Objective 10 – Public Health Reporting

Public Health Reporting – Objective 10

About this Objective: The EP is in active engagement with a public health agency to submit electronic public health data from CEHRT except where prohibited and in accordance with applicable law and practice.

Measures:

• Measure 1 – Immunization Registry Reporting: The EP is in active engagement with a public health agency to submit immunization data.
• Measure 2 – Syndromic Surveillance Reporting: The EP is in active engagement with a public health agency to submit syndromic surveillance data.
• Measure 3 – Specialized Registry Reporting: The EP is in an active engagement with a public health agency to submit data to a specialized registry.

Note: These measures are not shown on the ChartLogic MUC Report

Exclusions:

• Measure 1 – Immunization Registry Reporting: Any EP meeting one or more of the following criteria may be excluded from the immunization registry reporting measure if the EP
  1. Does not administer any immunizations to any of the populations for which data is collected by its jurisdiction’s immunization registry or immunization information system during the EHR reporting period.
  2. Operates in a jurisdiction for which no immunization registry or immunization information system is capable of accepting the specific standards required to meet the CEHRT definition at the start of the EHR reporting period.
  3. Operates in a jurisdiction where no immunization registry or immunization information system has declared readiness to receive immunization data from the EP at the start of the EHR reporting period.

• Measure 2 – Syndromic Surveillance Reporting: Any EP meeting one or more of the following criteria may be excluded from the syndromic surveillance reporting measure if the EP
  1. Is not in a category of providers from which ambulatory syndromic surveillance data is collected by their jurisdiction’s syndromic surveillance system.
  2. Operates in a jurisdiction for which no public health agency is capable of receiving electronic syndromic surveillance data from EPs in the specific standards required to meet the CEHRT definition at the start of the EHR reporting period.
  3. Operates in a jurisdiction where no public health agency has declared readiness to receive syndromic surveillance data from EPs at the start of the EHR reporting period.

• Measure 3 – Specialized Registry Reporting: Any EP meeting at least one of the following criteria may be excluded from the specialized registry reporting measure if the EP
  1. Does not diagnose or treat any disease or condition associated with, or collect relevant data that is required by a specialized registry in their jurisdiction during the EHR reporting period.
  2. Operates in a jurisdiction for which no specialized registry is capable of accepting electronic registry transactions in the specific standards required to meet the CEHRT definition at the start of the EHR reporting period.
  3. Operates in a jurisdiction where no specialized registry for which the EP is eligible has declared readiness to receive electronic registry transactions at the beginning of the EHR reporting period.

Alternate Exclusions:

• Measure 2 – Syndromic Surveillance Reporting: EPs may claim an alternate exclusion for measure 2 (syndromic surveillance reporting) for an EHR reporting period in 2016. (Will be updated as soon as ChartLogic knows more from CMS as to what the exclusion is.)
• Measure 3 – Specialized Registry Reporting: EPs may claim an alternate exclusion for measure 3 (specialized registry reporting) for an EHR reporting period in 2016. (Will be updated as soon as ChartLogic knows more from CMS as to what the exclusion is.)

Note: In the case of an CMS audit you will need to get an Active Engagement Letter/email from the registry, or supply relevant exclusion documentation.

Additional Information:

• Providers who have previously registered, tested, or begun ongoing submission of data to registry do not need to “restart” the process beginning at active engagement option 1. The provider may simply attest to the active engagement option which most closely reflects their current status.
• An exclusion for a measure does not count toward the total of two measures. If an EP excludes from a measure, they must meet or exclude from the remaining measures in order to meet the objective. If the 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. If no measures remain available, the EP can meet the objective by meeting the requirements for exclusion from all three measures.
• For Measure 3, a provider may report to more than one specialized registry and may count specialized registry reporting more than once (twice) to meet the required number of measures for the objective.
• In determining whether an EP meets the first exclusion, the registries in question are those sponsored by the public health agencies with jurisdiction over the area where the EP practices and national medical societies covering the EP’s scope of practice. Therefore, an EP must complete two actions in order to determine available registries or claim an exclusion:
  1. Determine if the jurisdiction (state, territory, etc.) endorses or sponsors a registry.
  2. Determine if a National Specialty Society or other specialty society with which the provider is affiliated endorses or sponsors a registry.

• Providers may use electronic submission methods beyond the functions of CEHRT to meet the requirements for the Specialized Registry Reporting measure.
• A specialized registry cannot be duplicative of any of the other registries or reporting included in other meaningful use requirements.
• If a provider does the action that results in a data element for a registry in the normal course of their practice and is in active engagement to submit to a registry, but simply has no cases for the reporting period, the provider is not required to take the exclusion and may attest to meeting the measure.

ChartLogic Tip: Reach out to your state to see if they are accepting this information electronically. If your state is accepting this data, you will need to get with them to set up a way to send the EMR data to them.

How to meet this Objective:

Your practice will need to reach out to your states Department of Health (DOH) and set up registries for each of the relevant measures above. The practices goal with each of these registries (dependent on applicability to the scope of practice)  is to set up and obtain a letter/e-mail showing an “Active Engagement” with the registry basically saying you are providing them relevant data. Please review your State’s DOH website or by contacting them to further figure out how to set up these registries or determine if your practice is needed to submit to such registries.

CMS Information

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