Immunization Registry 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 submit immunization data and receive immunization forecasts and histories from the public health immunization registry/immunization information system (IIS).
Reporting To meet this measure, the MIPS eligible clinician must attest YES to being in active engagement with a public health agency to submit immunization data and receive immunization forecasts and histories from the public health immunization registry/immunization information system. 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 Immunization Registry Reporting measure if the MIPS eligible clinician:

  1. Does not administer any immunizations to any of the populations for which data is collected by its jurisdiction's immunization registry or immunization information system during the performance period. OR
  2. Operates in a jurisdiction for which no immunization registry or immunization information system is capable of accepting 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 immunization registry or immunization information system has declared readiness to receive immunization data as of 6 months prior to the start of the performance period.

ECs interested in exchanging data with a public health immunization registry/immunization information system should contact Sevocity Support to begin the process of a new interface setup. Interface setup requirements and fees vary per request.

Customers who have an interface with a registry that provides history and forecast information will be able to access a patient’s immunization histories and forecasts from the patient chart or encounter.

  • Chart > Immunizations/Growth Charts > Hx/Forecast button
  • Encounter > Immunizations > Hx/Forecast button

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.

  • Bi-directionality provides that certified health IT must be able to receive and display a consolidated immunization history and forecast in addition to sending the immunization record.

  • Non-vaccinating clinicians can get credit for the Immunization Registry Reporting measure for Promoting Interoperability if they can query and receive results (i.e., the consolidated immunization record and forecast) into their EHR from the IIS. A non-vaccinating clinician may also submit historical immunizations provided from another source; this alone would not qualify for Promoting Interoperability, but the clinician can still qualify if they can also query and receive results from the IIS. IIS jurisdictions may select specific transactions to accept, as well as prioritize clinicians for participation in their registry. (Note: The vaccinating healthcare providers should continue to submit data and query the IIS for results, except where prohibited, and in accordance with applicable law and practice).

  • Exclusion #2 does not apply if an entity designated by the immunization registry or IIS can receive electronic immunization data submissions.

  • 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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