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Reporting on this measure requires selecting one of two options regarding active engagement with an Immunization registry. 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 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.
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 – The MIPS eligible clinician is in the process of moving towards sending "production data" to a public health agency (PHA) or clinical data registry (CDR), or is sending production data to a PHA or CDR.
Any MIPS eligible clinician meeting one or more of the following criteria may be excluded from the Immunization Registry Reporting measure if the MIPS eligible clinician:
- Does not administer any immunizations to any of the populations for which data is collected by its jurisdiction’s immunization registry or immunization information system during the performance period.
- 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 performance period.
- Operates in a jurisdiction where no immunization registry or immunization information system has declared readiness to receive immunization data as of 6 months prior to the start of the performance period.
Elation now offers Immunization Registry connections in over 30 states. Elation is also continuously working with the non-connected State Immunization Registries to establish a connection.
Learn more about the states where the Bidirectional Immunization Registry integration is available.
You must utilize Elation's Immunization Registry connection or separately connect to your State Immunization Registry outside of Elation to qualify for this measure. If you have an active Immunization Registry connection, select Option 2: Validated Data Production for this measure. If you do not have an active Immunization connection, you may select Option 1: Pre Production and Validation if you are seeking to establish a registry connection in 2024 and have begun the registration process.
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:
- Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the 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.
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 – The MIPS eligible clinician is in the process of moving towards sending "production data" to a public health agency (PHA) or clinical data registry (CDR), or is sending production data to a PHA or CDR.
Important Note: In 2024 Elation is building an integration for electronic Case Reporting which must be certified to meet this measure.
Any MIPS eligible clinician meeting one or more of the following criteria may be excluded from the Electronic Case Reporting measure if 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.
- 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 CEHRT definition at the start of the performance period.
- Operates in a jurisdiction where no public health agency has declared readiness to receive electronic case reporting data as of 6 months prior to the start of the performance period.
- Uses CEHRT that is not certified to electronic case reporting certification criterion prior to the start of the performance period they select in the 2022 calendar year.
To meet this measure you must select Option 1: Pre Production and Validation. To select Option 1: you must reach out to Elation Health and your regional Public Health Agency to declare intent to submit data and let Elation know your intention to submit data and enroll with your regional Public Health Agency.
2024 MIPS Promoting Interoperability Measure Specifications
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