NY Medicaid EHR Incentive Program

Public Health Frequently Asked Questions (FAQs)

  • FAQs is also available in Portable Document Format (PDF)

September 2017

MU Public Health Objective Support Team
MUPublicHealthHELP@health.ny.gov
1–877–646–5410 Option 3


Contents

Disclaimer

This document serves as an informational reference for Eligible Providers participating in the NY Medicaid or Medicare EHR Incentive Programs. Although reasonable effort has been made to assure the accuracy of the information within these pages at the time of posting, it is the responsibility of each provider to comply with the current policies and requirements of the program.


1. MEANINGFUL USE PUBLIC HEALTH REPORTING MEASURES

Contents

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1.1 How does an Eligible Provider successfully meet any of the Meaningful Use Public Health Reporting Measures?

1.1.1 Modified Stage 2 (2015–2017)

Published: 07/08/2014

Updated: 09/28/2016

Eligible Providers must register their intent to submit data to Public Health in the Meaningful Use Registration for Public Health (MURPH) System before or within 60 days of the start of one´s EHR Reporting Period. Once a registration of intent has been completed the Eligible Provider can attest "yes" for a given Public Health Reporting Measure*, if the Eligible Provider is actively engaged as demonstrated by one of the following options:

  • Option 1 – Completed Registration to Submit Data: The Eligible Professional (EP), Eligible Hospital (EH), or Critical Access Hospital (CAH) registered to submit data with the Public Health Agency (PHA) or, where applicable, the Clinical Data Registry (CDR) to which the information is being submitted; registration was completed within 60 days after the start of the EHR reporting period; and the EP, EH, or CAH is awaiting an invitation from the PHA or CDR to begin testing and validation.
  • Option 2 – Testing and Validation: The EP, EH, or CAH is in the process of testing and validation of the electronic submission of data. Eligible Providers must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within an EHR reporting period would result in that Eligible Provider not meeting the measure.
  • Option 3 – Production: The EP, EH, or CAH has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.

* Please note that if the Eligible Provider registers intent to submit data for multiple Public Health Reporting Measures that the Eligible Provider´s status for each Public Health Reporting Measure will be tracked separately and the Eligible Provider will undergo a separate onboarding process for each Public Health Reporting Measure.

1.1.2 Stage 3 (2017–2021)

Published: 09/28/2016

Updated: N/A

Eligible Providers must register their intent to submit data to Public Health in the Meaningful Use Registration for Public Health (MURPH) System before or within 60 days of the start of one´s EHR Reporting Period. Once a registration of intent has been completed the Eligible Provider can attest "yes" for a given Public Health Reporting Measure*, if the Eligible Provider is actively engaged as demonstrated by one of the following options:

  • Option 1 – Completed Registration to Submit Data: The Eligible Professional (EP), Eligible Hospital (EH), or Critical Access Hospital (CAH) registered to submit data with the Public Health Agency (PHA) or the Clinical Data Registry (CDR) to which the information is being submitted; registration was completed within 60 days after the start of the EHR reporting period; and the EP, EH, or CAH is awaiting an invitation from the PHA or CDR to begin testing and validation.

    This option allows providers to meet the measure when the PHA or the CDR has limited resources to initiate the testing and validation process. Eligible Providers that have registered in previous years do not need to submit an additional registration to meet this requirement for each EHR reporting period.
  • Option 2 – Testing and Validation: The EP, EH, or CAH is in the process of testing and validation of the electronic submission of data. Eligible Providers must respond to requests from the PHA or the CDR within 30 days; failure to respond twice within an EHR reporting period would result in that Eligible Provider not meeting the measure.
  • Option 3 – Production: The EP, EH, or CAH has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR. Eligible Providers must respond to requests from the PHA or the CDR within 30 days; failure to respond twice within an EHR reporting period would result in that Eligible Provider not meeting the measure

* Please note that if the Eligible Provider registers intent to submit data for multiple Public Health Reporting Measures that the Eligible Provider´s status for each Public Health Reporting Measure will be tracked separately and the Eligible Provider will undergo a separate onboarding process for each Public Health Reporting Measure.

1.2 When must an Eligible Provider engage with a Public Health registry in order to successfully meet Meaningful Use Public Health Reporting Measures?

Published: 09/09/2015

Updated: 09/28/2016

Eligible Providers must engage with each registry supporting the Meaningful Use Public Health Reporting Measures that the Eligible Providers intend to meet within the EHR Reporting Period for each Payment Year. Aside from registration of intent, which may be submitted prior to or within 60 days of the start of the EHR Reporting Period, all other activities required to meet the Public Health Reporting Measures must take place within the EHR Reporting Period. Actions taken after the end of the EHR Reporting Period will not count towards meeting the Public Health Reporting Measures for that Payment Year.

For example, an Eligible Professional (EP) intending to meet the Immunization Registry Reporting Measure for Payment Year 2016 must be actively engaged with the appropriate immunization registry during the EHR Reporting Period for 2016. Active engagement activities such as submission of a test performed during the 2017 calendar year would not suffice to meet the measure for Payment Year 2016.

Additional Resources:

1.3 If an Eligible Provider qualifies for an exclusion from a Public Health Reporting Measure, does excluding count as meeting that measure for the Meaningful Use (MU) Public Health Reporting Objective?

Published: 09/28/2015

Updated: N/A

No, an exclusion from a Public Health Reporting Measure does not count as meeting that measure for the Meaningful Use (MU) Public Health Reporting Objective. If the Eligible Provider qualifies for multiple exclusions and the remaining number of measures available to the Eligible Provider is less than the number of measures the Eligible Provider is required to meet for the MU Public Health Reporting Objective, then the Eligible Provider should meet any Public Health Reporting Measures for which they are qualified and claim the proper exclusions for the remaining measures.

