Immunization Registry Reporting | MIPS PI Measures for 2021 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 or clinical data registry or is sending production data to a public health agency (PHA) or clinical data registry (CDR).

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

• Option 1 – Completed Registration to Submit Data: The MIPS eligible clinician registered to submit data with the PHA or, where applicable, the CDR to which the information is being submitted; registration was completed within 60 days after the start of the MIPS performance period; and the MIPS eligible clinician is awaiting an invitation from the PHA or CDR to begin testing and validation. This option allows MIPS eligible clinicians to meet the measure when the PHA or the CDR has limited resources to initiate the testing and validation process. MIPS eligible clinicians that have registered in previous years do not need to submit an additional registration to meet this requirement for each MIPS performance period.
• Option 2 – Testing and Validation: The MIPS eligible clinician is in the process of testing and validation of the electronic submission of data. MIPS eligible clinicians must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a MIPS performance period would result in that MIPS eligible clinician not meeting the measure.
• Option 3 – 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

The MIPS eligible clinician must attest YES or TRUE to being 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).

For multiple registry engagement, report as YES or TRUE if there is active engagement with more than one immunization registry.

Scoring Information

• Required for the Promoting Interoperability Performance Category Score: Yes, must select at least two of the five Public Health and Clinical Data Exchange measures
• Measure Score: 10 points
• Eligible for Bonus Score: No

Note: The following measures are included in the Public Health and Clinical Data Exchange objective: Immunization Registry Reporting, Electronic Case Reporting, Public Health Registry Reporting, Clinical Data Registry Reporting, and Syndromic Surveillance Reporting.

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

• Submit a “yes” to the Prevention of Information Blocking Attestations; and
• Submit a “yes” to the ONC Direct Review Attestation, if applicable; and
• Submit a “yes” that they have completed the Security Risk Analysis measure during the calendar year in which the MIPS performance period occurs; and
• Report the required measures from each of the four objectives.

Additional Information

• In 2021, MIPS eligible clinicians may use certified technology meeting the existing 2015 Edition certification criteria, updated to the 2015 Edition Cures Update, or a combination of the two, to meet the CEHRT definition. (85 FR 84472) • To learn more about the 2015 Edition Cures Update and the changes to 2015 Edition certification criteria finalized in the 21st Century Cures Act final rule (85 FR 25642), we encourage MIPS eligible clinicians to visit https://www.healthit.gov/curesrule/final-rulepolicy/2015-edition-cures-update.
• To check whether a health IT product has been certified to criteria updated for the 2015 Edition Cures Update, visit the Certified Health IT Product List (CHPL) at https://chpl.healthit.gov/.
• 2015 Edition or 2015 Edition Cures Update 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 to the 2015 Edition or the 2015 Edition Cures Update by the last day of the performance period. MIPS eligible clinicians are required to report certain measures from each of the four objectives, with performance-based scoring occurring at the individual measure-level. Each measure is scored based on the MIPS eligible clinician’s performance for that measure, based on the submission of a numerator/denominator, or “yes or no” statement.
• 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 10 points for reporting two “yes” responses, 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 10 points will be redistributed to the Provide Patients Electronic Access to Their Health Information measure.
• If reporting active engagement with multiple registry measure (PI_PHCDRR_1_MULTI) then the objective has been met and no additional measures in this objective need to be reported.
• Reporting more than two measures for this objective will not earn the MIPS eligible clinician any additional points, but they will meet the requirements for the objective.
• More information about Promoting Interoperability performance category scoring is available on the QPP website.
• For the measure, a MIPS eligible clinician’s health IT system may layer additional information on the immunization history, forecast, and still successfully meet this measure.
• Bi-directionality provides that certified health IT must be able to receive and display a consolidated immunization history and forecast in addition to sending the immunization record.
• Non-vaccinating providers can get credit for the Immunization Registry Reporting measure for Promoting Interoperability if they can query and receive results (i.e., the consolidated immunization record and forecast) into their electronic health record (EHR) from the Immunization Information System (IIS) in accordance with HL7 Version 2.5.1: Implementation Guide for Immunization Messaging, Release 1.5 (October 2014). A non-vaccinating provider may also submit historical immunizations provided from another source; this alone would not qualify for Promoting Interoperability, but the provider can still qualify if they can also query and receive results from the IIS. IIS jurisdictions may select specific transactions to accept, as well as prioritize providers for participation in their registry. (Note: The vaccinating healthcare providers should continue to submit data and query the IIS for results, except where prohibited, and in accordance with applicable law and practice).
• Exclusion PI_PHCDRR_1_EX_2 does not apply if an entity designated by the immunization registry or IIS can receive electronic immunization data submissions. For example, if the immunization registry cannot accept the data directly or in the standards required by CEHRT, but has designated a Health Information Exchange (HIE) to do so on their behalf, and the HIE is capable of accepting the information in the standards required by CEHRT, the MIPS eligible clinician could not claim the exclusion.
• 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 provider 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.
• 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. However, the group must meet the requirements of the exclusion as a group.
• If registries have not declared six months before the start of the performance period whether the registry they are offering will be ready on January 1 of the upcoming year for use by providers seeking to meet performance periods in that upcoming year, MIPS eligible clinicians can claim an exclusion (83 FR 59815).
• 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 additional discussion, please see the 2018 Physician Fee Schedule final rule – Quality Payment Program final rule: 83 FR 59790.
• In order to meet this measure, a MIPS eligible clinician must use technology certified to the criterion at 45 CFR 170.315 (f)(1).

Certification Standards and Criteria

Below are the corresponding certification criteria for electronic health record technology that support this measure.

Certification Criteria:
Information about certification for 2015 Edition CEHRT can be found at the link below:
§170.315(f)(1) Transmission to Immunization Registries