Immunisation Registry Reporting

Identifying Attributes

Care Settings
Primary Care
Country
United States of America
Publishing Organisation
Centers for Medicare & Medicaid Services (CMS): Traditional Merit-based Incentive Payment System (MIPS)
Type of Quality Indicator
Process
IOM Quality Dimension
Safety
Domain
Infection and Sepsis

Defining Attributes

Definition

The MIPS eligible clinician is in active engagement with a public health agency to submit immunisation data and receive immunisation forecasts and histories from the public health immunisation registry/immunisation information system (IIS).

Numerator

Yes/No. The MIPS eligible clinician must attest YES to being in active engagement with a PHA to submit immunisation data and receive immunisation forecasts and histories from the public health immunisation registry/immunisation information system (IIS).

Denominator

This is a descriptive categorical indicator.

Exclusions

Any MIPS eligible clinician meeting one or more of the following criteria may be excluded from the Immunisation Registry Reporting measure if the MIPS eligible clinician: 1.Does not administer any immunisations to any of the populations for which data is collected by its jurisdiction's immunisation registry or immunisation information system during the performance period. OR 2.Operates in a jurisdiction for which no immunisation registry or immunisation information system is capable of accepting the specific standards required to meet the certified electronic health record technology (CEHRT) definition at the start of the performance period. OR 3.Operates in a jurisdiction where no immunisation registry or immunisation information system has declared readiness to receive immunisation data as of 6 months prior to the start of the performance period.

Use of Risk Adjustment
No
Risk Adjustments

None

Stratifications

Collection and Reporting Attributes

Type of Data Collection
Administrative data
Data Collection Methods

Merit-Based Incentive Payment System traditional reporting

Frequency of Data Collection
Annually
Frequency of Data Collection in Days
365
Reporting Methods
Reporting Frequency
Annually
Reporting Frequency in Days
365
Indicator Has Recommended Targets
No

Source and Reference Attributes

Link to Measurement Tools
Quality Indicator Confirmed to be Part of a Program Used to Monitor Quality and Safety of Care Among Older People at a Population-Level between 2012-2022
Yes
Assessed by the Australian Consortium for Aged Care Collaborators as Generally Containing Good Properties (Importance and Scientific Acceptability)
No
Australian Consortium for Aged Care Endorsed
No
Identified by PHARMA-Care Project
No
Upload Date
02 December 2025