EHR Incentive Program: 2015 and Beyond – Public Health

Jim TateBy Jim Tate, EMR Advocate
Meaningful Use Audit Expert
Twitter: @JimTate, eMail:

Recently I participated in a web presentation entitled: “Final Rule for Stage 3 MU Requirements and Modifying Stage 2”. During the Q and A period it became apparent one of the greatest concerns was the need for clarification on the Public Health (PH) meaningful use measures. For both Eligible Hospitals (EH) and Eligible Professionals (EP) the Public Health requirements have always been an integral part of meaningful use since the birth of the program in 2011. There has always been confusion on the requirements but with the recently announced “Stage 2 Modifications” there is a need to dive into the details that have taken effect for 2015 through 2017.

For both EPs and EHs the PH Stage 1 and Stage 2 measures have been consolidated. Let’s look closer at the two domains:

EP – The EP measure has 3 options: Immunization Registry Reporting, Syndromic Surveillance Reporting, and Specialized Registry Reporting. If you are in Stage 1 in 2015 you only have to meet one of the options but Stage 2 requires meeting two measures. For both 2016 and 2017 every EP must meet two of the options no matter which Stage they are in. There are exclusions for each of the three options.

EH – The EH measure has 4 options: Immunization Registry Reporting, Syndromic Surveillance Reporting, Specialized Registry Reporting, and Electronic Reportable Laboratory Result Reporting. Stage 1 hospitals in 2015 need to meet two of the measures. 2015 Stage 2 EHs and all EHs in 2016 and 2017 must meet three of the measures. Exclusions are available for all four of the options.

Here are a few of the questions that came up during the webinar:

Question: I am a 2015 Stage 2 EP. Can I meet the PH meaningful use requirement of 2 options by meeting one and excluding one?

Answer: No, if you are able to exclude one option that by itself would not satisfy the requirements. You would need to try and satisfy the third option. You could meet one of the options and exclude the other two if appropriate.

Question: I am a provider and none of the PH options are relevant to my practice. How do I meet this measure?

Answer: You may exclude all 3 options.

Question: Is it possible to meet the PH measure by meeting one of the options more than once?

Answer: Yes. The Final Rule states, “a provider may report to more than one specialized registry and may count specialized registry reporting more than once to meet the required number of measures for the objective.”

Question: For reporting purposes, what is the definition of a “public health agency”?

Answer: CMS defines a Public Health Agency as: “Public Health Agency — An entity under the jurisdiction of the U.S. Department of Health and Human Services, tribal organization, State level and/or city/county level administration that serves a public health function.”

Question: Where can I get more information on the updated PH requirements?

Answer: CMS has provided clarification in a FAQ and a good overview in included in the document EHR Incentive Programs: 2015 through 2017 (Modified Stage 2) Overview.

Jim Tate is known as the most experienced authority on the CMS Meaningful Use (MU) audit and appeal process. His unique combination of skills has brought successful outcomes to hospitals at risk of having their CMS EHR incentives recouped. He led the first appeal challenge in the nation for a client hospital that had received a negative audit determination. That appeal was decided in favor of the hospital. He has also been successful in leading the effort to reverse a failed appeal, even after the hospital had received notification of the failure with the statement, “This decision is final and not subject to further appeal”. That “final” decision was reversed in less than a week. If you are a hospital with questions or concerns about the meaningful use audit process, contact him at: