Immunization 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.

• 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.

• For the measure, a MIPS eligible clinician’s health IT system may layer additional information on the immunization history, forecast, and still successfully meet this measure.

• 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 in accordance with HL7 Version 2.5.1: Implementation Guide for Immunization Messaging, Release 1.5 (October 2014). 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.