Electronic Case Reporting

Measure: The MIPS ECClosed Eligible Clinician: a Medicare provider who qualifies for MIPS participation is in active engagement with a public health agency to electronically submit case reporting of reportable conditions.
Reporting To meet this measure, the MIPS eligible clinician must attest YES to being in active engagement with a public health agency to electronically submit case reporting of reportable conditions. The MIPS eligible clinician also must submit their level of active engagement, either Pre-production and Validation or Validated Data Production.
Exclusions

Any MIPS eligible clinician meeting one or more of the following criteria may be excluded from the Electronic Case Reporting measure if the MIPS eligible clinician:

  1. Does not treat or diagnose any reportable diseases for which data is collected by their jurisdiction's reportable disease system during the performance period. OR
  2. Operates in a jurisdiction for which no public health agency is capable of receiving electronic case reporting data in the specific standards required to meet the CEHRTClosed Certified EHR Technology, an EHR that conforms to the ONC's Health IT Certification Program criteria and standards definition at the start of the performance period. OR
  3. Operates in a jurisdiction where no public health agency has declared readiness to receive electronic case reporting data as of 6 months prior to the start of the performance period.

ECs interested in exchanging data with a public health agency (PHA) should contact Sevocity Support to begin the process of a new interface setup. Interface setup requirements and fees vary per request.

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 – 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.
  • 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.

Return to 2023 MIPS Promoting Interoperability Measures

 

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