2017 ACI Transition Measure: Immunization Registry Reporting

Under the Merit-based Incentive Payment System (MIPS) pathway of the MACRA Quality Payment Program, the Advancing Care Information (ACI) category replaces the Medicare EHR Incentive Program (Meaningful Use). ACI is one of the three performance categories that will be considered and weighted for scoring an eligible clinician’s performance under MIPS (four categories will be included starting in 2018)This measure is not required to achieve the ACI base score, but may be selected to earn additional performance score credit. For more information on ACI scoring methodology, please click here.


Public Health Reporting


Immunization Registry Reporting               
The MIPS eligible clinician is in active engagement with a public health agency to submit immunization data.

Scoring Information:

  • Required for Base Score (50%): No
  • Percentage of Performance Score (up to 90%): 0 or 10%
  • No bonus points available

Reporting Requirements

  • YES/NO: To meet this measure, MIPS eligible clinicians must attest YES to being in active engagement with a public health agency (PHA) to submit immunization data. In order to meet this objective and measure, a MIPS eligible clinician must use the capabilities and standards of certified EHR technology (CEHRT), including electronically recording and accessing immunization information in the EHR and electronically creating immunization information for electronic transmission in the EHR.

Practice Fusion Suggested Workflow
Practice Fusion suggests the following workflow to ensure that you gain credit for this measure using the Practice Fusion EHR.

  1. Visit your local immunization registry’s website and register your intent to submit immunization data within 60 days after the start of your performance period. If your registry does not have the capability to receive HL7 2.5.1 data electronically, the requirements cannot be fulfilled to gain credit for this measure.
  2. In Practice Fusion, navigate to the Immunization registry section of your practice Settings and set up your account for electronic transmission. Learn how to set up electronic transmission to your registry >>. This process will vary depending on the registry. Refer to the definition of "active engagement" below to determine if you have met the requirements for this measure based on the status of your integration. Your registry will be the contact for any confirmation about completion of this measure, so make sure to save documentation of all communication with your registry for your records.
  3. Once you are connected and have activated your integration in the Immunization registry section of your practice Settings, you can start submitting immunization files directly to your state registry on an individual patient basis. To do so, visit the Immunizations section of the patient’s chart and select Transmit all. Alternatively, click the Actions button and select Transmit to state registry.

For more information about the immunization submission process to certain state registries, view the relevant links below

New Jersey
New York
New York City
North Carolina
Rhode Island
South Carolina
West Virginia

How is active engagement defined? (Learn more for general CMS guidance)
CMS has indicated that active engagement may be demonstrated using any of the three options listed below:

  1. Completed Registration to Submit Data: The MIPS eligible clinician registered to submit data with the public health agency (PHA) or, where applicable, the clinical data repository (CDR) to which the information is being submitted; registration was completed within 60 days after the start of the MIPS performance period; and the 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. Clinicians who have registered in previous years do not need to submit an additional registration to meet this requirement for each MIPS performance period.
  2. Testing and Validation: The MIPS eligible clinician is in the process of testing and validation of the electronic submission of data. 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 requirements for the measure.
  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.
Data Validation
CMS has published guidance to help providers better understand the documentation they should retain around meeting MIPS requirements. CMS calls this guidance "MIPS Data Validation Criteria" because it describes the types of documentation that would validate the data the provider submits to CMS at the end of the performance period. You can learn more about this by reviewing CMS’ MIPS Data Validation Fact Sheet and you can see the specific documentation guidelines applicable to the ACI Transition Measures in CMS’ MIPS Data Validation Criteria for ACI Transition Measures.  

More information

  • Review the CMS specifications for more information about this measure.
  • For more information on the Merit-based Incentive Payment System (MIPS) program, you can visit Practice Fusion’s Quality Payment Program Center.
  • CMS also provides further resources about the Quality Payment Program here.

Quality Payment Program

  1. 2018 Quality Payment Program: What is the Merit-Based Incentive Payment System (MIPS)
  2. What is the MIPS Dashboard watch list and how do I use it?
  3. How does the MIPS Dashboard work?
  4. What is the Promoting Interoperability (formerly Advancing Care Information) performance category in MIPS?
  5. 2018 What is the Quality performance category in MIPS?
  6. 2018 What are Improvement Activities in MIPS?
  7. Which Improvement Activities qualify for the Promoting Interoperability performance category bonus in 2018?
  8. What is the Cost performance category of MIPS and how is it scored in 2018?
  9. How is the MIPS Final Score Calculated in 2018?
  10. What is a MIPS eligible clinician in 2018?
  11. MIPS for Small, Rural and Underserved Practices
  12. 2018 PI Transition Measure: Medication Reconciliation
  13. 2018 PI Transition Measure: Electronic Prescribing (eRx)
  14. 2018 PI Transition Measure: Secure Messaging
  15. 2018 PI Transition Measure: Security Risk Analysis
  16. 2018 PI Transition Measure: Health Information Exchange
  17. 2018 PI Transition Measure: Immunization Registry Reporting
  18. 2018 PI Transition Measure: Specialized Registry Reporting
  19. 2018 PI Transition Measure: Syndromic Surveillance Reporting
  20. 2018 PI Transitional Measure: View, Download, or Transmit (VDT)
  21. 2018 PI Transition Measure: Provide Patient Access
  22. 2018 PI Transition Measure: Patient-Specific Education
  23. What is the Practice Fusion QCDR?
  24. 2017 Quality Payment Program: What is the Merit-Based Incentive Payment System (MIPS)
  25. How do I report my 2017 MIPS data to CMS using the Practice Fusion QCDR?
  26. What is the Advancing Care Information (ACI) Performance Category for MIPS and how is it scored?
  27. 2017 ACI Transition Measure: Security Risk Analysis
  28. 2017 ACI Transition Measure: Electronic Prescribing (eRx)
  29. 2017 ACI Transition Measure: Provide Patient Access
  30. 2017 ACI Transition Measure: Health Information Exchange
  31. 2017 ACI Transition Measure: View, Download, or Transmit (VDT)
  32. 2017 ACI Transition Measure: Patient-Specific Education
  33. 2017 ACI Transition Measure: Secure Messaging
  34. 2017 ACI Transition Measure: Medication Reconciliation
  35. 2017 ACI Transition Measure: Immunization Registry Reporting
  36. 2017 ACI Bonus Measure: Syndromic Surveillance Reporting
  37. 2017 ACI Bonus Measure: Specialized Registry Reporting
  38. What is the Improvement Activities Performance Category for MIPS?
  39. What are the Quality performance category reporting requirements for MIPS?
  40. What is the difference between the two Advancing Care Information measure sets available in 2017?
  41. What are Alternative Payment Models (APMs) and Advanced APMs?
  42. What is Comprehensive Primary Care Plus (CPC+)?
  43. Which Improvement Activities Qualify for the Advancing Care Information (ACI) Bonus Score in 2017?
  44. How do I contact CMS about the Quality Payment Program?
  45. How do I indicate interest in the Practice Fusion QCDR and get my MIPS estimated scores?
  46. Chronic Care Management FAQs
  47. How do I export a JSON file for 2017 MIPS reporting?
  48. How is the MIPS Final Score Calculated in 2017?

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