Ex. If an Eligible Professional (EP) in Modified Stage 2 qualified for an exclusion from one of three available public health measures, then the EP would be required to meet the two remaining available measures. However, if the EP qualified for an exclusion from two of the three available public health measures, then the EP would only be required to meet the one remaining available measure.

For additional information on exclusion criteria for each Public Health Reporting Measure, please review the detailed registry information at the Meaningful Use Public Health Reporting Website.

Additional Resources:

1.4 Our Eligible Hospital´s (EH) laboratory unit does not perform laboratory tests for reportable conditions. All laboratory tests for reportable conditions are outsourced to an external laboratory and the laboratory results are then sent directly from the laboratory to NYSDOH. Will the EH meet the Electronic Reportable Laboratory Result Reporting measure requirements to attest to Meaningful Use?

Published: 08/20/2014

Updated: 9/26/17

The EH can be excluded from the Electronic Reportable Laboratory Result Reporting measure if no reportable laboratory testing is performed in the Hospital setting. This guidance may be subject to change based on Public Health Law and/or Public Health reporting policies.

An EH that can be excluded, for the reason stated above, should indicate the following exclusion in MEIPASS when attesting:

  • 1.4.1 Meaningful Use Stage 1 and Stage 2:
    • Operates in a jurisdiction for which no public health agency is capable of accepting the specific ELR standards required to meet the CEHRT definition at the start of their EHR reporting period.
  • 1.4.2 Meaningful Use Modified Stage 2 or Stage 3:
    • Does not perform or order laboratory tests that are reportable in their jurisdiction during the EHR reporting period.

Additional Resources:CMS FAQ#9204

1.5 I am looking to attest to a Public Health Reporting Measure, which registries are currently available?

Published: 08/20/2014

Updated: 9/26/17

Please see the proper payment year for the available NYS Department of Health (NYSDOH) and NYC Department of Health and Mental Hygiene (NYC DOHMH) sponsored Public Health registries:

Additional Information:

An Eligible Provider may be eligible to count engagement with a Specialized Registry as active engagement under Meaningful Use (MU) Stage 3 Public Reporting Measure or Clinical Data Registry Reporting Measure.

There are several requirements defined in the Stage 3 Final Rule (80 FR 62868) for an Eligible Provider to meet this qualification. Please see MU Stage 3 – Public Health Registry Reporting Grandfathering Regulation for additional information.

1.6 When should an Eligible Provider engage in registration and onboarding or claim an exclusion for a given Public Health Reporting Measure?

Published: 07/08/2014

Updated: 09/28/16

A Public Health registry´s policies may restrict a provider from onboarding beyond initial registration, however it is the NY Medicaid EHR Incentive Program´s stance that all Eligible Providers who have appropriate data should register intent to submit data before or within 60 days of the start of their EHR Reporting Period. Based on the registry´s onboarding policies Eligible Providers may not be invited to further participate in the onboarding process, but they will have successfully met the Public Health Reporting Measure requirement by achieving the status Active Engagement Option 1 - Completed Registration to Submit Data.

Eligible Providers who do not have appropriate or relevant data to submit to Public Health should instead claim an exclusion or pick another Public Health Reporting Measure.

Note: It is highly recommended that all providers review a Public Health Reporting Measure´s exclusions to see if they appropriately meet the exclusion criteria.

1.7 As an Eligible Provider, I would like to submit data to a registry outside of the New York State Department of Health (NYSDOH) and New York City Department of Health and Mental Hygiene (NYC DOHMH) Public Health Agencies to satisfy the Meaningful Use Measures. Is this allowed in the NY Medicaid EHR Incentive Program?

1.7.1 Modified Stage 2 (2015–2017)

Published: 03/16/2015

Updated: 01/13/16

The Centers for Medicare and Medicaid Services (CMS) Meaningful Use Stage 3 and Modifications to Meaningful Use in 2015 Through 2017 Final Rule DOES NOT restrict Eligible Providers from working with specialized registries outside of the NYSDOH and NYC DOHMH Public Health Agencies to satisfy the Meaningful Use Specialized Registry Reporting measure.

CMS has stated in the CMS Meaningful Use Stage 2 Final Rule Comments, "We are purposefully general in our description of specialized registry because we do not wish to exclude certain registries in an attempt to be more specific. The only limitation we place on our description of specialized registries is that the specialized registry cannot be duplicative of any of the other registries included in other meaningful use objectives and measures." (CMS Meaningful Use Stage 2 Final Rule, Vol. 77/No. 171/54030)

In the Stage 3 and Modification to Meaningful Use in 2015 Through 2017 Final Rule, CMS states, "We further note that we have previously supported the inclusion of a variety of registries under the specialized registry measure...We agree that a variety of registries may be considered specialized registries, which allows providers the flexibility to report using a registry that is most helpful to their patients. Therefore, we will continue to allow these registries to be considered specialized registries for purposes of reporting the EHR Reporting period in 2015, 2016, and 2017." (CMS Stage 3 and Modifications to Meaningful Use in 2015 Through 2017 Final Rule, Vol. 80/No. 200/62822-62823)

Does the Specialized Registry need to be operated by the NYSDOH and NYC DOHMH Public Health Agencies or a national medical specialty organization?

CMS further explains in the Meaningful Use Stage 2 Final Rule Comments, "... Specialized registries that can be used to satisfy the measure...are not limited only to reporting to registries operated by Public Health Agencies or national medical specialty organizations. Specialized registries operated by patient safety organizations and quality improvement organizations also enable knowledge generation or process improvement regarding the diagnosis, therapy and prevention of various conditions that affect a population." (CMS Meaningful Use Stage 2 Final Rule, Vol. 77/No. 171/54030)

What support services do the NY Medicaid EHR Incentive Program and Public Health Objective Support Teams offer to Eligible Providers working with Public Health Registries outside the NYSDOH and NYC DOHMH Public Health Agencies?

