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Immunization Registry Reporting

Updated: 05/28/2024|Views: 3191

The MIPS eligible clinician is in active engagement with public health agencies to submit immunization data and receive immunization forecasts and histories from the public health immunization registry/immunization information system (IIS).

Exclusions: Any MIPS eligible clinician meeting one or more of the following criteria may be excluded from the Immunization Registry Reporting measure if the MIPS eligible clinician:
  • 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 performance period.
  • 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 performance period.
  • Operates in a jurisdiction where no immunization registry or immunization information system has declared readiness to receive immunization data as of 6 months prior to the start of the performance period.
Attestation:  Yes / No

Their level of active engagement. See definitions below.
Performance Score Weight: 25 points if “yes” to both Immunization Registry Reporting and Electronic Case Reporting measures, OR if one “yes” and one exclusion is claimed. Then, if no “yes” responses and two exclusions are claimed the points are redistributed to “Provide Patient Electronic Access to their Health Information”.  If two “no” responses, then zero (0) for both Provide Patient Electronic Access to Health Information and Promoting Interoperability Performance Category.

 In order to meet this requirement, clinicians must enroll through Tebra to connect with the immunization registry.

To get started:
  • Contact your state immunization registries:
    • Inform the registry of your intent to submit electronic immunization data to them.
    • Obtain all the required information from them, including the contact name and phone number of the person who will be working on your request.
  • Create a Customer Care case with Tebra:
    • Provide the information received from your state registries (including name & phone number of their contact).
  • Complete the process with Tebra:
    • Your case with Tebra will be assigned to our specialist.
    • Our specialist will communicate with the contact at the registry and start/complete the interface setup.
    • Our specialist will contact you for testing and to complete the process.
  • Keep all supporting documentation
Definition of Active Engagement: The MIPS eligible clinician is in the process of moving towards sending "production data" to a public health agency (PHA) or clinical data registry (CDR), or is sending production data to a PHA or CDR.
  • Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. MIPS eligible clinicians that have registered in previous years do not need to submit an additional registration for subsequent performance periods. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, when applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.
  • Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.
Definition of Production Data: Refers to data generated through clinical processes involving patient care and it is used to distinguish between data and “test data” which may be submitted for the purposes of enrolling in and testing electronic data transfers.

Review Immunization Registry FAQs to learn more.

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