Clinical Data Registry Reporting | MIPS PI Measures for 2024 Reporting

Definition of Terms

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.

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.

Reporting Requirements
YES/NO (this is an optional measure)

The MIPS eligible clinician must attest YES to being in active engagement to submit data to a clinical data registry.

OPTION 1/OPTION 2

In addition to submitting a response, MIPS eligible clinicians must submit their level of active engagement, either Pre-production and Validation or Validated Data Production for each measure they report beginning with the performance period in CY 20242024.

Scoring Information

• Required for Promoting Interoperability Performance Category Score: No
• Measure Score: N/A
• Eligible for Bonus Score: Yes, 5 points

Note:The following measures are included in the Public Health and Clinical Data Exchange objective: Immunization Registry Reporting (required), Electronic Case Reporting (required), Public Health Registry Reporting (optional), Clinical Data Registry Reporting (optional), and Syndromic Surveillance Reporting (optional). Each measure is addressed in a separate specification sheet.

In order to earn a score greater than zero for the Promoting Interoperability performance category, MIPS eligible clinicians must:

• Complete the Security Risk Analysis measure
• Complete the High Priority Practices SAFER Guide measure
• Complete the ONC Direct Review attestation (optional)
• Attest to the “Actions to limit or restrict compatibility or interoperability of CEHRT” statement
• Submit their complete numerator and denominator or Yes/No data for all required measures
• Submit their CMS certification identification number
• Submit their level of active engagement for the Public Health and Clinical Data Exchange measures
• Failure to report at least a “1” in all required measures with a numerator or reporting a “No” for a Yes/No response measure will result in a total score of 0 points for the Promoting Interoperability performance category.
• Submit data for a minimum of 180 consecutive days within the calendar year

Additional Information

• MIPS eligible clinicians must use technology certified to ONC Certification Criteria for Health IT necessary to meet the CEHRT definition (88 FR 79307).
• To check whether a health IT product has been certified to ONC Certification Criteria for Health IT, visit the Certified Health IT Product List (CHPL) at https://chpl.healthit.gov/.
• Certified functionality must be used as needed for a measure action to count in the numerator during a performance period. However, in some situations the product may be deployed during the performance period, but pending certification. In such cases, the product must be certified by the last day of the performance period.
• The measures under the Public Health and Clinical Data Exchange objective are reported using “yes or no” responses. The MIPS eligible clinician will receive the full 25 points for reporting two “yes” responses for the two required measures, or for submitting a “yes” for one measure and claiming an exclusion for another. If there are no “yes” responses and two exclusions are claimed, the 25 points will be redistributed to the Provide Patients Electronic Access to Their Health Information measure.
• Reporting on more than one of the three optional measures for this objective will not result in more than 5 bonus points.
• The definition of jurisdiction is general, and the scope may be local, state, regional or at the national level. The definition will be dependent on the type of registry to which the clinician is reporting. A registry that is ‘‘borderless’’ would be considered a registry at the national level and would be included for purposes of this measure.
• Eligible clinicians may achieve active engagement with a public health agency by utilizing an intermediary, such as a health information exchange, health information network, QHIN or other platform facilitating information exchange.
• If the CDR does not use a specified standard, it must use another standard specified in 170.205 to meet the measure. For example, the transmission could be in the form of a Consolidated Clinical Document Architecture (C-CDA) per 170.205(a)(4), or Quality Reporting Document Architecture (QRDA) per 170.205(h)(2).
• Beginning with the performance period in CY 2024, MIPS eligible clinicians may spend only one performance period at the Pre-production and Validation level of active engagement per measure, and must progress to the Validated Data Production level in the next performance period for which they report a particular measure.
• MIPS eligible clinicians who have previously registered, tested, or begun ongoing submission of data to a registry do not need to “restart” the process.
• MIPS eligible clinicians may claim the exclusions if they are reporting as a group.
• When MIPS eligible clinicians choose to report as a group, data should be aggregated for all MIPS eligible clinicians under one Taxpayer Identification Number (TIN). This includes those MIPS eligible clinicians who may qualify for reweighting through an approved Promoting Interoperability hardship exception, hospital or ASC-based status, or in a specialty which is not required to report data to the Promoting Interoperability performance category.

Regulatory References

• For further discussion, please see the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) final rule: 81 FR 77229.
• For further discussion, please see the 2022 and 2023 Physician Fee Schedule final rules.
• No health IT certification criteria at this time.