The NY Medicaid EHR Incentive Program and Public Health Objective Support Teams do not provide registration, administrative onboarding, compliance, or audit support to Eligible Providers satisfying a Public Health Reporting Measure when leveraging a registry outside the NYSDOH and NYC DOHMH Public Health Agencies.

Please be aware that as an Eligible Professional, you are responsible for:

  • Meeting Public Health Reporting Objective onboarding deadlines such as registering intent to submit data within 60 days of the start of one´s EHR Reporting Period.
  • Securing documentation such as registration, testing and submission of production data confirmations from each registry to support any potential pre-payment and/or post-payment audits.
  • Engaging and testing with the registry to achieve the submission of production data.
  • Saving audit documentation for up to six years after an EHR Incentive Payment is approved.

Additional Resources:

1.7.2 Stage 3 (2017-2021)

Published: 09/28/2016

Updated: N/A

For Stage 3, Specialized Registry Reporting has been categorized into two separate measures, Public Health Registry Reporting and Clinical Data Registry Reporting. See the definitions below of a Public Health Registry and Clinical Data Registry:

  1. Public Health Registry: A registry that is administered by, or on behalf of, a local, state, territorial, or national public health agency and which collects data for public health purposes.
  2. Clinical Data Registry: A registry that is administered by, or on behalf of, other non-public health agency entities.

The Centers for Medicare and Medicaid Services (CMS) Meaningful Use Stage 3 and Modifications to Meaningful Use in 2015 Through 2017 Final Rule DOES NOT restrict Eligible Providers from working with public health registries outside of the NYSDOH and NYC DOHMH Public Health Agencies to satisfy the Meaningful Use Public Health Registry Reporting Measure.

Currently, the 2015 ONC Final Rule has defined specific certification criteria for Transmission to Cancer Registries, Transmission to PHA - Health Care Surveys, and Transmission to PHA - Antimicrobial Use and Resistance. In addition to reporting cancer cases to the New York State Cancer Registry (NYSCR), Eligible Providers can report to the CDC for National Health Care Surveys and Antimicrobial Use and Resistance.

In addition, please see the MU Stage 3 - Public Health Registry Reporting Grandfathering Regulation for information on meeting the Public Health Registry Reporting Measure through submitting production data to a Specialized Registry.

Please note that the NY Medicaid EHR Incentive Program and Public Health Objective Support Teams do not provide registration, administrative onboarding, compliance, or audit support to Eligible Providers satisfying a Public Health Reporting Measure when leveraging a registry outside the NYSDOH and NYC DOHMH Public Health Agencies.

Please be aware that as an Eligible Provider, you are responsible for:

  • Meeting Public Health Reporting Objective onboarding deadlines such as registering intent to submit data within 60 days of the start of one´s EHR Reporting Period.
  • Securing documentation such as registration, testing and submission of production data confirmations from the respective Public Health Registry to back any potential pre-payment and/or post-payment audits.
  • Engaging and testing with the Public Health Registry to achieve the submission of production data.
  • Saving audit documentation for up to six years after an EHR Incentive Payment is approved.

Additional Resources:

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2. REGISTRATION & THE MEANINGFUL USE REGISTRATION FOR PUBLIC HEALTH (MURPH) SYSTEM

Contents

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2.1 How does an Eligible Provider register their intent to submit data and engage in testing with a Public Health registry for the Meaningful Use Public Health Reporting Measures?

Published: 09/28/2016

Updated: N/A

Eligible Providers must register their intent to submit data to Public Health in the Meaningful Use Registration for Public Health (MURPH) System before or within 60 days of the start of one´s EHR Reporting Period. A confirmation will be sent through e-mail to each Eligible Provider who registers their intent in the MURPH System.

Once a registration is received, the Public Health registries will triage new registrants and prioritize Eligible Providers based on staff/resource availability, volume of data, practice size, reporting periods and other criteria. When the Public Health registry staff is ready to work with the Eligible Provider, they will e–mail an Invitation to Test to the Registration and Alternate Contacts listed in the registration and staff will change the Eligible Provider´s status to "Invited to Test." As soon as a timely response is received, registry staff will change the status to Active Engagement Option 2 – Testing and Validation.

A timely response is defined as a response from an Eligible Provider to a registry´s Invitation to Test before the expiration of the program time limits. An Eligible Provider will be sent up to two invitations, each having a 30–day time limit. If an Eligible Provider fails to respond to the first and then second Invitation to Test before the 30–day time limits expire, then the provider will be deemed "Non–Responsive" and not a meaningful user of Certified EHR Technology.

2.2 If an Eligible Provider achieved submission of production data prior to the start of their Meaningful Use EHR Reporting Period and is currently submitting production data for a given Public Health Reporting Measure, should the Eligible Provider still register their intent in the Meaningful Use Registration for Public Health (MURPH) System?

Published: 07/08/2014

Updated: 11/10/2015

An Eligible Provider who achieved submission of production data prior to the start of their Meaningful Use EHR Reporting Period and sustains submission of production data throughout the EHR Reporting Period is strongly encouraged to register their intent in the Meaningful Use Registration for Public Health (MURPH) System. Further testing will not be required if the registry confirms that submission of production data has been achieved. By registering in MURPH, the EHR Incentive Programs will have a complete picture of Eligible Providers who are in submission of production data and can further provide the Eligible Providers with appropriate documentation to support a post-payment audit. In addition, submitting a registration will protect Eligible Providers who believe they are in submission of production data, but are assigned a status that requires registration of intent within 60 days of the start of the EHR Reporting Period.

