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Promoting Interoperability

Public Health Reporting
Posted: December 25, 2018

Overview

Reporting data to public health agencies (PHA) and clinical data registries (CDR) via certified EHR technology can assist providers in evaluating treatment plans and efficacy as well as promote community welfare.

MU Objective and Calculation

The objective is for the EP to be in active engagement with a public health agency to submit electronic public health data in a meaningful way using certified EHR technology, except where prohibited, and in accordance with applicable law and practice.

There are a total of five possible measures for this objective and EPs would be required to successfully attest to “active engagement” with at least two measures:

  • Immunization Registry Reporting
  • Syndromic Surveillance Reporting
  • Electronic Case Reporting
  • Public Health Registry Reporting*
  • Clinical Data Registry Reporting*

* EPs can choose to actively engage with more than one public health or clinical data registry to meet the number of measures required to meet the objective.

“Active engagement” may be demonstrated by any of the following options:

  • Completed registration to submit data:  The EP registered to submit data with the PHA or CDR to which the information is being submitted, registration was completed within 60 days after the start of the EHR reporting period and the EP is awaiting an invitation from the PHA or CDR to begin testing and validation.  This option allows providers to meet the measure when the PHA or the CDR has limited resources to initiate the testing and validation process. Providers that have registered in previous years do not need to submit an additional registration to meet this requirement for each PI reporting period.
  • Testing and Validation:  The EP is in the process of testing and validation of the electronic submission of data. Providers must respond to requests from the PHA or CDR within 30 days. Failure to respond twice within an EHR reporting period would result in that provider not meeting the measure.
  • Production:  The EP has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.

 

Measures

Measure 1 – Immunization Registry Reporting: The EP 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).

Exclusion for Measure 1:  Any EP meeting one or more of the following criteria may be excluded from the immunization registry reporting measure if the EP: 

  1. Does not administer any immunizations to any of the populations for which data is collected by their jurisdiction’s immunization registry or immunization information system during the PI reporting period;
  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 CEHRT definition at the start of the PI reporting period; or
  3. operates in a jurisdiction where no immunization registry or immunization information system has declared readiness to receive immunization data at the start of the PI reporting period.

Measure 2 – Syndromic Surveillance Reporting: The EP is in active engagement with a public health agency to submit syndromic surveillance data from a non-urgent care ambulatory setting.

Exclusion for Measure 2: Any EP meeting one or more of the following criteria may be excluded from the syndromic surveillance reporting measure if the EP:

  1. Is not in a category of providers from which ambulatory syndromic surveillance data is collected by their jurisdiction’s syndromic surveillance system;
  2. operates in a jurisdiction for which no public health agency is capable of receiving electronic syndromic surveillance data from EPs in the specific standards required to meet the CEHRT definition at the start of the PI reporting period; or
  3. operates in a jurisdiction where no public health agency has declared readiness to receive syndromic surveillance data from EPs at the start of the PI reporting period.

Measure 3—Electronic Case Reporting: The EP is in active engagement with a PHA to submit case reporting of reportable conditions.

Exclusion for Measure 3: Any EP meeting one or more of the following criteria may be excluded from the electronic case reporting measure if the EP:

  1. Does not treat or diagnose any reportable diseases for which data is collected by their jurisdiction’s reportable disease system during the PI reporting period;
  2. Operates in a jurisdiction for which no PHA is capable of receiving electronic case reporting data in the specific standards required to meet the CEHRT definition at the start of the PI reporting period; or
  3. Operates in a jurisdiction where no PHA has declared readiness to receive electronic case reporting data as of six months prior to the start of the PI reporting period.

Measure 4—Public Health Registry Reporting: Public Health Registry Reporting: The EP is in active engagement with a PHA to submit data to public health registries.

Exclusion for Measure 4:Any EP meeting at least one of the following criteria may be excluded from the public health registry reporting measure if the EP:

  1. Does not diagnose or directly treat any disease or condition associated with a public health registry in their jurisdiction during the PI reporting period;
  2. Operates in a jurisdiction for which no PHA is capable of accepting electronic registry transactions in the specific standards required to meet the CEHRT definition at the start of the PI reporting period; or
  3. Operates in a jurisdiction where no PHA for which the eligible hospital or critical access hospital (CAH) is eligible has declared readiness to receive electronic registry transactions as of six months prior to the start of the PI reporting period.

Measure 5—Clinical Data Registry Reporting: The EP is in active engagement to submit data to a CDR.

Exclusion for Measure 5: Any EP meeting at least one of the following criteria may be excluded from the clinical data registry reporting measure if the EP:

  1. Does not diagnose or directly treat any disease or condition associated with a specialized registry in their jurisdiction during the PI reporting period;
  2. Operates in a jurisdiction for which no CDR is capable of accepting electronic registry transactions in the specific standards required to meet the CEHRT definition at the start of the PI reporting period; or
  3. Operates in a jurisdiction where no CDR for which the eligible hospital or critical access hospital (CAH) is eligible has declared readiness to receive electronic registry transactions as of six months prior to the start of the PI reporting period.

 

EXCLUSION NOTES

An exclusion for a measure does not count toward the total of two measures.  Instead, in order to meet this objective, an EP would need to meet two of the total number of measures available to them.  If the EP qualifies for multiple exclusions and the remaining number of measures available to the EP is less than two, the EP can meet the objective by meeting all of the remaining measures available to them and claiming the applicable exclusions.

Official CMS Fact Sheet (pending)

Promoting Interoperability Discussion and Conclusion

Optometrists have traditionally had difficulty participating in public health or registry reporting objectives given the lack of applicable options to which data could be submitted.  However, the readiness of the AOA’s registry, AOA MORE, as well as an increasing number of options at the state level, provides optometrists a path for success with this objective.  Additional flexibility is added via exclusions for use when success is not possible.

 

 




  


  


  


  

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Updates Prior to 2018