Connecticut State Department of Public Health

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Promoting Interoperability

 CMS Promoting Interoperability and Merit-based Incentive Payment System


The Centers for Medicare & Medicaid Services (CMS) have revised existing public health reporting requirements for eligible clinicians (ECs) participating in the Merit-based Incentive Payment System (MIPS) and eligible hospitals (EHs) and critical access hospitals (CAHs) participating in Promoting Interoperability Program (PIP) in the calendar year (CY) 2024.

The CT DPH 2024 Project Status Letter (PIP & MIPS) is available here: 

For your reference, the 2023 Project Status Letter is here:

CMS Updates

In CY 2024, there are two options for active engagement for ECs, EHs, and CAHs:

  • Option 1 Pre-production and Validation. The eligible participant has completed registration with DPH to submit data and is engaged in testing and validation or waiting for an invitation to begin testing and validation. Please note that there are additional requirements to be met during Option 1 engagement.
  • Option 2 Validated Data Production. The eligible participant has completed testing and validation of the electronic submission and its electronically submitting production data (clinical level data) to the PHA or CDR.

If an EC/EH/CAH is already engaged with DPH programs for these public health reporting measures, they will move to one of these Options automatically. New engagements in 2024 will start with Option 1.

The specific requirements for ECs/EHs/CAHs for public health reporting to DPH are as follows:

  • For the ECs participating in the 2024 MIPS, the regulation requires reporting of two measures associated with the Public Health and Clinical Data Exchange Objective: Immunization Registry Reporting, and Electronic Case Reporting. An EC must be engaged or newly engaged in Option 1 or be engaged in Option 2 to receive points. If ECs cannot meet these measures, they must request an exclusion or hardship based on CMS criteria.
  • For the EHs and CAHs participating in the 2024 Medicare PIP, the regulation requires reporting of four of the five Public Health and Clinical Data Exchange Objective measures: Syndromic Surveillance Reporting, Immunization Registry Reporting, Electronic Case Reporting, Electronic Reportable Laboratory Result Reporting, and Antimicrobial Use and Resistance (AUR) Surveillance. AUR Surveillance is newly added for 2024. An EH or CAH must be engaged or newly engaged in Option 1 or be engaged in Option 2 to receive points. If EHs or CAHs cannot meet these measures, they must request an exclusion or hardship based on CMS criteria.

Additional information for ECs can be found in the CMS Quality Payment Program Resource Library. Additional information for EHs and CAHs can be found on the Promoting Interoperability Programs website.

DPH Contacts

To register for submitting data to DPH for one of the following performance measures, please see the link or email below:

Contact information is on the linked pages. Please follow instructions or email contacts about registration and/or verification for attestation.

Exclusions

If a participant is taking an exclusion, they are not required to register with DPH. If registered, the participant is considered in active engagement Option 1 and cannot claim an exclusion. DPH is not involved in granting exclusions. To follow-up with CMS directly, see information below:

  • For MIPS: Eligible clinicians may contact the Quality Payment Program help desk for assistance at qpp@cms.hhs.gov or 1-866-288-8292
  • For PIP: Medicare eligible hospitals may contact the QualityNet help desk for assistance at qnetsupport@hcqis.org or 1-866-288-8912

Information for EHR Vendors and Healthcare Organizations

  • PIP and MIPS require the use of certified EHR technology (CERHT) that meets the 2015 Edition Health IT Certification Criteria including the 2015 Edition Cures Update for eCR implementation. Standards, implementation specifications, and certification criteria for EHR technology have been adopted by the Secretary of the Department of Health and Human Services. EHR technology must be tested and certified by an Office of the National Coordinator (ONC) Authorized Testing and Certification Body (ATCB) for a provider to qualify for EHR incentive payments. HTI Final Rule was passed on January 9, 2024. It adopts the United States Core Data for Interoperability (USCDI) Version 3 (v3) as the new baseline standard within the ONC Health IT Certification Program (Certification Program) as of January 1, 2026, but developers of certified health IT can also move to USCDI v3 sooner if desired. USCDI v3 includes updates to prior USCDI versions and is focused on advancing more accurate and complete patient characteristics data that could help promote equity, reduce disparities, and support public health data interoperability. 

Please use the links below to obtain more information.

Helpful Websites and Resources: