Declaration of Readiness Criteria

Modified Stage 2 Public Health Objectives

CMS released regulation to streamline Stage 1 and Stage 2 into Modified Stage 2 criteria. Providers may attest a public health reporting measure specification by demonstrating “active engagement” with a public health agency (PHA) or clinical data registry.

Public Health Measures for EPs

2016 Modified Stage 2 - Public Health Objective for EPs

NJDOH Declaration of Readiness

Maximum Measure Can Count Towards Objective

Measure 1 - Immunization: NJDOH is accepting data sent to the New Jersey Immunization Information System

Ready to Accept Data

1

Measure 2 - Syndromic Surveillance: NJDOH is only accepting Syndromic data from Hospital Emergency Departments

NOT Currently Accepting Data  or Registrations

1

Measure 3 - Specialized Registry: NJDOH has not identified any specialized registries within the DOH that is ready to accept clinical data electronically from Certified EHR Technology (CEHRT) at this time

NOT Currently Accepting Data  or Registrations Please see link and note below

2 for EPs

Note: EPs scheduled to be in Stage 1 and Stage 2 in 2016 are required to attest to at least two measures from the Public Health Reporting measures 1‐3. There are Clinical Data Registries external to NJDOH that can satisfy the requirement for Measure 3 – Specialized Registry reporting. Provider should research registries that are relative to their practice and verify that the registry is qualified to satisfy the meaningful use public health reporting objectives. Here is a link to a partial list of clinical registries that providers can investigate: https://www.thepcpi.org/pcpi/media/documents/nqrn-national-clinical-registry-inventory_1.pdf. Providers can also reach out to their medical societies for further suggestions on registries relevant to their practice.

Public Health Measures for Eligible Hospitals and CAHs

2016 Modified Stage 2 - Public Health Objective for EHs & CAHs NJDOH Declaration of Readiness Maximum Measure Can Count Towards Objective
Measure 1 - Immunization: NJDOH is accepting data sent to the New Jersey Immunization Information System
Ready to Accept Data
1
Measure 2 - Syndromic Surveillance: NJDOH is only accepting Syndromic data from Hospital Emergency Departments
Ready to Accept from Emergency Dept. Only
1
Measure 3 - Specialized Registry: NJDOH has not identified any specialized registries within the DOH that is ready to accept clinical data electronically from Certified EHR Technology (CEHRT) at this time ? 3 for EH/CAHs
Measure 4 - Reportable Lab Results: NJDOH is accepting data through the Electronic Lab Reporting System Ready to Accept Data 1

 EH/CAH are required to attest to at least three measures from measures 1-4. 

What Is Active Engagement? 

  • Active Engagement Option 1—Completed Registration to Submit Data: The EP/EH/CAH 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 EHR reporting period; and the EP/EH/CAH is awaiting an invitation from the PHA or CDR to begin testing and validation. This option allows providers to meet the measure when the PHA or the CDR has limited resources to initiate the testing and validation process. Providers who have registered in previous years do not need to submit an additional registration to meet this requirement for each EHR reporting period.
  • Active Engagement Option 2—Testing and Validation: The EP/EH/CAH is in the process of testing and validation of the electronic submission of data. Providers must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within an EHR reporting period would result in that provider not meeting the measure.
  • Active Engagement Option 3—Production: The EP/EH/CAH has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR

 

