Meaningful Use Public Health Reporting in 2017 Optional Stage 3

In 2017, eligible providers who are attesting with Medicare and who have previously attested to at least one year of Meaningful Use (MU) or eligible providers attesting directly with the state for the Medicaid EHR Incentive Program can attest to MU Modified Stage 2 or MU Optional Stage 3. For details on completing MU Modified Stage 2 in 2017 please see Public Health Reporting in 2017 – Modified Stage 2.

All Eligible Providers demonstrating MU: Any continuous 90–day period in the calendar year

  • Immunization Registry Reporting Measure: 2015 Edition CEHRT is required for this measure, when completing Optional Stage 3 in 2017.
  • All Other Measures: At least 2014 Edition CEHRT is required, but an Eligible Provider may utilize 2015 Edition CEHRT.

Note:2015 Edition CEHRT will not be required for all of the other measures until 2018

Please see the ONC 2014 Edition Final Rule, 2014 Edition Release 2 Final Rule, and 2015 Edition Final Rule for additional details on the CEHRT requirements.

The available Public Health Reporting Measures are below, along with the maximum times the measure can be counted towards the Public Health Reporting Objective for both EPs and EHs.

Measure Maximum times measure can count towards objective for EP Maximum times measure can count towards objective for EH or CAH
Measure 1 – Immunization Registry Reporting 1 1
Measure 2 – Syndromic Surveillance Reporting 1 1
Measure 3 – Case Reporting* N/A* N/A*
Measure 4 – Public Health Registry Reporting 2 4**
Measure 5 – Clinical Data Registry Reporting 2 4**
Measure 6 – Electronic Reportable Laboratory Results N/A 1

*Measure 3 – Case Reporting does not begin until 2018 and is not an available measure for providers completing Optional Stage 3 in 2017

Meeting the Public Health Reporting Objective

To successfully meet a MU Public Health Reporting Measure the Eligible Provider must be actively engaged with the public health agency (PHA) or clinical data registry (CDR). Please see Public Health FAQ #1.1 for details on active engagement.

  EPs EHs
Minimum Number of Measures 2 4**

** EHs and CAHs that are attesting directly with CMS for the Medicare EHR Incentive Program or as a dual-eligible hospital are only required to meet 3 of the available Public Health Reporting Measures for 2017. EHs and CAHs that are attesting directly with the Medicaid EHR Incentive Program for Optional Stage 3 are required to meet 4 of the available Public Health Reporting Measures.

The EP, EH, or CAH is in active engagement with a public health agency to submit immunization data and receive immunization forecasts and histories from the public health immunization registry or immunization information system (IIS).

Available Registries

Exclusions

Any EP or EH that meets one or more of the following criteria may be excluded from this measure:

  • the EP or EH 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;
  • the EP or EH operates in a jurisdiction for which no immunization registry or immunization information system is capable of accepting the specific standards required to meet the CEHRT definition at the start of their EHR Reporting Period; or
  • the EP or EH operates in a jurisdiction where no immunization registry or immunization information system has declared readiness to receive immunization data as of 6 months prior to the start of their EHR reporting period.

The EP, EH, or CAH is in active engagement with a public health agency to submit electronic syndromic surveillance data from an urgent care setting.

Available Registries

Exclusions

Eligible Professionals

Any EP that meets one or more of the following criteria may be excluded from this measure:

  • the EP is not in a category of providers from which ambulatory syndromic surveillance data is collected by their jurisdiction´s syndromic surveillance system;
  • the EP operates in a jurisdiction for which no public health agency is capable of receiving electronic syndromic surveillance data in the specific standards required to meet the CEHRT definition at the start of their EHR Reporting Period; or
  • the EP operates in a jurisdiction where no public health agency has declared readiness to receive syndromic data as of 6 months prior to the start of their EHR Reporting Period.
Eligible Hospitals and Critical Access Hospitals

Any EH or CAH that meet one or more of the following criteria may be excluded from this measure:

  • the EH or CAH does not have an emergency or urgent care department;
  • the EH or CAH operates in a jurisdiction for which no public health agency is capable of receiving electronic syndromic surveillance data in the specific standards required to meet the CEHRT definition at the start of their EHR Reporting Period; or
  • the EH or CAH operates in a jurisdiction where no public health agency has declared readiness to receive syndromic data as of 6 months prior to the start of their EHR Reporting Period.

