Public Health Registry Reporting

The objective of this measure is to submit electronic data to health registries.

This measure may not apply to eyecare. Check with your state health agency to determine if there is a health information exchange (HIE) you're required to report to. 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.

The MIPS-eligible clinician is in active engagement with a public health agency to submit data to public health registries.

Active engagement may be demonstrated in one of the following ways:

  • Preproduction and Validation. The MIPS-eligible clinician must first register to submit data with the public health agency (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.
  • 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.

This measure is not required to fulfill the Public Health and Clinical Data Exchange objective. If you attest YES, you must also report your level of active engagement—preproduction and validation or validated-data production. This measure contributes up to 5 bonus points.

You can receive up to 5 bonus points for one of the following measures. You cannot receive more than 5 bonus points.

You may receive bonus points even if you claimed an eligible exclusion from both of the required measures and, thus, your Public Health and Clinical Data Exchange objective was reweighted to zero.

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.