The Medicare and Medicaid Promoting Interoperability (PI) Programs
Formerly Meaningful Use EHR Incentive Program
Public Health Registry Reporting
The Florida Cancer Data System is currently receiving registrations and submissions of EHR cancer event reports to fulfill the Medicare and Medicaid Promoting Interoperability (PI) Programs. We are accepting both the 2014 and 2015 CERHT editions.
Important Message: Participation in Meaningful Use Cancer reporting is voluntary. All targeted physicians who participate in Meaningful Use must continue to report cases through one of the Department of Health approved methods (claims, single entry, etc.) to meet state required reporting. Targeted physicians include oncology, dermatology, hematology, and urology practices.
In support of physician cancer reporting and Meaningful Use, the Florida Cancer Data System (FCDS) has implemented electronic reporting from certified electronic health record technology (CEHRT) systems as of January 1st, 2014 for Stage 2 using 2014 Edition CEHRT. Active engagement to the FCDS using this EHR reporting method will assist eligible professionals in receiving Medicare and Medicaid incentive funds for demonstration of Meaningful Use.
The FCDS also declares its readiness to the Stage 3 measures using 2015 Edition CEHRT. The FCDS plans to accept this criteria beginning on January 1, 2017. The Cancer Implementation Guide for ambulatory provider cancer reporting to state registries is updated to HL7 CDA (r) Release 2 Implementation Guide: Reporting to Public Health Cancer Registries from Ambulatory Healthcare Providers, Release 1, DSTU Release 1.1 - US Realm in the 2015 Edition CEHRT.
Included in the strategy for demonstrating Meaningful Use of an EHR system is the submission of cancer case reports. This objective applies only to Eligible Professionals (EP), also known as individual practitioners.
Meaningful Use Criteria for Cancer Reporting
Inclusions: Only EPs who diagnose or treat cancer patients may choose to report to the cancer registry under the Objective 10 and Measure 3 option: Public Health Reporting to a Specialized Registry. Additionally, only EPs who have the certified technology for cancer reporting (170.314(f)(5) and 170.314(f)(6)) are eligible for reporting to the FCDS.
Exclusions: EPs who do not diagnose or treat cancer patients are excluded from cancer reporting. Practices that diagnose and/or treat cancer but do not have the certified technology may claim an alternate exclusion in 2015.
If you are an EP who diagnoses and/or treats cancer patients but DOES NOT have the certified technology for cancer reporting, there is an option to report to the CDC's National Health Care Survey to fulfill this measure. Please visit their webpage for information on registration and reporting. www.cdc.gov/ehrmeaningfuluse/national_health_care_surveys.html
If you are interested in reporting to the FCDS using a certified EHR, or have questions, please send us an email.
Onboarding Process for Cancer Messages
To meet the Meaningful Use (MU) cancer reporting objective, Eligible Professionals (EP) must register and complete all steps in the on-boarding process. Providers registered in the FCDS Meaningful Use Registration System will receive acknowledgement of the FCDS MU status they have achieved at the end of their reporting period. Statuses include Registered, Invited to Onboard, Testing and Validation, and In Production.
Click on the choices below to learn more.
1. Registration and Connectivity: Eligible Professional (EP) registers intent to submit cancer data for MU and
sets up transport option.
- Register using the FCDS MU Registration System.
- FCDS will provide an email confirmation to designated recipients of successful registration. A list of each EP
by name and NPI will be provided on the confirmation email for attestation purposes. Your MU status will be "Registered."
2. Message Structure Validation: EP submits cancer messages using defined structure for FDH staff to validate.
The message contains test data.
- FCDS will provide an email invitation indicating that the EP should begin the onboarding process. Your MU status
will be "Invited to Onboard" and once you begin to submit messages it will change to "Testing and Validation."
How is MU registration different from the existing FCDS physician registration process?
Registration for MU cancer reporting is almost identical to the existing FCDS physician registration process with the exception of a few additional required data items such as practice name, EHR vendor, and additional contact information. If the MU option is selected as the method for cancer reporting, then FCDS will begin to track the onboarding process as well as provide necessary communications for MU attestation purposes.
The registration system will continue to be based on the existing IDEA registration system for physicians. The FCDS has developed technical documentation on how to utilize and navigate the system for MU registration, as well as how to utilize the account to view status updates, and how to access copies of MU communications.
The existing registration system requires an FCDS-generated unique physician provider ID (PPID) for each physician. If you do not currently have one issued, please contact Mike Thiry at FCDS to receive an ID for each physician. firstname.lastname@example.org, (305) 243-2639.
If I am a physician practicing in the private setting and I am already reporting to FCDS through claims and/or manual entry, but I want to report via MU what do I have to do?
