Under the Merit-Based Incentive Payment System (MIPS) pathway of the MACRA Quality Payment Program, Promoting Interoperability (PI) is one of the four performance categories that will be considered and weighted for scoring an eligible clinician’s performance under MIPS.
In 2018, there are 2 measure set options for submission depending on the Certified EHR Technology (CEHRT) edition a clinician is using:
Promoting Interoperability Measures
Promoting Interoperability (PI) Transition Measures
Depending on the CEHRT Edition, there will be different objectives from which the MIPS eligible clinician may choose to report. This article outlines the measure details and specifications for the 2018 PI Transition Measure: Immunization Registry Reporting.
PI Transition Measures
Public Health Reporting
Immunization Registry Reporting
The MIPS eligible clinician is in active engagement with a public health agency to submit immunization data.
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.
CMS has indicated that active engagement may be demonstrated using any of the three options listed below (Learn more) :
Completed Registration to Submit Data: The MIPS eligible clinician registered to submit data with the public health agency (PHA) 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 to begin testing and validation.
This option allows MIPS eligible clinicians to meet the measure when the PHAhas 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 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.
For information on meeting the requirements of this measure in Practice Fusion, see the Practice Fusion Suggested Workflow section below.
Measure Requirements: Practice Fusion Suggested Workflow
Practice Fusion suggests the following workflow to help ensure that you meet the workflow requirements for this measure within the Practice Fusion EHR.
Visit your local immunization registry 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" above 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 (see Graphic 1 below). Alternatively, click the Actions button and select Transmit to state registry.
Graphic 1: Transmitting Immunization Files Within Practice Fusion
For more information about the immunization submission process in your state, click the appropriate link below:
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.