Syndromic Surveillance Reporting | MIPS PI Measures for 2026 Reporting

Definition of Terms

Active Engagement:
The MIPS eligible clinician is in the process of moving towards sending "production data" to a PHA or 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 don't 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" Response (Optional Measure)

The MIPS eligible clinician must attest "Yes" to being in active engagement with a PHA to submit syndromic surveillance data from an urgent care setting.

Level of Active Engagement: 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 (PI_PHCDRR_2_PRE) or Validated Data Production (PI_PHCDRR_2_PROD), when reporting this measure.

Scoring Information

• Required for MIPS 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: Electronic Case Reporting (required), Immunization Registry Reporting (required), Public Health Registry Reporting (optional), Clinical Data Registry Reporting (optional), Syndromic Surveillance Reporting (optional), and Public Health Reporting Using Trusted Exchange Framework and Common Agreement^TM (TEFCA^TM) (optional). Each measure is addressed in a separate specification sheet.

A MIPS eligible clinician must use technology certified to the Office of the National Coordinator for Health Information Technology (ONC) Certification Criteria for Health Information Technology (IT) (45 CFR 170.315) necessary to meet the CEHRT definition (42 CFR 414.1305(2)), and meet the following requirements to earn a score greater than zero for the MIPS Promoting Interoperability performance category:

• Provide their CMS EHR Certification ID from the Certified Health IT Product List (CHPL)
• Submit data for a minimum of 180 consecutive days within the calendar year
• Submit 2 "Yes" attestations for completing both components of the Security Risk Analysis measure during the calendar year in which the performance period occurs
• Submit a "Yes" attestation for the High Priority Practices Safety Assurance Factors for EHR Resilience (SAFER) Guide measure confirming the completion of an annual self-assessment using the 2025 High Priority Practices SAFER Guide during the calendar year in which the performance period occurs
• Submit a "Yes" response for the ONC Direct Review attestation
• Submit a "Yes" response for the Actions to Limit or Restrict Compatibility or Interoperability of CEHRT attestation
• Submit their complete count of numerators (report at least a "1" for all required measures with a numerator) and denominators or "Yes" response (for attestation measures) for all required measures (or claim an exclusion, if available and applicable)
• Submit their level of active engagement for the required measures under the Public Health and Clinical Data Exchange objective

Also, as an optional attestation, a MIPS eligible clinician can attest (if they received a request for surveillance) to work in good faith with an ONC-Authorized Certification Bodies (ACB) that conducts surveillance of their health information technology certified under the ONC Health IT Certification Program.

Additional Information

• 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).
• Certified functionality must be used as needed for a measure action to count 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.
• Urgent care is defined for the purposes of this measure with the use of the Place of Service (POS) 20 code. POS 20 is used in medical billing when urgent care facility services are provided to the patient. This is distinct from a hospital emergency room, an office, or a clinic, whose purpose is to diagnose and treat illness or injury for unscheduled, ambulatory patients seeking immediate medical attention.
• 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 2 "Yes" responses for the 2 required measures, or for reporting a "Yes" response for 1 measure and claiming an exclusion for the other measure. If there are no "Yes" responses and 2 exclusions are claimed, the 25 points will be redistributed to the Provide Patients Electronic Access to Their Health Information measure.
• Reporting 1, more than 1, or all 4 optional measures included in the Public Health and Clinical Data Exchange objective won't result in more than a total of 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.
• MIPS eligible clinicians may achieve active engagement with a PHA by utilizing an intermediary, such as a health information exchange (HIE), health information network (HIN), Qualified Health Information Network^TM (QHIN^TM) or other platform facilitating information exchange.
• 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 don't need to "restart" the process.
• When reporting as a group, virtual group, or Alternative Payment Model (APM) Entity, data should be aggregated across all instances of CEHRT used by all MIPS eligible clinicians within a group/under one Taxpayer Identification Number (TIN), across all instances of CEHRT used by all TINs within a virtual group, or across all instances of CEHRT used by all participant TINs within an APM Entity. Such aggregation includes MIPS eligible clinicians who may qualify for a MIPS Promoting Interoperability Performance Category Hardship Exception due to being part of a small practice, being a non-patient facing MIPS eligible clinician, or having a hospital-based or ambulatory surgery center (ASC)-based status. For additional information, please review the 2026 MIPS Promoting Interoperability Performance Category Hardship Exception Application Guide available in the Quality Payment Program Resource Library.
• When reporting as a subgroup (MIPS Value Pathway), aggregated data of the affiliated group should be submitted.
• APM Entities can choose to report MIPS Promoting Interoperability performance category data at the individual, group, virtual group, or APM Entity level when participating in MIPS. Review the Frequently Asked Questions on the Shared Savings Program Requirement to Report Objectives and Measures for the MIPS Promoting Interoperability Performance Category (PDF, 271KB) for more information.

Regulatory References

• The most recent regulatory references can be found in the Calendar Year (CY) 2023 Physician Fee Schedule final rule (87 FR 70074).

Certification Criteria

Below are the corresponding certification criteria for health IT that support this measure.

Certification Criteria:
§170.315(f)(2) Transmission to Public Health Agencies — Syndromic Surveillance
Urgent Care Setting Only