Public Health Reporting: How to Meet the New Meaningful Use Measure

CMS revised the criteria for Stage 1 and Stage 2 of meaningful use and requires all providers to attest to a single set of objectives and measures. The single set includes a new objective that replaces and consolidates the previous menu measures related to public health: Objective 10: Public Health Reporting [PDF].

There are three measure options under the public health reporting objective. In 2016, all eligible professionals scheduled to be in Stage 2 must report two out of three measure options. If an EP excludes from a measure, they must meet or exclude from the remaining measures in order to meet the objective. If the EP qualifies for multiple exclusions and the remaining number of measures available to the EP is less than two, the EP can meet the objective by meeting the one remaining measure available to them.

1. Immunization registry reporting

• Ophthalmologists can take an exclusion for this if they don’t administer immunizations.

2. Syndromic surveillance reporting

• In 2015 , CMS allowed exclusions for all eligible professionals if there was not an intent to report the measure. However, such flexibility is not permitted in 2016.
• Most, but not all, ophthalmologists will be able to qualify for Exclusion 1 for not being in a category of providers from which ambulatory syndromic data is collected by their jurisdiction’s syndromic surveillance system. However, ophthalmologists in all states should check with their state public health agency to verify that the agency does not collect ophthalmic syndromic surveillance data.
• The Academy has reached out to the state public health departments, and has found that Kentucky, North Dakota, Ohio, Virginia, Wisconsin and Wyoming are accepting ophthalmic syndromic surveillance data. Ophthalmologists in those states must register with their state public health departments to submit syndromic surveillance data within 60 days of the start of their reporting period. To meet the measure, registering with the state’s syndromic surveillance system is sufficient, and no actual transmission of data is required.

3. Specialized registry reporting

• In 2015, CMS allowed exclusions for all eligible professionals if there was not an intent to report the measure. However, such flexibility is not permitted in 2016.
• All ophthalmologists can meet this measure by registering to participate in the American Academy of Ophthalmology IRIS ® Registry within 60 days of the start of their reporting period. Because the IRIS Registry is the only eye care specialized registry, it is the only specialized registry that the American Academy of Ophthalmology recommends to its members (PDF).
• CMS confirmed to Academy staff that active engagement with one specialized registry combined with the exclusions for the first two public health measures is sufficient to meet the objective, as there is no other specialized registry relevant to eye care or recommended by the Academy.

Because registries such as IRIS Registry collect and use data for a number of purposes outside of quality measure reporting, participating physicians can satisfy the requirements of CQM reporting for PQRS and Meaningful Use, as well as the Meaningful Use Public Health Objective’s Specialized Registry measure. For example, outside of CQM reporting, IRIS Registry collects and utilizes data to support population health management, improvement in patient and population outcomes, data mining and analytics and clinical research. Academy members are encouraged to continue using IRIS Registry to report CQMs to satisfy PQRS and Meaningful Use, and to also use IRIS Registry to satisfy the specialized registry public health measure for Meaningful Use.