronic Case Reporting
Reporting Requirements
YES/NO
The MIPS eligible clinician must attest YES to being in active engagement with a PHA to submit data to public health registries.
OPTION 1/OPTION 2
In addition to submitting a response, MIPS eligible clinicians must submit their level of active engagement, either Pre-production and Validation or Validated Data Production for each measure they report.
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 clinical data registry (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 do not 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.
Exclusion/Exceptions
Each registry has its own exclusions.
Required Measure
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).
Scoring
25 points
DEFINITION OF TERMS
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 (PHA) or clinical data registry (CDR).
Clinicians may only attest to Option Level 1 for 1 year starting 2024.
Click on each registry option to learn more.
