Clinical Data Registry Reporting

CMS defines active engagement as the process of moving towards sending production data to a public health agency (PHA) or clinical data registry (CDR), or sending production data to a 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.

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.

• The definition of jurisdiction is general, and the scope may be local, state, regional or at the national level. The definition will be dependent on the type of registry to which the provider is reporting. A registry that is "borderless" would be considered a registry at the national level and would be included for purposes of this measure.
• ECs who have previously registered, tested, or begun ongoing submission of data to a registry do not need to "restart" the process.