Specialized/Public Health/Clinical Data Registry Reporting

Specialized/Public Health/Clinical Data Registry Reporting

The Specialized Registry Reporting Measure (Measure 3) that was available in Modified Stage 2, is not available in Stage 3.

The registries that were used in prior program years, and attested to under the Specialized Registry Measure, may still be attested to in Stage 3, under either Public Health Registry Reporting (Measure 4), or Clinical Data Registry Reporting (Measure 5) if all of the requirements are met as outlined in the Specifications Sheets, and Final Rules, issued by CMS.

To use a Registry in Stage 3, that may have been used when attesting to Modified Stage 2, the registry must use specified standards for data transmission. If it does not, it can’t be used; unless, it falls under the definition of a Public Health Registry and the provider achieved the Active Engagement Option 3 – Production status in a prior program year attestation. If in the prior program year Active Engagement Option 3 – Production status was not obtained, the registry cannot be used in Stage 3.

Public Health Registry vs. Clinical Data Registry

The Final Rule states:

The National Quality Registry Network defines clinical data registries as those that record information about the health status of patients and the health care they receive over varying periods of time. We proposed to further differentiate between clinical data registries and public health registries as follows: For the purposes of meaningful use, “public health registries” are those administered by, or on behalf of, a local, state, territorial, or national public health agencies; and, “clinical data registries” are administered by, or on behalf of, other non-public health agency entities.”

See the Objective 8 specification sheet for specific details.

Public Health Registry Reporting (Measure 4):

From the CMS Specifications Sheet:

Measure:

The EP is in active engagement with a PHA to submit data to public health registries

Exclusions:

An EP may take an exclusion if any of the following apply:

  1. He or she does not diagnose or directly treat any disease or condition associated with a public health registry in their jurisdiction during the EHR reporting period;
  2. He or she practices in a jurisdiction for which no PHA is a capable of accepting electronic registry transactions in the specific standards required to meet the CEHRT definition at the start of the EHR reporting period; or
  3. He or she practices in a jurisdiction where no PHA for which the EP is eligible to submit data has declared readiness to receive electronic registry transactions as of six months prior to the start of the EHR reporting period.

Clinical Data Registry Reporting (Measure 5):

From the CMS Specifications Sheet:

Measure:

The EP is in active engagement to submit data to a Clinical Data Registry.

Exclusions:

An EP may take an exclusion if any of the following apply:

  1. He or she does not diagnose or directly treat any disease or condition associated with a CDR in their jurisdiction during the EHR reporting period;
  2. He or she practices in a jurisdiction for which no CDR is a capable of accepting electronic registry transactions in the specific standards required to meet the CEHRT definition at the start of the EHR reporting period; or
  3. He or she practices in a jurisdiction where no CDR for which the EP is eligible to submit data has declared readiness to receive electronic registry transactions as of six months prior to the start of the EHR reporting period.

Per the Stage 3 CMS specification sheets:

  • For Measure 4 and 5 (in Stage 3), a provider may count a specialized registry (such as prescription drug monitoring) if the provider achieved the phase of active engagement defined under Active Engagement Option 3: Production, including production data submission with the specialized registry in a prior year under the applicable requirements for the PI Program for that year.
  • For Measure 4 and 5 (in Stage 3), if the PHA or CDR does not use a specified standard, it must use another standard specified in 170.205 to meet the measure. For example, the transmission could be in the form of a Consolidated Clinical Document Architecture (C-CDA) per 170.205(a)(4), or Quality Reporting Document Architecture (QRDA) per 170.205(h)(2). If an EP practices in a jurisdiction where no PHA or CDR for which they are eligible to submit data has declared readiness to receive electronic registry transactions in accordance with the 2015 Edition standards as of six months prior to the start of the EHR reporting period, they may take an exclusion from these measures, as appropriate.

How to determine what registries are available

  • Check with your state to determine if there is a registry available.
  • Check with specialty societies with which the professional is affiliated with, to determine if the societies maintain or endorse any registries.
  • Check the CMS FAQ page.
  • CMS has developed a Centralized Repository for public health agency and clinical data registry reporting to provide a centralized source of information for eligible professionals, eligible hospitals, and critical access hospitals looking for public health, clinical data, or specialized registry reporting options.

In Michigan, the following Registries are available:

Specialized RegistryAvailable forCriteria for Reporting
Michigan Cancer Surveillance Program (MCSP)EPsProviders who diagnose or treat certain reportable cancer cases
Michigan’s Dental Registry (MiDR) – If the provider achieved a Production status in a prior program year.EPsProviders who treat children under the age of 18
Michigan Birth Defects Registry (MBDR) for EPs

Michigan Birth Defects Registry (MBDR) for EHs
EPs, EHs/CAHs
Providers who diagnose or treat birth defects identified in infants and children under the age of two years
Newborn Screening (NBS)EHs/CAHsHospitals with a birthing facility and the capability to submit pulse oximetry results in the standard format
Michigan Birth Registry (MBR)EHs/CAHsHospitals with a birthing facility that are interested in piloting electronic submission of live birth and fetal death information
Michigan Automated Prescription System (MAPS)EPs, EHs/CAHsProviders who prescribe or dispense controlled substances

Please review the websites noted above to determine if any of the registries would be applicable.