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Public Health Reporting in 2017
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Medicaid EHR Incentive Program
Public Health Reporting Requirement
Program Requirement:
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All EPs must be actively engaged with 2 public health registries.
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| | Exclusions Available: | Exclusions are available for all public health reporting measures. |
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Questions? Contact Trish Harkness at 620.874.8034.
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In the 2015 EHR Incentive Programs Final Rule published on October 16, 2015, CMS implemented a public health reporting measure requiring all eligible professionals (EPs) to be actively engaged with two of the following public health registries:
- Immunization Registry Reporting
- Syndromic Surveillance Reporting
- Specialized Registry Reporting (Up to 2 per EP)
As you may recall, there are three options for active engagement:
- Option 1: A completed registration to submit data was submitted to the public health registry within 60 days of the start of the reporting period and the EP is awaiting an invitation to begin testing and validation. The registration can be submitted prior to the reporting year and does not need to be resubmitted to the same public health registry each reporting period. We recommend that you keep a copy of your completed registration and an acknowledgement of receipt from the public health registry in your MU supporting documentation.
- Option 2: The EP is in the process of testing and validating the electronic submission of data.
- Option 3: The EP has completed testing and validation of the electronic submission and is electronically submitting production data to the public health registry.
For Options 2 and 3, we recommend that you keep a copy of your public health registry's notification of submission status in your MU supporting documentation.
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Immunization and Syndromic Surveillance Registries
It is important to understand that reporting an exclusion does not count as reporting a measure. However, if an EP qualifies for multiple exclusions and the remaining number of measures available to the EP is less than two, the EP can meet the objective by meeting the one remaining measure available to them and claiming the applicable exclusions or claiming applicable exclusions for all measures.
Immunization Registry
The only exclusion applicable to EPs in Kansas is for those who do not administer any immunizations to any of the populations for which data is collected. An EP that administers any immunizations (including influenza, pneumonia, tetanus, etc.) is required to be actively engaged with KDHE's WebIZ immunization registry.
Syndromic Surveillance Registry
The exclusion most applicable to EPs in Kansas is not being in a category of providers from which ambulatory syndromic surveillance data is collected by their jurisdiction's syndromic surveillance system. KDHE's Kansas Meaningful Use Public Health Reporting website indicates "KDHE cannot accept syndromic data from eligible providers at this time".
After releasing the 2015 EHR Incentive Programs Final Rule, CMS realized that EPs in states that did not accept syndromic surveillance data were essentially being forced to submit data to a specialized registry. Thus, several frequently asked questions (FAQs) were issued. CMS FAQ 14401 states "We do not intend to inadvertently penalize providers for changes to their systems or reporting made necessary by the provisions of the 2015 EHR Incentive Programs Final Rule". Thus, in 2015 and 2016, CMS allowed an alternate exclusion for public health reporting measures "which might require the acquisition of additional technologies they did not previously have or [EPs] did not previously intend to include in their activities for meaningful use"; this alternate exclusion was limited to syndromic surveillance reporting and specialized registry reporting. (This is also supported by CMS FAQ 14397.) A CMS source has indicated that CMS will not extend this alternate exclusion to 2017.
Specialized Registries
For 2017, it will be very important for EPs to determine their options for specialized registry reporting. If the EP provides immunization, only one specialized registry will be needed. The EHR Incentive Programs in 2015 through 2017: Public Health Reporting for Eligible Professionals in 2016 guidance states "if the EP can exclude from all measures except for Specialized Registry, the EP should report to two specialized registry measures if they are able to, in order to meet the objective". The guidance indicates steps that must be taken to determine the availability of a specialized registry:
- An EP should check with their State (or the entity used as their reporting jurisdiction, such as a county) to determine if there is an available specialized registry maintained by a public health agency.
- An EP should check with any specialty society with which they are affiliated to determine if the society maintains a specialized registry and for which they have made a public declaration of readiness to receive data for meaningful use no later than the first day of the provider's EHR reporting period.
In 2017, CMS is developing a centralized repository of self-reported public health registries. Although it has not yet been posted, we recommend that you look at the list when it becomes available (in addition to the two steps noted above) to determine specialized registry options. If the EP determines no registries are available, an exclusion may be claimed. We recommend that you document your search for specialized registries as supporting documentation if you determine that no specialized registries are available.
CMS FAQ 13653 provides guidelines on what can count as a specialized registry:
- The receiving entity must declare that they are ready to accept data as a specialized registry and be using the data to improve population health outcomes; to date, most public health agencies and clinical data registries are declaring readiness via a public online posting.
- The receiving entity must also be able to receive electronic data generated from CEHRT. The electronic file can be sent to the receiving entity through any appropriately secure mechanism including, but not limited to, a secure upload function on a web portal, sFTP, or Direct. Please note that manual data entry into a web portal would not qualify for submission to a specialized registry.
- The receiving entity should have a registration of intent process, a process to take the provider through testing and validation, and a process to move into production.
- The receiving entity should be able to provide appropriate documentation for the sending provider for their current status in Active Engagement.
- For qualified clinical data registries (QCDRs), reporting may count for the public health specialized registry measure as long as the submission to the registry is generated by certified EHR technology, submitted electronically and the data is used for a public health purpose. QCDRs are often used to meet the requirements for the Physician Quality Reporting System (PQRS) or the EHR Incentive Programs (also known as MU).
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Contact the HCCN Grant Project Team
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Feel free to contact any member of the KAMU HCCN Grant Project Team below for assistance with project activities.
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