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: Syndromic Surveillance Reporting.
PI Transition Measures
Public Health Reporting
Syndromic Surveillance Reporting
The MIPS eligible clinician is in active engagement with a public health agency (PHA) to submit syndromic surveillance data.
YES/NO: To meet this measure, MIPS eligible clinicians must attest YES to being in active engagement with a PHA 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.
CMS has indicated that active engagement may be demonstrated in one of the following ways:
Completed Registration to Submit Data: The MIPS eligible clinician registered to submit data with the 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 PHA 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; 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.
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.
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.
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.
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.
To generate the syndromic surveillance file in the EHR, click the Actions dropdown 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.
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).
To maintain active engagement with your public health agency, continue to follow Steps 2 and 3 for all applicable patients. Active engagement is defined above under Scoring Requirements.
Retain documentation that confirms your submissions to the specialized registry for at least 6 years as required by the CMS document retention policy.
Graphic 1: Generating a Syndromic Surveillance File Within Practice Fusion
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.