Public Health Reporting
Specialized Registry Reporting
The MIPS eligible clinician is in active engagement to submit data to a specialized registry.
YES/NO: To meet this measure, MIPS eligible clinicians must attest YES to being in active engagement to submit data to a specialized registry. 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.
Register with the specialized registry to which you plan to submit data. For details on how CMS has defined a specialized registry, refer to CMS FAQ 22517.
Contact your selected specialized registry (or registries) to confirm the registry’s data submission method and requirements.
Practice Fusion supports the following data types that can be submitted to a specialized registry:
CCDA .xml files
Immunization HL7 2.5.1
Syndromic Surveillance HL7 2.5.1
- To maintain active engagement with the specialized registry, continue the data submission process for all applicable patients using the registry’s specified data submission method. Active engagement is defined below under Additional Measure Information.
Retain documentation that confirms your submissions to the specialized registry for at least 6 years as required by the CMS document retention policy.
Additional Measure Information
CMS has indicated that active engagement may be demonstrated in one of the following ways (Learn More):
- 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.
- 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.
- 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.
- 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.