2.4 How can information submitted in the Meaningful Use Registration for Public Health (MURPH) System be changed?

Published: 01/05/2015

Updated: 09/28/2016

If any changes are required to the registration information, the Registration and Alternate contacts listed on the registration can log back into HCS to make any update by following the steps below:

  1. Log into HCS: https://commerce.health.state.ny.us
  2. Click on "My Content" on the top navigation bar
  3. Click on "All Applications" in the drop down
  4. Click on the letter "M"
  5. Click on "Meaningful Use Registration for Public Health"
  6. Click on "Eligible Hospitals" or "Eligible Professionals", under "Register"
  7. Click on the "Edit" icon from the Actions column
  8. Make any necessary updates and click "Submit". An updated confirmation will be generated at that time.

Additional Resources:

Please see the Eligible Professional MURPH Registration Guide or Eligible Hospital MURPH Registration Guide for additional details on modifying a registration in the MURPH System.

2.5 If an Eligible Professional (EP) practices in multiple locations, what is the procedure for registering in the Meaningful Use Registration for Public Health (MURPH) system?

Published: 09/28/2016

Updated: N/A

If all practice sites are located in the same jurisdiction (i.e. all inside or all outside the five boroughs of NYC), a single practice registration should be submitted in the MURPH System. Each practice location where at least one EP is registering intent for a Meaningful Use Public Health Reporting Measure should be added to the same MURPH registration. In addition, every EP, working across all practice sites, who will be submitting data to any Public Health Registry in order to meet the Public Health Reporting Measures should also be added to the same MURPH registration.

Exception:

If all practice sites are NOT located in the same jurisdiction, then a MURPH registration will need to be submitted for the location(s) outside the five boroughs of NYC and a second MURPH registration will need to be submitted for the location(s) inside the five boroughs of NYC.

Please work with your practices to ensure duplicate registrations for an EP are not being created for the same practice location. Registering based on practice location allows the NY Medicaid EHR Incentive Program to alert the correct registries in each jurisdiction to begin onboarding.

Additional Resources:

Please see the Eligible Professional MURPH Registration Guide or Eligible Hospital MURPH Registration Guide for additional details on modifying a registration in the MURPH System.

2.6 If an Eligible Provider has multiple Certified EHR Technologies (CEHRTs), what is the procedure for registering in the Meaningful Use Registration for Public Health (MURPH) System?

Published: 09/28/2016

Updated: N/A

If an Eligible Provider has multiple CEHRTs being utilized they are not required to submit multiple registrations in the MURPH system.

  • The system allows Eligible Hospitals (EHs) to select the CEHRT being utilized for each Meaningful Use Public Health Reporting Measure.
  • The system allows Eligible Professionals (EPs) to select the CEHRT for each location listed in the MURPH registration.

Additional Resources:

Please see the Eligible Professional MURPH Registration Guide or Eligible Hospital MURPH Registration Guide for additional details on modifying a registration in the MURPH System.

2.7 Eligible Providers who registered on the Meaningful Use Registration for Public Health (MURPH) System in 2014 or 2015 are being asked to register a second time by the Meaningful Use (MU) Public Health Objective Support Team in the updated MURPH System. However, there is a CMS FAQ#11964 advising providers only need to register once. Why are Eligible Providers being asked to register a second time?

Published: 09/28/2016

Updated: N/A

An Eligible Provider who has registered intent to submit data to a public health agency on the MURPH System, during the 2014 or 2015 years, are not required to submit a new registration. However, the NY Medicaid EHR Incentive Program does highly recommend that a new registration be submitted in the current MURPH System, launched in January 2016. This will allow an Eligible Provider to readily change and update information, ensure the registries are properly notified of the Eligible Provider´s intent to submit data and provide the appropriate compliance documentation needed to support attestation or audit, and allow the MU Public Health Objective Support Team to provide the best possible service, ensuring providers are kept up to date on any program changes, deadlines, and requirements.

Please be aware that as an Eligible Provider, you are responsible for:

  • Meeting Public Health Reporting Objective onboarding deadlines such as registering intent to submit data within 60 days of the start of the EHR Reporting Period.
  • Securing documentation such as registration, testing and submission of production data confirmations from each registry to support any potential audits.
  • Saving audit documentation for up to six years after an EHR Incentive Payment is approved.

Additional Resource: CMS FAQ#11964

2.8 Does an Eligible Provider who will be claiming an exclusion for all Meaningful Use Public Health Reporting Measures need to submit a registration in the Meaningful Use Registration for Public Health (MURPH) System?

Published: 05/11/2015

Updated: 05/12/2016

No, although the "Exclusion" option is available for each of the Public Health Reporting Measures in the MURPH System, registration is not required for an Eligible Provider who will be claiming an exclusion for all Meaningful Use Public Health Reporting Measures.

Please note that providers will need to support their eligibility to seek an exclusion in the case of an audit.

2.9 I am an Eligible Professional (EP) reporting to a Public Health Registry (PHR) or Clinical Data Registry (CDR) outside of the New York State Department of Health (NYSDOH) and New York City Department of Health and Mental Hygiene (NYC DOHMH) Public Health Agencies (PHAs) to satisfy a Meaningful Use (MU) Public Health Reporting Measure. Should I select "Yes" in the "EP Intends to Meet the Measure" drop-down list for one of the registry options in the Meaningful Use Registration for Public Health (MURPH) System?

Published: 05/11/2015

Updated: 10/27/2016

No, selecting "Yes" in the "EP Intends to Meet the Measure" drop–down list for the registries options in the MURPH System only supports reporting to the PHAs sponsored by the NYSDOH and NYC DOHMH.

