Frequently Asked Questions
CMS EHR Incentive Programs and Quality Payment Program Measures for Public Health: Measure 1 - Immunization Registry Reporting
1. What is needed to meet the measure for Immunization Registry reporting beginning in 2015? Any Eligible Hospital (EH), Critical Access Hospital (CAH), or medical practice where an Eligible Professional (EP) or Eligible Clinician (EC) works that is interested in sending immunization data to ODH should create an account to request data exchange enrollment at www.OhioPublicHealthReporting.info. Enrollment should be requested and the entity should register to submit immunization data by the 60th day of the entity’s EHR Incentive Program reporting period.
2. What is needed to meet the measure for Immunization Registry reporting beginning in 2017? In addition to what is described in FAQ #1, any Eligible Hospital (EH), Critical Access Hospital (CAH), or medical practice where an Eligible Professional (EP) or Eligible Clinician (EC) works that is interested in sending immunization data to ODH should be ready to submit National Drug Code (NDC) codes to identify administered immunizations and enable a user to request, access and display the evaluated immunization history and forecast from the immunization registry for a patient.
3. When will ODH support the use of NDC codes and Bi-directional reporting? ODH has declared readiness to support the 2017 program requirements and is supporting their use at this time. Because of limited program resources and broad interest in bidirectional reporting, ODH will invite, test, and onboard entities as resources allow. Most entities should expect to be waiting for an invitation for an extended period of time.
4. Which transport standards will ODH support? ODH will support reporting via SFTP, SOAP (using the CDC WSDL), and HTTPS POST. Entities may also periodically log in to the registry and directly upload HL7 files through the user interface.
5. Does my facility need to be sending production data for public health measures by the end of the reporting period to meet the measure? No. Ongoing submission is one of the ways to meet the public health reporting requirements. If an entity has registered to submit data and is awaiting an invitation from ODH or is currently working with ODH on testing and validation, the measure is met. The entity must attest YES to meeting one of the following criteria under the umbrella of active engagement.
- Completed Registration to Submit Data: The EP, EC, EH, or CAH registered to submit data with ODH; 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 ODH to begin testing and validation.
- Testing and Validation: The EP, EC, EH, or CAH is in the process of testing and validation of the electronic submission of data. Providers must respond to requests from ODH within 30 days; failure to respond twice within an EHR reporting period would result in that provider not meeting the measure.
- Production: The EP, EC, EH, or CAH has completed testing and validation of the electronic submission and is electronically submitting production data to ODH to populate the production immunization registry.
6. If my facility is not in production by the end of the first year of CMS EHR Incentive Program or Quality Payment Program participation because we are awaiting an invitation from ODH or we are in the testing and validation stage, do I need to re-register to submit data during a subsequent year? No. ODH does not require facilities to re-register to submit data for any subsequent reporting period. CMS requires entities to register before the 60th day of the reporting period. Registering to submit data in a previous reporting period is before the 60th day of the current reporting period. There is no need to re-register to indicate interest in bi-directional reporting.
7. When will ODH invite my facility to begin the testing and validation stage? This depends on several factors, including the volume of health events that will be sent to us through your connection, the way that you will transport the data to us, and the degree of familiarity we have in working with your EHR.
8. We do not administer immunizations at my facility. Do I need to register to submit data? No, EPs and hospitals not administering immunizations during the reporting period are excluded from that measure.
9. Which patients and which immunizations are required by ODH’s immunization registry? There is no mandate to report to ODH’s immunization registry. The immunization registry contains immunization histories for patients of all ages and accepts all vaccines recommended by the Advisory Committee for Immunization Practices: http://www.cdc.gov/vaccines/hcp/acip-recs/index.html. These include immunizations against influenza and pneumonia.
10. What information do I need to send? Documentation about our requirements, CDC standards, the onboarding process, and ways to connect to us are found here: https://www.ohiopublichealthreporting.info/Enrollment/Programs/Immunizations
11. If we began sending data to ImpactSIIS before 2014, do I need to upgrade to HL7 version 2.5.1? ODH will continue to accept earlier versions of HL7, but we will work with you to upgrade if you need to send from a different product because the older one is not certified for CMS EHR Incentive Program or Quality Payment Program participation.
12. Do I need consent to send immunization data? If you send information about an immunization to the ODH immunization registry, ODH assumes that you have authorization from the patient to send the information to the ODH immunization registry, and that you have informed the patient in a manner approved by ODH. Patients who do not want any of their data made available to other providers can complete a form and send it to us, and we will remove their data.
13. Do I need to send immunization refusals? There is no mandate to report to ODH’s immunization registry, but we can load refusals, contraindications, and immunity if sent to us according to CDC standards.
14. Do I need to send historical immunization data? There is no mandate to report to ODH’s immunization registry, but we can load historical data if sent to us according to CDC standards. Note that this requires the exact date the vaccine was administered.