Public Health Registries: Reporting Guidance

On this page you will find information about:

How to meet the public health reporting objective
Public health reporting exclusions
Demonstrating "Active Engagement"
Available public health and clinical data registry reporting measures
Public health reporting attestation guidance
Wisconsin Department of Health Services, Division of Public Health (DPH) Declaration of Readiness
Acknowledgements for public health programs

Overview

For Stage 3 of the Promoting Interoperability Program, providers are required to be in “active engagement” with a public health agency to submit electronic public health data from certified electronic health record technology (CEHRT). Active engagement means the provider is progressing toward sending production data to DPH or is sending production data to DPH. Production data submission is the ability of a provider to regularly report data generated through clinical processes involving patient care from CEHRT to a public health program using appropriate standards and specifications.

Meeting the public health reporting objective

In Program Year 2020 and beyond, providers attest to Stage 3, where Eligible Professionals and Hospitals must meet any combination of two measures.

Public health reporting exclusions

There are multiple exclusions for each of the public health reporting measures. Claiming an exclusion for a measure does not count toward the total number of public health reporting measures a provider must meet. Instead, to meet the public health objective, a provider must attest to “active engagement” for either:

The minimum number of measures for their scheduled stage OR
Less than the minimum number of measures for their scheduled stage AND claim an applicable exclusion for all remaining measures.

Providers who do not collect appropriate or relevant data to submit to a public health program may be able to claim an exclusion or pick another public health reporting measure. If a provider appropriately meets the exclusion criteria, he/she can claim the exclusion to the measure. If a provider is part of a group that submits data to a registry, but the provider does not contribute to that data (e.g., he/she does not administer immunizations), the provider should not attest to meeting the measure and should claim the exclusion.

While exclusions are available for the public health reporting measures, Wisconsin does not formally grant exclusions to providers or offer documentation for providers to use when taking an exclusion. Providers will self-attest to exclusions in the attestation system based on the Centers for Medicare & Medicaid Services (CMS) exclusion criteria. It is the provider’s responsibility to attest to an exclusion and maintain the proper documentation to substantiate the attestation.

Providers who intend to claim an exclusion for a public health measure are not required to register for that measure with DPH.

Demonstrating "active engagement"

A provider can meet a public health reporting measure by registering to submit data with DPH and demonstrating any of the following “active engagement” options:

Active Engagement Option 1 – Completed Registration to Submit Data: The eligible professional or hospital registered to submit data with DPH. Registration was completed no later than 60 days after the start of their EHR reporting period, and the provider is awaiting invitation to begin testing and validation. (For more information on how to register to submit data, see “Getting Started” on the Public Health Promoting Interoperability home page.)
- This option allows providers to meet the measure when DPH has limited resources to initiate the testing and validation process.
- Providers that have registered in previous years do not need to submit an additional registration to meet this requirement for each EHR reporting period.
- Eligible professionals and eligible hospitals are able to meet the measure by registering their intent to report with a registry if a registry declares readiness at any point in the calendar year after the initial 60 days. (However, if an eligible professional or eligible hospital had already planned to exclude based on the registry not being ready to allow for registrations of intent within the first 60 days of the reporting period, they may still exclude for that calendar year.)
Active Engagement Option 2 – Testing and Validation: The eligible professional or hospital is in the process of testing and validation of the electronic submission of data to DPH.
- Providers must respond to requests from DPH or, where applicable, an agent acting on behalf of DPH (e.g., Wisconsin Statewide Health Information Network [WISHIN], Wisconsin State Lab of Hygiene) within 30 days. Failure to respond to a request within 30 days on two separate occurrences in an EHR reporting period would result in that provider not meeting the measure.
Active Engagement Option 3 – Production: The eligible professional or hospital has completed testing and validation of the electronic submission and is electronically submitting production data to DPH.
- A provider may use this option once DPH or, where applicable, an agent acting on behalf of DPH (e.g., WISHIN, Wisconsin State Lab of Hygiene) moves the provider into a production phase.
- If an eligible professional or hospital had already achieved production status prior to the beginning of their EHR reporting period for relevant data submission per the applicable standards under Promoting Interoperability to DPH but had not registered with DPH, the eligible professional or hospital should register to receive a written acknowledgement that they are in production in case their attestation is audited.