The Electronic Case Reporting Measure is not available to providers completing Optional Stage 3 in 2017.

The EP, EH, or CAH is in active engagement with a public health agency (PHA) to submit data to public health registries.

Available Registries

*The Population Health Registry may only count towards the Public Health Registry Reporting Measure based on the Grandfathering Regulation set forth by CMS in the Final Rule. Please see the MU Stage 3 – Public Health Registry Reporting Grandfathering Regulation.

Exclusions

Any EP, EH, or CAH that meets one or more of the following criteria may be excluded from this measure:

  • the EP or EH does not diagnose or directly treat any disease or condition associated with a public health registry in their jurisdiction during the EHR Reporting Period;
  • the EP or EH operates in a jurisdiction for which no public health agency is capable of accepting electronic registry transactions in the specific standards required to meet the CEHRT definition at the start of their EHR Reporting Period; or
  • the EP or EH operates in a jurisdiction where no public health registry has declared readiness to receive electronic registry transactions as of 6 months prior to the start of their EHR Reporting Period.

The EP, EH, or CAH is in active engagement with a public health agency (PHA) to submit data to a clinical data registry (CDR).

Available Registries

  • There are no CDR registries supported by the NY Medicaid EHR Incentive Program – MU Public Health Objective Support Team.
  • CMS released the Centralized Repository to assist providers in locating available registries.
    IMPORANT: CMS has not reviewed any of the entries on the centralized repository list for compliance with program requirements. Therefore, it is up to the eligible provider to ensure the registry can meet the MU requirements set forth in CMS FAQ#13653.

Exclusions

Any EP, EH, or CAH that meets one or more of the following criteria may be excluded from this measure:

  • the EP or EH does not diagnose or directly treat any disease or condition associated with a CDR in their jurisdiction during the EHR Reporting Period;
  • the EP or EH operates in a jurisdiction for which no CDR is capable of accepting electronic registry transactions in the specific standards required to meet the CEHRT definition at the start of their EHR Reporting Period; or
  • the EP or EH operates in a jurisdiction where no CDR has declared readiness to receive electronic registry transactions as of 6 months prior to the start of their EHR Reporting Period.

The EH or CAH is in active engagement with a public health agency to submit electronic reportable laboratory (ELR) results.

Available Registries

Exclusions

Any EH or CAH that meets one or more of the following criteria may be excluded from this measure:

  • the EH does not perform or order laboratory tests that are reportable in their jurisdiction during the EHR Reporting Period;
  • the EH 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; or
  • the EH operates in a jurisdiction where no public health agency has declared readiness to receive ELR results as of 6 months prior to the start of their EHR Reporting Period.

Eligible Providers must formally register their intent to submit data to Public Health for a given Public Health Reporting Measure, using the Meaningful Use Registration for Public Health (MURPH) System. All Eligible Providers must register their intent to submit data before or within 60 days of the start of their EHR Reporting Period.

Meaningful Use Registration for Public Health (MURPH) System

MURPH is a statewide system hosted on the Health Commerce System (HCS) that accepts Eligible Providers´ registration and is used by the public health registries and the EHR Incentive Program to manage onboarding and program compliance.

Quick Access to MURPH:

  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"

*If you need an HCS account click here for instructions. Account sign-up can also be initiated from the HCS Login screen.

Note: Please see the Eligible Professional MURPH Registration Guide or Eligible Hospital MURPH Registration Guide for additional details.

Eligible Professionals
Public Health Reporting Measure 5 Boroughs of NYC NYS (Excluding the 5 Boroughs of NYC)
Immunization Registry Reporting Citywide Immunization Registry (CIR) NYS Immunization Information System (NYSIIS)
Syndromic Surveillance Reporting NYC Department of Health and Mental Hygiene (NYC DOHMH) NYS Department of Health (NYSDOH)
Public Health Registry Reporting – Cancer Case Reporting NYS Cancer Registry (NYSCR)

Eligible Hospitals
Public Health Reporting Measure 5 Boroughs of NYC NYS (Excluding the 5 Boroughs of NYC)
Immunization Registry Reporting Citywide Immunization Registry (CIR) NYS Immunization Information System (NYSIIS)
Syndromic Surveillance Reporting NYC Department of Health and Mental Hygiene (NYC DOHMH) NYS Department of Health (NYSDOH)
Electronic Reportable Laboratory Result Reporting Electronic Clinical Laboratory Reporting System (ECLRS)