Electronic Case Reporting

Verify that your local and state public health agencies are collecting data relevant to your scope of practice (for example, melanoma diagnoses).

If you cannot complete this measure, because no public health agency is currently collecting data relevant to your scope of practice, and you have exhausted all attainable Public Health and Clinical Data Exchange measures, you may claim an eligible exclusion from this measure citing that it is outside your scope of practice.

The MIPS-eligible clinician is in active engagement with a public health agency to electronically submit case reporting of reportable conditions.

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.

Any MIPS-eligible clinician (EC) who meets one or more of the following criteria may be excluded from the Immunization Registry Reporting measure:

• The MIPS-eligible clinician does not treat or diagnose any reportable diseases for which data is collected by their jurisdiction's reportable disease system during the performance period; OR
• The MIPS-eligible clinician operates in a jurisdiction for which no public health agency is capable of receiving electronic case reporting data in the specific standards required to meet the certified EHR definition at the start of the performance period; OR
• The MIPS-eligible clinician operates in a jurisdiction where no public health agency has declared readiness to receive electronic case reporting data as of six months prior to the start of the performance period.

The MIPS-eligible clinician must attest YES and report their level of active engagement—preproduction and validation or validated-data production. 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 for exclusions, attesting to the fact that reporting specific cases falls outside of your scope of practice.