Public Health Reporting
Immunization Registry Reporting
- 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.
- 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.
- 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.
- 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 York City
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:
- 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.
- 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.
- 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.
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.