Public Health and Clinical Data Registry Reporting (Medicaid)

The objective of this measure is to actively engage with a public health agency (PHA) or clinical data registry (CDR) to submit electronic public health data in a meaningful way using a certified EHR, except where prohibited, and in accordance with applicable law and practice

This page provides information related to the Medicaid Promoting Interoperability program. If you're looking for Medicare MIPS information, go to Achieving Medicare Promoting Interoperability Requirements.

This measure may not apply to eyecare. If you cannot complete this measure and you have exhausted all attainable Public Health and Clinical Data Exchange measures, you may claim an eligible exclusion from this measure.

This measure may not apply to eyecare. If you cannot complete this measure and you have exhausted all attainable Public Health and Clinical Data Exchange measures, you may claim an eligible exclusion from this measure.

An EP must satisfy two measures for this objective. If the EP cannot satisfy at least two measures, they may take exclusions from all measures they cannot meet.

  • Immunization Registry Reporting. The EP is in active engagement with a PHA to submit immunization data and receive immunization forecasts and histories from the public health immunization registry/immunization information system (IIS).
  • Syndromic Surveillance Reporting. The EP is in active engagement with a PHA to submit syndromic surveillance data.
  • Electronic Case Reporting. The EP is in active engagement with a PHA to submit case reporting of reportable conditions.
  • Public Health Registry Reporting. The EP is in active engagement with a PHA to submit data to public health registries.
  • CDR Reporting. The EP is in active engagement to submit data to a CDR.

Threshold

This is a Yes/No measure. The EP must attest Yes.

  • Immunization Registry Reporting.An EP may take an exclusion if any of the following apply:
    • He or she does not administer immunizations to any of the populations for which data is collected by their jurisdiction’s immunization registry or IIS during the EHR reporting period; or
    • He or she practices in a jurisdiction for which no immunization registry or IIS is capable of accepting the specific standards required to meet the certified EHR definition at the start of the EHR reporting period; or
    • He or she practices in a jurisdiction where no immunization registry or IIShas declared readiness to receive immunization data as of six months prior to the start of the EHR reporting period.
  • Syndromic Surveillance Reporting. An EP may take an exclusion if any of the following apply:
    • He or she is not in a category of providers from which ambulatory syndromic surveillance data is collected by their jurisdiction’s syndromic surveillance system; or
    • He or she practices in a jurisdiction for which no PHA is capable of receiving electronic syndromic surveillance data from EPs in the specific standards required to meet the certified EHR definition at the start of the EHR reporting period; or
    • He or she practices in a jurisdiction where no PHA has declaredreadiness to receive syndromic surveillance data from EPs as of sixmonths prior to the start ofthe EHR reporting period.
  • Electronic Case Reporting. An EP may take an exclusion if any of the following apply:
    • He or she does not diagnose or directly treat any reportable diseases for which data is collected by their jurisdiction’s reportable disease system during the EHR reporting period; or
    • He or she practices in a jurisdiction for which no PHA is capable of receiving electronic case reporting data in the specific standards required to meet the certified EHR definition at the start of the EHR reporting period; or
    • He or she practices 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 EHR reporting period.
  • Public Health Registry Reporting. An EP may take an exclusion if any of the following apply:
    • He or she does not diagnose or directly treat any disease or condition associated with a public health registry in their jurisdiction during the EHR reporting period; or
    • He or she practices in a jurisdiction for which no PHA is capable of accepting electronic registry transactions in the specific standards required to meet the certified EHR definition at the start of the EHR reporting period; or
    • He or she practices in a jurisdiction where no PHA for which the EP is eligible to submit data has declared readiness to receive electronic registry transactions as of six months prior to the start of the EHR reporting period.
  • CDR Reporting. An EP may take an exclusion if any of the following apply:
    • He or she does not diagnose or directly treat any disease or condition associated with a CDR in their jurisdiction during the EHRreporting period; or
    • He or she practices in a jurisdiction for which no CDR is capable of accepting electronic registry transactions in the specific standards required to meet the certified EHR definition at the start of the EHR reporting period; or
    • He or she practices in a jurisdiction where no CDR for which the EP is eligible to submit data has declared readiness to receive electronic registry transactions as of six months prior to the start of the EHR reporting period.

This measure is part of the Public Health and Clinical Data Exchange objective. Two measures from this objective are required to achieve a promoting interoperability score. The Public Health and Clinical Data Exchange objective is worth up to 10 points.

Not applicable.

The auditor may ask you to sign a written statement attesting to the fact that reporting specific cases falls outside of your scope of practice.