If you are already registered to report with FCDS and have elected to report via claims or manual entry, but you would like to begin reporting via MU CDA messaging, you need to change your reporting option through the IDEA registration system. Either you or your office manager should have an IDEA account that is linked to your registration profile.
If I am a physician practicing in the private setting and I am already reporting to FCDS through claims and/or manual entry am I required to change my method of reporting?
No. The MU registration is only for physicians who elect to participate in the CMS program. As a physician who already reports to FCDS, you can continue to report through any of the options available (claims, manual entry, alternate layout, etc.). If you would like to change your reporting option you can modify your method of reporting through your IDEA user account.
How does MU registration apply to individual physicians not a part of a group practice?
If you are an individual physician who is not coordinating MU reporting with a larger group practice, you will need to register through the FCDS system and indicate that you are the primary contact for whom all MU cancer registry communications should be directed. You will not be required to enter a group NPI number, but you will be required to enter your individual NPI number as assigned from the National Plan & Provider Enumeration System (NPPES).
How does MU registration apply to group practices?
For physicians who belong to a single group practice, under which all MU activities are coordinated, it is recommended that a single person from the practice serve as the primary MU administrator and contact representative. This administrator will register all EPs under the practice name in a single registration session and will provide a single group NPI during the registration process. If your practice has more than one group NPI, please enter just one group NPI during registration. This group NPI will then be associated to all your registered physicians and will serve as the practice ID in the FCDS IDEA system.
What if I am a hospital-based physician and I want to report my cases via CDA messages?
CMS publishes strict guidelines on the MU incentive qualifications for physicians who practice in a hospital setting. While you may not qualify for CMS incentives under MU EP guidelines, the FCDS will still accept CDA messages from any private physician who elects to report using this method. Please note that if you are a hospital-based physician who diagnosis and/or treats cancer patients, the hospital facility is already reporting these cases to the cancer registry.
If I am a dermatologist can I report via MU?
Yes. The FCDS is enabling a feature as part of the dermatology IDEA menu bar that will allow you to change the method of reporting to MU. Providers will have to select a transport option to send reports (SFTP, HTTPS).
If multiple eligible professionals (EPs) are using the same certified EHR technology across several physical locations, can a single test or onboarding effort serve to meet the measures of these objectives?
Yes. Providers that are registered through FCDS under the same practice/organization from which the same EHR technology is shared can conduct on test that covers all providers registered.
For example, if a large group of EPs with multiple physical locations use the same EHR technology and those locations are connected using a network that the group has either operational control of or license to use, then a single test would cover all EPs in that group. Similarly, if a provider uses an EHR technology that is hosted (cloud-based) on the developer's network, then a single test would allow all EPs using the EHR technology that is hosted (cloud-based) on the developer's network to meet the measure.
What are the reporting periods for an EP to begin the onboarding and reporting process?
In 2015 only, the EHR reporting period for EPs is any continuous 90-day period within the calendar year. EPs may select an EHR reporting period for any continuous 90 days from January 1, 2015 through December 31, 2015.
Beginning with 2016, the EHR reporting period must be completed within January 1 and December 31 of the calendar year. EPs that are new participants in the program would have an EHR reporting period of any continuous 90-day period between January 1, 2016 and December 31, 2016. However, for all returning participants, the EHR reporting period would be a full calendar year from January 1, 2016 through December 31, 2016.
In 2017, the EHR reporting period would be one full calendar year for all providers except new participants and/or providers who choose to implement Stage 3, who are allowed a 90-day reporting period.
How do I successfully engage with the public health reporting for cancer registries option?
Meeting the measure for Public Health Registry Reporting is achieved when the registered Eligible Professional is in active engagement to submit data to public health registries. Providers are allowed to choose to meet MU3 objectives optionally in 2017, but they are required to meet MU3 objectives for 2018 and beyond. In Modified Stage 2 and MU3 final rules, the prior ongoing submission requirement has been replaced with an "active engagement" requirement, which will be more aligned with the process Providers undertake to report to a clinical registry or public health agency. "Active engagement" means the Provider is in the process of working towards sending "production data" to a public health agency or clinical data registry, or is sending production data to a public health agency or clinical data registry(see section 4.2 for additional details on Active Engagement)
Helpful Resources for Certified EHR Reporting
The Centers for Medicare & Medicaid Services final rule change for the 2015 EHR Reporting Period.
The Florida Regional Extension Centers (RECs) support physicians with individualized on-site services, technical assistance, and ongoing support to select, implement or upgrade EHRs, and provide guidance for meaningful use.
The Office of the National Coordinator for Health IT (HIT) offers web-based interoperability training on Public Health Reporting, including state cancer reporting.
Questions about the Centers for Medicare and Medicaid Services (CMS) EHR Incentive program registration, attestation, eligibility, and other meaningful use criteria should be directed to the CMS EHR Incentive Program.