Please note that the NY Medicaid EHR Incentive Program and Public Health Objective Support Teams do not provide registration, administrative onboarding, compliance, or audit support to Eligible Professionals (EPs) satisfying a Public Health Objective when leveraging a PHR or CDR outside the NYSDOH and NYC DOHMH PHAs.

Please be aware that as an EP, you are responsible for:

  • Meeting Public Health Reporting Objective onboarding deadlines such as registering intent to submit data within 60 days of the start of one´s EHR Reporting Period.
  • Securing documentation such as registration, testing and submission of production data confirmations from the respective Public Health Registry (PHR) or Clinical Data Registry (CDR) to back any potential pre–payment and/or post–payment audits.
  • Engaging and testing with the PHR or CDR to achieve the submission of production data.
  • Saving audit documentation for up to six years after an EHR Incentive Payment is approved.

Additional Resources:

2.10 Who do I contact if I experience a problem with my Health Commerce System (HCS) account?

Published: 02/06/2015

Updated: N/A

The Commerce Accounts Management Unit (CAMU) Help Desk is available for HCS user account assistance and log in assistance. The CMAU Help Desk can be reached at 1–866–529–1890 or hinhpn@health.ny.gov.

2.11 What is the CMS Registration ID and how do I locate it?

Published: 03/16/2015

Updated: 11/10/2015

The CMS Registration ID is assigned to the provider by CMS at the time of registration for the Medicare / Medicaid EHR Incentive Program. It is a 10–digit number starting with 1000 (generic example: 1000123456). If you are unable to retrieve the CMS Registration ID, you can contact the CMS Support Team at 1–888–734–6433 for further assistance.

2.12 If a provider is participating in the Quality Payment Program (QPP) under the Merit-Based Incentive Payment System (MIPS) or Advanced Alternative Payment Models (APMs) and they would like to actively engage with a public health agency (PHA), then where do they register their intent to participate with the PHA?

Published: 12/27/2016

Updated: 06/30/2017

Providers participating in the QPP who wish to engage with a PHA that is supported by the New York City Department of Health and Mental Hygiene (NYC DOHMH) or New York State Department of Health (NYSDOH) may register their intent on the Meaningful Use Registration for Public Health (MURPH) System, which is the same system utilized for registration of intent for the Medicaid and Medicare EHR Incentive Programs. The registration should be completed as an "Eligible Professional" and during the process, the provider will be given the option to advise which program they are participating in.

Please note that the Meaningful Use (MU) Public Health Objective Support Team is only able to provide detailed program information to providers participating in the EHR Incentive Program. Therefore, if a provider has questions on the QPP, MIPS, or APMs programs, they should reach out to CMS directly for further information at (866)288–8292, between 8:00AM and 8:00PM EST.

Additional Information:
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3. REGISTRIES & CERTIFIED EHR TECHNOLOGY (CEHRT)

Contents

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3.1 The healthcare practitioners in our practice or hospital system immunize across New York State and New York City Public Health jurisdictions, which registry do I report to?

Published: 01/05/2016

Updated: 05/12/2016

If a healthcare practitioner immunizes across New York State and New York City Public Health jurisdictions then it is required under Public Health Law Article 21, Title 6, (3a) that immunizations be reported to the respective registries in which the immunizations have taken place.

  • Immunizations performed outside the five boroughs of New York City will be reported to the New York State Immunization Information System (NYSIIS).
  • Immunizations performed inside the five boroughs of New York City will be reported to Citywide Immunization Registry (CIR).

If you are a healthcare practitioner who performs immunizations across jurisdictions, please refer to Public Health FAQ #2.5 for details on how to register when the organization spans jurisdictions.

3.2 Do I need to report immunization data for 19 years and older patients to be deemed a "Meaningful User" of Certified EHR Technology?

Published: 05/10/2013

Updated: 12/11/2015

To be considered a Meaningful User of Certified EHR Technology (CEHRT), the NY Medicaid EHR Incentive Program requires that a provider reports all immunizations data for persons less than 19 years of age and for those 19 years of age or older when the express verbal or written consent is given by the vaccinee.

The NY Medicaid EHR Incentive Program requests that providers offer verbal or written "Consent for Participation" to vaccinees´ 19 years of age or older. If consent is granted, the vaccinee´s immunization data and history must be submitted to the correct immunization registry.

19 Years of Age or Older Consent Forms

Immunization Reporting Resources

3.3 I am an Eligible Professional (EP) who treats adult patients and rarely administers immunizations. Should I plan to attest "yes" to the Meaningful Use Immunization Registry Reporting measure or claim an exclusion under the criterion "the EP does not administer any immunizations to any of the populations for which data is collected by their jurisdiction´s immunization registry or immunization information system during the EHR reporting period"?

Published: 07/08/2015

Updated: 09/28/2016

In order to determine whether it would be appropriate to attest "yes" or claim an exclusion to the Immunization Registry Reporting measure, the NY Medicaid EHR Incentive Program suggests you consider the following questions:

  1. Will the EP administer any immunizations during the EHR Reporting Period?
    • If NO: If the EP does not administer any immunizations during the EHR Reporting Period, he/she is eligible to claim an exclusion.
    • If YES: If the EP does administer immunizations during the EHR Reporting Period, continue to question 2.
  2. If the EP will administer immunizations during the EHR Reporting Period, will the immunizations be administered to patients who are 18 years of age and younger, or 19 years of age and older?
    • If 18 years of age and younger: If the EP does administer immunizations during the EHR Reporting Period to patients who are 18 years of age or younger, the EP cannot claim an exclusion and Public Health Law requires that the immunization be reported to the Citywide Immunization Registry (CIR) if administered within the five boroughs of New York City or to the New York State Immunization Information System (NYSIIS) if administered outside of the five boroughs.*
    • If 19 years of age and older: CIR and NYSIIS also accept immunization records for patients who are 19 years of age or older as long as the patient gives consent for the immunization to be reported and consent is captured in the record. Continue to question 3.
  3. If the EP will be administering immunizations to patients aged 19 years and older, is there a process in place to seek patient consent to report the immunization record and does the Certified EHR Technology (CEHRT) capture that consent?
    • If YES: If the EP does administer immunizations during the EHR Reporting Period to patients who are 19 years of age or older, receives patient consent to report the immunization, and records consent in the CEHRT, the EP cannot claim an exclusion. Such immunization records are accepted by the CIR and NYSIIS.*
    • If NO: If the EP only administers immunizations to patients aged 19 years or older and patient consent is not sought and captured, such immunization records are prohibited from being reported, and the EP may claim an exclusion.

* Please note, EPs who intend to attest "yes" to any Public Health Reporting Measure must register their intent before or within 60 days of the start of the EHR Reporting Period in the Meaningful Use Registration for Public Health (MURPH) System.

Additional Resources:

3.4 We are using Certified EHR Technology (CEHRT) to generate HL7 messages for submission to a public health registry. We use an interface engine or other intermediary such as a health information exchange (HIE) to modify messages to meet the registry´s requirements. Does the interface engine or HIE need to be certified by ONC in order for us to be in compliance with the public health reporting objective?

Published: 10/22/2014

Updated: N/A

If the HL7 message is generated by CEHRT and slight modifications are made by the interface engine or health information exchange (HIE) to meet requirements of the public health registry (ex: including a calculated value from a field or including a field that is required by the public health registry, but is optional in the national implementation guide), the intermediary technology does not have to be certified by ONC in order for the message to be in compliance with Meaningful Use requirements.

However, if the Hl7 message is generated by CEHRT and the message is modified by the interface engine or health information exchange (HIE) such that the message structure no long adheres to the national implementation guide/certification standards, the message produced would not be in compliance with Meaningful Use requirements.

In an alternate scenario, if an HL7 message is generated by non–certified EHR technology and transformed by an intermediary to meet the public health registry´s requirements, the intermediary must be certified by ONC in order for the message to be in compliance with Meaningful Use requirements.

Additional Resource: ONC Regulations FAQ #18

3.5 What data are collected by Eligible Professionals who intend to meet the Syndromic Surveillance Reporting Measure?

Published: 02/12/2016

Updated: 9/26/2017

As of the start of 2016, the New York City Department of Health and Mental Hygiene (NYC DOHMH) collects Syndromic Surveillance data from Eligible Professionals (EPs) practicing at an urgent care center within the five boroughs of NYC. The data must be structured in accordance with NYC–specific HL7 v2.5.1 message requirements, which are based largely on the PHIN Messaging Guide for Syndromic Surveillance.

The surveillance data collected by NYC DOHMH include the following syndromes: respiratory, vomiting, diarrhea, influenza–like–illness, fever, and asthma.

As of the January 1, 2017, the New York State Department of Health (NYSDOH) collects Syndromic Surveillance data from EPs practicing at an urgent care center outside the five boroughs of NYC. The data must be structured in accordance in accordance with New York State HL7 Message Requirements for Syndromic Surveillance Reporting.

The NYSDOH collects syndromic surveillance data from EPs, which includes the following syndromes: asthma, carbon monoxide, drug overdose, fever, gastrointestinal infection, heatwave, heroin overdose, hypothermia, neurological, rash, respiratory, and synthetic drugs.

Additional Information: CMS FAQ#3615

3.6 I am an Eligible Professional (EP) who has previously met the Syndromic Surveillance Reporting Measure by reporting aggregate count influenza–like–illness (ILI) data to the Primary Care Information Project (PCIP), a bureau of the New York City Department of Health and Mental Hygiene (NYC DOHMH). However, CMS FAQ#3615 states that NYC DOHMH is now collecting Syndromic Surveillance data from EPs at urgent care centers in order to satisfy the measure. How does my reporting aggregate count ILI now count towards the Meaningful Use Public Health Reporting requirements?

Published: 02/12/2016

Updated: 09/28/2016

In October of 2012, PCIP began collecting aggregate count ILI data from EPs demonstrating Meaningful Use (MU) who practice within the five boroughs of NYC. Engagement with PCIP – including the submission of one or more test messages, additional testing and validation, or the submission of production ILI data – satisfied the Syndromic Surveillance Reporting Measure for MU Stage 1, MU Stage 2, and Modified Stage 2 in 2015.

To align with the CMS definition of EP Syndromic Surveillance included in the Stage 3 Final Rule, in January of 2016 the NYC DOHMH began accepting Syndromic Surveillance data from EPs demonstrating MU who practice at an urgent care center within the five boroughs of NYC. Engagement with the NYC DOHMH towards the submission of production ambulatory Syndromic Surveillance data (including registering intent within 60 days of the start of the EP´s EHR Reporting Period) or the submission of production ambulatory Syndromic Surveillance data will satisfy the Syndromic Surveillance Reporting Measure for Modified Stage 2 in 2016 and future years.

For EPs demonstrating MU who practice within the five boroughs of NYC and have been submitting production ILI data or wish to begin submitting ILI data, engagement with the NYC DOHMH Population Health Registry will satisfy the Modified Stage 2 Specialized Registry Reporting Measure in 2016 and 2017. EPs who achieve Active Engagement Option 3 - Production under the Modified Stage 2 Specialized Registry Reporting Measure may be eligible to continue to count this engagement towards Meaningful Use Stage 3 Public Health Reporting requirements.

