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Public Health Reporting for Meaningful Use and the Quality Payment Program

Background

The expansion and use of electronic health records (EHRs) is a national goal established under the Health Information Technology for Economic and Clinical Health Act (HITECH Act). The Centers for Medicare and Medicaid Services (CMS) EHR Incentive Programs, commonly referred to as Meaningful Use (MU), and the Medicare Access and CHIP Reauthorization Act (MACRA) Quality Payment Program promote  the adoption and use of interoperable health information technology (HIT) by eligible hospitals (EHs), critical access hospitals (CAHs), eligible professionals (EPs), and eligible clinicians (ECs).

Quality Payment Program and MU measures for exchanging data with public health agencies have been established at the national level.  Measures relevant for the submission of data to the Ohio Department of Health (ODH) include Immunization Registry Reporting, Syndromic Surveillance Reporting, Specialized Registry Reporting—Cancer Case Reporting, and Electronic Reportable Laboratory Results Reporting.

Declaration of Readiness by ODH

ODH has the capability to accept data for public health reporting from EHs, CAHs EPs, and ECs according to federal guidelines and technical standards*. Data for the following measures may be transmitted directly to ODH or through one of Ohio’s health information exchanges: 

EH/CAH MU Measures: (1) Immunization Registry Reporting, (2) Syndromic Surveillance Reporting, and (4) Electronic Reportable Laboratory Results Reporting. Please note that ODH is not currently accepting data from EHs or CAHs for Measure 3, Specialized Registry Reporting – Cancer Case Reporting.

EP MU Measures: (1) Immunization Registry Reporting, (2) Syndromic Surveillance Reporting, and (3) Specialized Registry Reporting – Cancer Case Reporting

Getting Started: The Active Engagement Requirement

There are three options to meet the active engagement requirement to receive MU credit for the health measures available through ODH: (1) Completed Registration to Submit Data, (2) Testing and Validation, and (3) Production. The active engagement requirement and steps outlined below apply to each measure separately. For example, an EH, CAH, or EP may meet the active engagement requirement through option 3 (Production) for one measure and option 2 (Testing and Validation) for another.

Step 1—Registration to Submit Data:  All EHs, CAHs, and EPs must start by registering to submit data to ODH by the 60th day of their reporting period at www.OhioPublicHealthReporting.info. There is no need to re-register for a measure when transitioning between stages or reporting periods. It is preferred that provider groups and health systems register as entities, not individuals.

Step 2—Determine Invitation Status: After registration to submit data, ODH may or may not invite an entity to begin the onboarding process. Invitations are emailed to the contact(s) provided during the registration to submit data process. The current status of an invitation is also available at www.OhioPublicHealthReporting.info.

  • Entities that are not invited should attest that they have met the active engagement requirement by stating that they have Completed Registration to Submit Data during the attestation process (option 1). No additional work is necessary unless an invitation is received from ODH at a later time. 

  • Entities that are invited should move to Step 3

Step 3—Begin Technical Work: ODH onboarding staff will work with EHs, CAHs, and EPs to begin submitting data for the measures. The process generally involves reviewing technical specifications, submitting test files and making any fixes identified by ODH onboarding staff.

  • Entities that have not moved to production by the end of their reporting period should attest that they have met the active engagement requirement by stating that they are in the Testing and Validation stage for the measure (option 2). Testing and validation work should continue in subsequent reporting periods or an entity risks not meeting the active engagement requirement in future years.

  • Entities that have moved to production by the end of their reporting period should attest that they have met the active engagement requirement by stating that they are in Production (option 3). Entities in production must maintain production and work to resolve any unexpected issues to maintain their active engagement status during future reporting periods.

Proof of an entity’s invitation and active engagement status for MU attestation purposes is available at www.OhioPublicHealthReporting.info. In addition, entities will receive an email notification when a status change occurs. 

* ODH accepts HL7 messages that meet the standards in either the 2014 or 2015 Edition of Certified Electronic Health Record Technology (CEHRT), including the messages types involved in bi-directional data exchange for Immunization Registry Reporting.

Last Update: 3/22/17