All providers participating in the Promoting Interoperability Program should register for the public health programs to which they intend to electronically submit data. All providers who have appropriate data should register their intent to submit data no later than 60 days after the start of their EHR reporting period. Based on the registry's onboarding policies, providers may not be invited to further participate in the onboarding process; however, they will have successfully demonstrated the public health reporting objective criteria for Active Engagement Option 1 – Completed Registration to Submit Data (and would not have to claim an exclusion).

Available Public Health and Clinical Data Registry Reporting Measures in Stage 3
Measure Detail	Maximum Times Measure Can Count Towards Objective	Exclusion Criteria
Measure 1 – Immunization Registry Reporting: The eligible professional, eligible hospital, 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 registry/immunization information system (IIS).	Eligible Professionals: 1 Eligible Hospitals: 1	Does not administer any immunizations to any of the populations for which data is collected by their jurisdiction during the EHR reporting period OR Operates in a jurisdiction for which no immunization registry or IIS is capable of accepting the specific MU standards at the start of the EHR reporting period OR Operates in a jurisdiction where no immunization registry or IIS has declared readiness as of six months prior to the start of the EHR reporting period
Measure 2 – Syndromic Surveillance Reporting: The eligible professional, eligible hospital, or CAH is in active engagement with a public health agency to submit syndromic surveillance data.	Eligible Professionals: 1 Eligible Hospitals: 1	Is not in a category of providers from which ambulatory syndromic surveillance data is collected by their jurisdiction OR Operates in a jurisdiction for which no public health agency is capable of receiving electronic syndromic surveillance data from eligible professionals per specific MU standards at the start of the EHR reporting period OR Operates in a jurisdiction where no public health agency has declared readiness as of six months prior to the start of the EHR reporting period
Measure 3 – Electronic Case Reporting: The eligible professional, eligible hospital, or CAH is in active engagement with a public health agency to submit case reporting of reportable conditions.	Eligible Professionals: 1 Eligible Hospitals: 1	Does not directly treat or diagnose any reportable diseases for which data is collected by their jurisdiction’s reportable disease system during the EHR reporting period OR Operates in a jurisdiction for which no public health agency is capable of receiving electronic case reporting data per specific MU standards at the start of the EHR reporting period OR Operates in a jurisdiction where no public health agency has declared readiness as of six months prior to the start of the EHR reporting period
Measure 4 – Public Health Registry Reporting: The eligible professional, eligible hospital, or CAH is in active engagement with a public health agency to submit data to a public health registry.	Eligible Professionals: 2 Eligible Hospitals: 2	Does not diagnose or directly treat any disease or condition associated with a public health registry in their jurisdiction during the EHR reporting period, OR Operates in a jurisdiction for which no public health agency is capable of accepting electronic registry transactions in the specific MU standards at the start of the EHR reporting period OR Operates in a jurisdiction where no public health registry has declared readiness as of six months prior to the start of the EHR reporting period
Measure 5 – Clinical Data Registry Reporting: The eligible professional, eligible hospital, or CAH is in active engagement to submit data to a clinical data registry.	Eligible Professionals: 2 Eligible Hospitals: 2	Does not diagnose or directly treat any disease or condition associated with a clinical data registry in their jurisdiction during the EHR reporting period OR Operates in a jurisdiction for which no clinical data registry is capable of accepting electronic transactions in the specific MU standards at the start of the EHR reporting period OR Operates in a jurisdiction where no clinical data registry has declared readiness as of six months prior to the start of the EHR reporting period
Measure 6 – Electronic Reportable Laboratory Result Reporting: The eligible hospital or CAH is in active engagement with a public health agency to submit ELR results.	Eligible Professionals: n/a Eligible Hospitals: 1	Does not perform or order laboratory tests that are reportable in their jurisdiction during the EHR reporting period OR Operates in a jurisdiction for which no public health agency is capable of accepting the specific MU standards at the start of the EHR reporting period OR Operates in a jurisdiction where no public health agency has declared readiness to receive ELR results from eligible hospitals or CAHs as of six months prior to the start of the EHR reporting period

Public health reporting attestation guidance

DPH has created attestation guidance documents for Eligible Professionals regarding the Stage 3 Public Health and Clinical Data Registry Reporting Objective, the Eligible Professional Attestation Guidance for Stage 3 Public Health and Clinical Data Registry Reporting Objective, P-01850-21. Eligible Professionals should use this document to review DPH guidance on how to begin electronically submitting data to DPH programs and to help determine if they are ready to attest to the relevant public health objective.

