2017 ACI Bonus Measure: Syndromic Surveillance 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 bonus score measure can contribute an additional 5% to a clinician’s total ACI score, but the completion of this measure is not required in order to earn the full 100% for the total ACI score. For more information on ACI scoring methodology, please click here.

Objective

Public Health Reporting

Measure

Syndromic Surveillance Reporting

The MIPS eligible clinician is in active engagement with a public health agency to submit syndromic surveillance data.

Scoring Information

  • Required for Base Score (50%): No
  • Percentage of Performance Score (up to 90%): 0%
  • Eligible for Bonus Score: Yes, 5%

Reporting Requirements

  • YES/NO: To meet this measure, MIPS eligible clinicians must attest YES to being in active engagement with a public health agency to submit syndromic surveillance data.

Note: Eligible clinicians must earn the full base score in order to earn additional credit through the ACI bonus score.

Practice Fusion Suggested Workflow
Practice Fusion suggests the following workflow to ensure that you meet the requirements of this measure within the Practice Fusion EHR.

  1. Locate your local public health agency and initiate contact with them to confirm whether they are able to accept syndromic surveillance data in HL7 2.5.1 format.
  2. Once you have confirmed that your public health agency can accept syndromic surveillance data in HL7 2.5.1 format, confirm with them their list of reportable diseases and whether they accept ambulatory syndromic surveillance data.
  3. If you collect reportable syndromic surveillance data and your public health agency can accept the file in HL7 2.5.1 format, you may proceed to send them the syndromic surveillance file via a transmission method accepted by the public health agency. You do not need to transmit the file using Practice Fusion to meet the requirements of this measure.
  4. To generate the syndromic surveillance file in the EHR, click the Actions drop-down menu from within the patient encounter and select "Syndromic Surveillance" (see Graphic 1 below). Select Save to file to save the file to your computer.
  5. Once saved, you can submit the exported file to your local public health agency via their specified reporting method (contact the agency to confirm the required submission process).
  6. To maintain active engagement with your public health agency, continue to follow Steps 4 and 5 for all applicable patients.
  7. Retain documentation that confirms your submissions to the public health agency for at least 6 years as required by the CMS document retention policy.

Graphic 1: Generating a Syndromic Surveillance File Within Practice Fusion
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Additional Measure Information
CMS has indicated that active engagement may be demonstrated in one of the following ways (Learn More):

  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 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. 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.
  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 measure specifications for more information about the requirements for 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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