 What is Active Engagement? Further Clarification

  • Providers only need to register once with a PHA or CDR and can register before the reporting period begins. Previous registrations with a PHA or CDR that occurred in previous stages of meaningful use can count toward Active Engagement Option 1 for any of the EHR reporting periods in 2015, 2016, or 2017. To meet Active Engagement Option 1, registration with the applicable PHA or CDR is required where a provider seeks to meet meaningful use using a measure they have not successfully attested to in a previous EHR reporting period.
  • NOTE: If a registry declares readiness at any point in the calendar year after the initial 60 days, a provider may still register their intent to report with that registry to meet the measure under Active Engagement—Option 1. However, a provider who could report to that registry may still exclude for that calendar year if they had already planned to exclude based on the registry not being ready to allow for registrations of intent within the first 60 days of the reporting period. For example, if the registry was not available on Feb 29th, the eligible hospital/CAH has a choice to exclude or register once the registry has declared readiness.
  • Demonstrating Meaningful Use: Providers can demonstrate meaningful use by using communications and information provided by a PHA or CDR to the provider directly. A provider also may demonstrate meaningful use by using communications and information provided by a PHA or CDR to the practice or organization of the provider as long as the provider shares the same CEHRT as the practice or organization. The Medicare program does not require providers to identify for CMS which registries they are reporting to for the public health reporting objective. However, we recommend providers document their decisions in case of an audit or if they are attesting to Medicaid, which may require specific registries to be identified depending on the state.
  • Active Engagement – Option 3: To meet any of the measures using Active Engagement—Option 3 (production), a provider only may successfully attest to meaningful use when the receiving PHA or CDR moves the provider into a production phase. Live data may be sent during the Testing and Validation phase of Active Engagement—Option 2, but in such a case, the data received in Option 2 is insufficient for purposes of meeting Option 3 unless the PHA and CDR is actively accepting the production data from the provider for purpose of reporting.

Count As A Specialized Registry? (CMS FAQ#13653)

  • A submission to a specialized registry may count if the receiving entity meets the following requirements: 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. Until such time as a centralized repository is available to search for registries, most public health agencies and clinical data registries are declaring readiness via a public online posting. Registries should make this information publically available for potential registrants.
  • 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. 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 test and validation and a process to move into production. The receiving entity should be able to provide appropriate documentation for the sending provider or their current status in Active Engagement.
  • For qualified clinical data registries, reporting to a QCDR may count for the public health specialized registry measure as long as the submission to the registry is not only for the purposes of meeting CQM requirements for PQRS or the EHR Incentive Programs. In other words, the submission may count if the registry is also using the data for a public health purpose. Many QCDRs use the data for a public health purpose beyond CQM reporting to CMS. A submission to such a registry would meet the requirement for the measure if the submission data is derived from CEHRT and transmitted electronically.

What are the Alternate Exclusions for 2016?

  • EPs may claim an alternate exclusion for the Public Health Reporting measure 2 (Syndromic Surveillance) and 3 (Specialized Registry Reporting) which might require the acquisition of additional technologies they did not previously have or did not previously intend to include in their activities for meaningful use.
  • Eligible hospitals and CAHs may claim an alternate exclusion for Public Health Reporting measure 3 (Specialized Registry Reporting) which might require the acquisition of additional technologies they did not previously have or did not previously intend to include in their activities for meaningful use.
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Stage 3 Public Health Objectives:

CMS has offered six public health reporting measures in total, (five for EP's) for Stage 3. EPs must successfully attest to two measures out of the five options offered to them, while Eligible hospitals and CAHs will be required to successfully attest to four out of the six options offered to them.

 

Measure 1—Immunization Registry Reporting

Measure 2—Syndromic Surveillance Reporting

Measure 3—Case Reporting

Measure 4—Public Health Registry Reporting

Measure 5—Clinical Data Registry Reporting

Measure 6—Electronic Reportable Laboratory Results (Eligible hospitals and CAH only)

Note that Measures 4 and 5 may be counted more than once towards the total number of measures required to meet the objective. In detail, they may be counted up to two times for Eligible professionals and four times for Eligible hospitals and CAHs.

Additional Information:

Electronic Health Record Incentive Payment Program - Public Health Reporting Measures and Standards For Eligible Professionals (EPs), Eligible Hospitals (EHs), Critical Access Hospitals (CAHs) 2014 Edition, Certified Electronic Health Record Technology (CEHRT) and 2015 Edition CEHRT: https://www.cdc.gov/ehrmeaningfuluse/docs/mod_stage2_stage3_table_08_18_2016.pdf

Electronic Health Record (EHR) Incentive Payment Program - Public Health Reporting Measures & Standards (Modified Stage 2 & Stage 3): https://www.cdc.gov/ehrmeaningfuluse/docs/tabular_summary_modified_stage2_stage_ehr_mu_public_health_requirements_eps_ehs.pdf

Public Health and Clinical Data Registry Reporting for CMS Programs: https://www.cdc.gov/ehrmeaningfuluse/docs/joint_public_health_forum_nationwide/2016-05-20-public-health-reporting-may2016_final_webversion.pdf

Last Reviewed: 2/16/2017