DPH declaration of readiness

Wisconsin providers must be able to determine which public health measures are supported by DPH. Providers are required to check the current status of each DPH program's capability to accept data at the start of their EHR reporting period, as the program's capability may change. The following table provides declaration of DPH program readiness to receive electronic data in appropriate standards and specifications for the public health measures:

Declaration of DPH program readiness to receive electronic data
Public Health Reporting Measure	Eligible Professionals	Eligible Hospitals
Immunization Registry Reporting	DPH is capable of accepting immunization data sent from eligible professionals directly to the Wisconsin Immunization Registry (WIR) or via WISHIN to the Wisconsin Immunization Registry (WIR).	DPH is capable of accepting immunization data sent from eligible hospitals directly to WIR or via WISHIN to WIR.
Syndromic Surveillance Reporting	Effective January 1, 2021, DPH is capable of accepting ambulatory syndromic surveillance data from select eligible professionals based on their Provider Type and Specialty code (directly to the BioSense Platform or via WISHIN). Refer to the table in Appendix B of the Eligible Professional Attestation Guidance for Stage 3 Public Health and Clinical Data Registry Reporting Objective, P-01850-20, to determine if syndromic surveillance data is being collected from your Provider Type and Specialty. However, DPH has limited resources to support testing and data validation so providers that have not yet been onboarded will remain in the registration queue for onboarding until resources become available. Eligible professionals can still meet this measure under Active Engagement Option 1 described above on this page. Any eligible professional that is already in production submitting syndromic surveillance data to the BioSense Platform (directly or via WISHIN) should continue to send data.	DPH is capable of accepting syndromic surveillance data sent from eligible hospitals (directly to the BioSense Platform or via WISHIN). However, DPH currently has limited resources to support testing and data validation, so hospitals that have not yet been onboarded will remain in the registration queue for onboarding until resources become available. Eligible hospitals can still meet this measure under Active Engagement Option 1 described above on this page. Any eligible hospital that is already in production submitting syndromic surveillance data to the BioSense Platform (directly or via WISHIN) should continue to send data.
Electronic Case Reporting	On June 30, 2017, DPH announced the intent to be capable of accepting electronic case reporting data sent from eligible professionals to WEDSS.	On June 30, 2017, DPH announced the intent to be capable of accepting electronic case reporting data sent from eligible hospitals to WEDSS.
Public Health Registry Reporting	Cancer Registry – DPH is capable of accepting cancer case reporting data sent from eligible professionals through the Wisconsin Cancer Reporting System (WCRS).	DPH has not identified any specialized registries for eligible hospitals with readiness to accept clinical data electronically from CEHRT.
Clinical Data	DPH has not identified any clinical data registries with readiness to accept clinical data electronically from CEHRT.	DPH has not identified any clinical data registries with readiness to accept clinical data electronically from CEHRT.
Electronic Reportable Laboratory Result Reporting	N/A	DPH is capable of accepting data through the Wisconsin State Laboratory of Hygiene.

To learn about the process to formally register your intent to submit data to DPH for one or all of these measures, visit the PHREDS Enrollment and Registration of Intent page. To learn about a public health program’s onboarding process (e.g., technical and resource capacity, information required to register, and detailed onboarding checklist), select one of the program links in the top left menu.

Acknowledgements for public health programs

Documentation You Will Need in Case of an Audit: Acknowledgements are the mechanism DPH uses to acknowledge providers have either registered, completed a test, or reached ongoing submission of production data from CEHRT. The PHREDS Acknowledgements page contains additional details on the format of the published Acknowledgements. We strongly encourage providers to retain these documents (i.e., registration confirmation email and acknowledgements files), as they are the only forms of documentation produced by DPH for this purpose.

It is recommended that all organizations/sites save a copy of the acknowledgements file (in Excel format) dated after the end of their EHR reporting period, even if they are still in the onboarding queue or have achieved ongoing submission of production data.

In the event of an audit, providers will use the PHREDS Acknowledgments files to substantiate their attestation. If you are audited, the auditor will want to see an acknowledgments file with a date occurring after the end of the EHR reporting period being audited to confirm the organization/site’s active engagement status with the public health registry at that time. For this reason, we encourage you to save a printed or PDF copy of the PHREDS Acknowledgements Files page explaining acknowledgement statuses and contents of acknowledgements files.

Please note DPH does not provide Acknowledgements for any specialized registries outside of those sponsored by DPH and listed on the Public Health Promoting Interoperability website. We encourage providers to consider the availability of supporting documentation to support their “active engagement” before attesting to the use of a specialized registry outside of those offered by DPH.