Additional Information:

3.7 What is the Population Health Registry?

Published: 06/21/2016

Updated: N/A

The Population Health Registry is a specialized registry used by the New York City Department of Health and Mental Hygiene to support public health, epidemiologic, quality, and utilization programs. The registry data is used to assess acute and chronic health conditions and disparities across the NYC population. Eligible Professionals (EPs) who practice in the 5 boroughs of New York City may report data to the Population Health Registry to meet the Specialized Registry Reporting Measure under the Meaningful Use Public Health Reporting Objective.

Additional Resources:

3.8 What data are collected from Eligible Professionals who are or intend to be engaged with the Population Health Registry at the New York City Department of Health and Mental Hygiene (NYC DOHMH) in order to meet the Specialized Registry Reporting Measure?

Published: 06/21/2016

Updated: N/A

Eligible Professionals (EPs) who practice in the 5 boroughs of New York City may report data to the Population Health Registry to meet the Specialized Registry Reporting Measure. The Population Health Registry currently recognizes the following reporting options and transmission standards. If new transmission options are added, providers will be given sufficient time to work with their EHR vendor to demonstrate active engagement for their required reporting period.

  1. Aggregate influenza–like–illness (ILI) surveillance data
  2. EPs using eClinicalWorks electronic health record (EHR) can join the Macroscope/Hub Population Health Network for no cost. Membership includes feedback on performance of key health conditions. See the NYC Macroscope Website for more information. This option is not available to EPs using other EHR vendors.

Additional Resources:

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4. MU PUBLIC HEALTH REPORTING STATUS & COMPLIANCE

Contents

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4.1 Will I receive a Registration Confirmation for each Eligible Provider? If so, how long should I save confirmations for post–payment audit purposes?

Published: 07/08/2014

Updated: 09/28/2016

An email confirmation will be sent to the Registration and Alternate Contacts whenever the registration is submitted and updated. Registration confirmations can also be viewed and printed from the Meaningful Use Registration for Public Health (MURPH) System. From the MURPH Home page, click on "Eligible Hospitals" or "Eligible Professionals", under "Register". From the Actions column, select "Original Registration Confirmation" to view the Registration Confirmation or select "Latest Registration Update Confirmation" to view the Registration Update Confirmation generated upon the latest submission. All confirmations must be saved for at least 6 years within the provider´s supporting documentation file.

Note: If the confirmation does not open, you may need to disable any pop–up blockers. The confirmation will open in a new window or tab.

Please see Post–Payment Audit Guidance for additional information.

4.2 How does an Eligible Provider determine one´s current status when engaged in the registration and onboarding process?

Published: 07/08/2014

Updated: 09/28/2016

An Eligible Provider´s onboarding status will be tracked by each registry. The registries will send notifications to the provider as the status updates or changes. These notifications should be kept for at least 6 years within the provider´s supporting documentation file.

A provider´s current status can be requested by sending an email to MUPublicHealthHELP@health.ny.gov. Please be sure to indicate which registry and EHR Reporting Period you are inquiring about.

4.3 A Public Health Registry has sent our Eligible Professional (EP) or Eligible Hospital (EH), who is currently in Active Engagement Option 2 – Testing and Validation in the Meaningful Use Public Health Reporting onboarding process, a Request for Action communication. What happens if we cannot fully comply with their request?

Published: 01/05/2015

Updated: 11/10/2015

If an appropriate action* is not taken by the EP or EH to resolve the issue within 30 days from the sent date, then another Request for Action communication will be sent to the Registration, Alternate, and/or Technical contact. If an appropriate action* is not taken by the EP or EH within 30 days from the second sent date, then the Public Health Registry is authorized to report to the EHR Incentive Programs that the EP or EH did not meet the Public Health Reporting Measure onboarding requirements within the specified EHR Reporting Period.

*Appropriate action is specific to the testing/onboarding requirements and is the determination of the Public Health Registry.

4.4 I received notification of ongoing submission from the New York State Immunization Information System (NYSIIS). However, I am currently submitting immunization data in HL7 2.3.1. Does this count as Active Engagement Option 3 – Production for the Modified Stage 2 Immunization Registry Reporting Measure?

Published: 12/11/2015

Updated: 06/29/2017

In order to attest "yes" to the Modified Stage 2 Immunization Registry Reporting Measure, an Eligible Provider must be in active engagement with a public health agency to submit immunization data. Eligible Providers can demonstrate active engagement through one of three ways:

  • Active Engagement Option 1 – Completed Registration to Submit Data
  • Active Engagement Option 2 – Testing and Validation
  • Active Engagement Option 3 – Production

In order to achieve Active Engagement Option 3 – Production, an Eligible Provider must be submitting production data in HL7 2.5.1. While Eligible Providers submitting production data in HL7 2.3.1 cannot attest to Active Engagement Option 3 – Production, an Eligible Provider who has registered intent to submit data within 60 days of the start of the EHR Reporting Period and is awaiting an invitation from NYSIIS to begin testing and validation has achieved Active Engagement Option 1 – Completed Registration to Submit Data and may still attest "yes" to the Immunization Registry Reporting Measure.

Additional Resources:

4.5 How does an Eligible Provider determine if they are compliant with submission of production data?

Published: 07/08/2014

Updated: 11/10/2015

NY Medicaid EHR Incentive Program defines submission of production data as an Eligible Provider who continuously and successfully submits structured, production–level data from a Certified EHR Technology to the appropriate Public Health registry when the data is made available by the Certified EHR Technology and according to the timing and frequency determined by Public Health Law or registry policies.

Submission of production data is initially achieved when the Eligible Provider completes testing and validation and the Public Health registry staff determines the Eligible Provider´s live data is being received by the registry and is correct in structure and content. When submission of production data is achieved, the Eligible Provider´s status will be changed from Active Engagement Option 2 – Testing and Validation to Active Engagement Option 3 – Production. Email communications between the registry and the Eligible Provider indicating that submission of production data has been achieved is considered the Eligible Provider´s acknowledgment of this status.

Additional Details

  • Verifying that structured data is continuously being submitted successfully is the responsibility of the Eligible Provider
  • If the data is not being submitted successfully, it is the responsibility of the Eligible Provider, with assistance from the Public Health registry, to remediate the issues to maintain the status of Active Engagement Option 3 – Production
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5. ARCHIVED PUBLIC HEALTH FAQS

Please see the Archives section of the website for all of the archived FAQs.


6. CMS PUBLIC HEALTH FAQS

Contents

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6.1 Public Health and Certified EHR Technology

  • CMS FAQ 2809 What is the purpose of certified electronic health record (EHR) technology?
  • CMS FAQ 2811 How do I know if my electronic health record (EHR) system is certified? How can I get my EHR system certified?
  • CMS FAQ 2893 Must providers have their electronic health record (EHR) technology certified prior to beginning the EHR reporting period in order to demonstrate Meaningful Use under the Medicare and Medicaid EHR Incentive Programs?
  • CMS FAQ 3369 If my certified electronic health record (EHR) technology is capable of submitting batch files to an immunization registry using the standards adopted by the Office of the National Coordinator of Health Information Technology, is that sufficient to meet the Meaningful Use objective "submit electronic data to immunization registries" for the Medicare and Medicaid EHR Incentive Programs?
  • CMS FAQ 11982 If an eligible professional (EP) or hospital meets an exclusion for a public health objective, does the EP or hospital need to have CEHRT that meets the certification criteria related to that public health objective?

6.2 Meeting Meaningful Use Public Health Reporting Measures

  • CMS FAQ 2883 If an eligible professional (EP) is unable to meet the measure of a Meaningful Use objective because it is outside of the scope of his or her practice, will the EP be excluded from meeting the measure of that objective under the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs?
  • CMS FAQ 6097 I entered numerator and denominator information during my Medicare Electronic Health Record (EHR) Incentive Program attestation from my certified EHR technology, but subsequently discovered that the method of calculation included in the software was flawed. The software vendor has updated the reports. If CMS audits me, will I be held responsible for the difference between what I reported and what the updated software calculates?
  • CMS FAQ 8908 How does a provider attest to a meaningful use objective (e.g., the transitions of care, view/download patient data, and public health objectives) where the provider electronically transmits data using technical capabilities provided by a health information exchange (HIE)?
  • CMS FAQ 11964 To meet public health objectives in the Medicare and Medicaid Electronic Health Records (EHR) Incentive Programs, must providers register their intent to submit data for Stage 2 of Meaningful Use during each year of participation to meet the measure?
  • CMS FAQ 11978 For the Stage 2 objectives of the Medicare and Medicaid Electronic Health Records (EHR) Incentive Programs that require submission of electronic data to Public Health Agencies (PHA), can a provider meet the objective even though they may not have successfully submitted data to the PHA for their entire EHR reporting period?
  • CMS FAQ 11984 If an eligible professional (EP) in the Medicare and Medicaid Electronic Health Records (EHR) Incentive Programs is part of a group practice that has achieved ongoing submission to a public health agency (PHA), but the EP himself/herself did not administer any immunizations to any of the populations for which data is collected by their jurisdiction´s immunization registry during their EHR reporting period, can he/she attest to meeting the measure since they are part of the group practice that is submitting data to the registry?
  • CMS FAQ 12657 What if your product is decertified?
  • CMS FAQ 13413 Does integration of the PDMP (Prescription Drug Monitoring Program) into an EHR count as a specialized registry?
  • CMS FAQ 13653 What can count as a specialized registry?
  • CMS FAQ 13657 What steps does a provider have to take to determine if there is a specialized registry available for them, or if they should instead claim an exclusion?
  • CMS FAQ 14117 What steps do eligible hospitals and Critical Access Hospitals need to take to meet the specialized registry objective? Is it different from EPs?
  • CMS FAQ 14393 Can a provider register their intent after the first 60 days of the reporting period in order to meet the measures if a registry becomes available after that date?
  • CMS FAQ 14397 What should a provider do in 2016 if they did not previously intend to report to a public health reporting measure that was previously a menu measure in Stage 2 and they do not have the necessary software in CEHRT or the interface the registry requires available in their health IT systems? What if the software is potentially available but there is a significant cost to connect to the interface?
  • CMS FAQ 14401 For 2016, what alternate exclusions are available for the public health reporting objective?
  • CMS FAQ 16985 Is there an alternate exclusion available to accommodate the changes to how the measures are counted?
  • CMS FAQ 17005 What if software is potentially available but there is a significant cost to connect to the interface?

6.3 General Public Health Related Questions

  • CMS FAQ 2793 What is meaningful use, and how does it apply to the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs?
  • CMS FAQ 2807 Where can I get answers to my privacy and security questions about electronic health records (EHRs)?
  • CMS FAQ 3605 Where can I find a list of public health agencies and immunization registries to submit my data as required by the public health objectives for the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs?
  • CMS FAQ 3615 For the meaningful use objective "Capability to submit electronic syndromic surveillance data to public health agencies," what is the definition of "syndromic surveillance?"
  • CMS FAQ 9204 If an eligible hospital (EH) or critical access hospital (CAH) does not have any reportable lab results during the EHR reporting period (for example, the EH or CAH outsources all lab testing to a commercial lab or does not perform any lab tests for conditions that are reportable in their jurisdiction) can they be excluded from the requirement in the Electronic Health Records (EHR) Incentive programs to submit reportable lab results to a public health agency?
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