Specialized Registry Reporting

Specialized Registry Reporting

Measure:

The EP, eligible hospital, or CAH is in active engagement to submit data to a specialized registry

Exclusions:

Any EP, eligible hospital, or CAH meeting at least one of the following criteria may be excluded from the specialized registry reporting measure if the EP, eligible hospital, or CAH –

  • Does not diagnose or treat any disease or condition associated with, or collect relevant data that is collected by, a specialized registry in their jurisdiction during the EHR reporting period;
  • 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; or
  • 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.

How to determine what specialized registries are available

CMS outlined the steps required to determine if there is a specialized registry available in CMS FAQ 13657 (EP) and CMS FAQ 14117 (EH/CAH). These FAQs describe the steps that are required to meet due diligence in the search for specialized registries.  In summary, the steps are:

  • Check with your state to determine if there is a specialized registry available.
  • Check with specialty societies with which the professionals or hospital are affiliated to determine if the societies maintain or endorse any specialized registries.

In Michigan, the following Specialized 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)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.

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

Providers should also check with their affiliated specialty societies to determine if any specialized registries are available.

Additional Considerations

  • Providers may use electronic submission methods beyond the functions of CEHRT to meet the requirements for the Specialized Registry Reporting measure.
  • A provider may report to more than one specialized registry and may count specialized registry reporting more than once to meet the required number of measures for the objective.
  • A specialized registry cannot be duplicative of any of the other registries or reporting included in other meaningful use requirements.Special consideration exists for providers who diagnose or treat cancer but are using certified EHR technology (CEHRT) that is not certified for cancer case reporting – Special Consideration for Cancer Case Reporting in 2017.
  • Special consideration exists for providers who diagnose or treat cancer but are using certified EHR technology (CEHRT) that is not certified for cancer case reporting – see Special Consideration for Cancer Case Reporting in 2017.
  • 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. This is noted in CMS FAQ 13653.
  • The Center for Disease Control and Prevention (CDC), National Center for Health Statistics is currently accepting National Health Care Survey data from Eligible Professionals (EP), Eligible Hospitals (EH) and critical Access Hospitals (CAH) to fulfill the Meaningful Use EHR Incentive Programs Public Health Objective, Measure 3, submission of data for specialized registry reporting.  More information about the National Health Care Surveys can be found at http://www.cdc.gov/ehrmeaningfuluse/national_health_care_surveys.html.

CMS Resources

  • CMS FAQ 13653 – What counts as a specialized registry
  • CMS FAQ 13657 – How to determine if a specialized registry is available
  • CMS FAQ 14117 – Steps EHs must take to meet the specialized registry objective