Under the Promoting Interoperability’s (PI) Public Health and Clinical Data Exchange Objective, clinicians can attest “yes” to being actively engaged with a clinical data registry (CDR) in order to receive 5 bonus points toward the PI score. CMS states that “Active Engagement” can be demonstrated in one of the following ways:

Option 1: Pre-production and Validation

• Completed registration to submit data, testing and validation
• Transmitting data to the AQUA Registry OR be making strides to send us data for the participating year
• Started the validation of performance measures for the participating year
• Actively engage with the AQUA Registry (i.e. respond to our communication, attend review calls etc.)

Option 2:  Validated Data Production

• Transmitting data to the AQUA Registry for the participating year
• Validated all their AQUA performance scores by October 31st of each participating year.
• Practice must be actively engaged (i.e. respond to our communication, attend review calls etc.)

Additionally, CMS has noted that clinicians may only spend one performance year at the "pre-production and validation" level. After the first year, clinicians must progress to the “validated data production” level in order to continue claiming credit under this objective.

AQUA Registry participants meeting the above criteria will receive a letter, including their active engagement level, as proof on being engaged with a CDR. Participants should save this letter, as it can be shared with CMS in the case of a future MIPS audit.

If you have any questions regarding the CDR participation letter requirements, please contact your AQUA Registry Client Account Coordinator (CAC) at AQUA@auanet.org.