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 – 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 may achieve active engagement with a public health agency by utilizing an intermediary, such as a health information exchange, health information network, QHIN or other platform facilitating information exchange.
• Beginning with the performance period in CY 2024, MIPS ECs may spend only one performance period at the Pre-production and Validation level of active engagement per measure, and must progress to the Validated Data
• ECs who have previously registered, tested, or begun ongoing submission of data to a registry do not need to "restart" the process.