Stage 1 Menu Set Objective for Eligible Providers, Eligible Hospitals or Critical Access Hospitals (CAHs) to Submit Immunization Information
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Meaningful Use Requirements - Objectives and Measures
Eligible providers may choose at least one of two public health objectives and measures from a menu set to meet the meaningful use requirements in Stage 1. These objectives include submitting electronic immunization information to immunization registries or immunization information systems, and/or submitting electronic syndromic surveillance data to public health agencies. Eligible hospitals must also choose at least one public health objective from the menu set which includes the two objectives previously listed and/or submitting electronic laboratory results to public health agencies. See
eHealth in Public Health for more information about meaningful use.
In order to fulfill the public health objective of capability to submit immunization information to immunization registries or immunization information systems, eligible providers (EPs), hospitals and CAHs must comply with two federal regulations:
I. Centers for Medicare and Medicaid Services Final Rules EHR Incentive Program Section 495.6(e)(9), Paragraph Citation 75 FR 44568 and 495.6(g)(8), Paragraph Citation 75 FR Page 44570 (Also see CMS Final Rules for the EHR Incentive Program).
Objective: Capability to submit electronic data to immunization registries or immunization information systems and actual submission according to applicable law and practice.
Measure: Performed at least one test of certified EHR technology’s capacity to submit electronic data to immunization registries and follow up submission if the test is successful (unless none of the immunization registries to which the EP/eligible hospital/CAH submits such information has the capacity to receive the information electronically).
Exclusion for Eligible Providers: Exclusion in accordance with paragraph (a)(2) of this section. An EP who administers no immunizations during the EHR reporting period or where no immunization registry has the capacity to receive the information electronically.
Exclusion for Eligible Hospitals and CAHs: Exclusion in accordance with paragraph (b)(2) of this section. An eligible hospital or CAH that administers no immunizations during the EHR reporting period or where no immunization registry has the capacity to receive the information electronically.
II. Office of National Coordinator Final Rules Health Information Technology Standards, Implementation Specifications, and Certification Criteria for Electronic Health Record Technology (75 FR 44590)
Summary of Immunization Standards, Implementation Specifications and Certification Criteria
Frequently Asked Questions Regarding Immunization Information Submission:
Since there are privacy and security concerns, can I submit a test with “dummy” data instead of “real” immunization information from an actual patient?
CMS Final Rules state: “While the use of test patient information may increase the risk that the system will not be testing to its full capability, given the privacy and security concerns surrounding the transmission of actual patient information we do not require it for the purposes of a test. Therefore, the use of test information about a fictional patient that would be identical in form to what would be sent about an actual patient would satisfy this objective. However, we note that this is one of the objectives that a State may modify in accordance with the discussion in II.A.2.c. of the proposed rule. Therefore, more stringent requirements may be established for EPs and eligible hospitals under the Medicaid program in states where this capability exists.” (75 FR Page 44365)
California has not modified any requirements to date, so currently test information is acceptable for Stage 1 of Meaningful Use.
If my EHR technology is capable of submitting batch files to an immunization registry using the adopted standards (HL7 2.3.1 or 2.5.1 and CVX), is that sufficient for demonstrating compliance with the certification criterion specified at 45 CFR 170.302(k)?
This question was submitted to the Office of the National Coordinator for Health Information Technology (Question [9-10-002-1]). Their answer is below:
The certification criterion at 45 CFR 302(k) does not specify, and is not intended to specify, when submissions should be made or the periodicity of the submissions. Consequently, submitting batch files to an immunization registry, provided that they are formatted according to one or both of the adopted standards, is not prohibited by this certification criterion and would be acceptable.
When can I submit the immunization information?
CMS Final Rules state: “The testing could occur prior to the beginning of the EHR reporting period, but must occur prior to the end of the EHR reporting period.” (75 FR Page 44365-6)
The CMS website lists Meaningful Use reporting timelines and other important dates.
For Medi-Cal, see the Department of Health Care Services (DHCS) website.
Where do I submit the immunization information?
CMS Final Rules state: “Capability to submit electronic data to immunization registries or immunization information systems and actual submission according to applicable law and practice.” Section 495.6(e)(9)(i) and 495.6(g)(8)(i) CMS Final Rules also state: “As specified in the proposed rule, this test must involve the actual submission of information to a registry or immunization information system, if one exists that will accept the information.” (75 FR Page 44365)
The California Department of Public Health (CDPH) is not able to receive immunization information from providers, hospitals and CAHs. We recommend that you submit your immunization information to your designated regional California Immunization Registry (CAIR) who can better utilize the data if the test is successful. Please see this list (PDF)
and this map of Local Health Departments (LHDs) that can or cannot currently accept immunization information through their designated regional immunization registries.
How do I send my immunization information to the public health agency?
CDPH is presently developing an implementation guide and technical standard to assist EPs, eligible hospitals and CAHs with preparing their EHR systems for the exchange of immunization information with the seven CAIR regions currently currently using the CAIR software, namely CAIR NorCal, CAIR Greater Sacramento, CAIR Bay Area, CAIR Central Valley, CAIR Central Coast, CAIR Inland Empire, and CAIR LA-Orange. Please go to the CAIR website to determine which CAIR region you are in. The implementation guide is expected to be available in Spring 2012.
Can I submit the immunization information to another CAIR registry in another region if the designated registry for my area cannot accept my data?
No - CMS Final Rules state: “Capability to submit electronic data to immunization registries or immunization information systems and actual submission according to applicable law and practice.” Applicable law and practice is synonymous with ‘‘where required and accepted’’ (75 FR Page 44364-5); thus, EPs, eligible hospitals, and CAHs must submit immunization information to their designated regional immunization registry.
The reason for this lies in the CMS Final Rules statement: “Performed at least one test of certified EHR technology’s capacity to submit electronic data to immunization registries and follow up submission if the test is successful (unless none of the immunization registries to which the EP/eligible hospital/CAH submits such information has the capacity to receive the information electronically).” EPs, eligible hospitals, and CAHs must submit their immunization information only to their regional (CAIR) immunization registry as successful testing will require each entity to continue submitting data. The designated registry will provide local providers and hospitals with immunization information for their patients.
What if my regional immunization registry is not able to receive my data?
CMS Final Rules state: “We agree that many areas of the country currently lack the infrastructure to support the electronic exchange of information. As meaningful use seeks to ensure certified EHR technology has the capability to submit electronic data to registries, we only require a single test if a receiving entity is available and follow up submission only if that test is successful. If none of the immunization registries to which the EP, eligible hospital or CAH submits information has the capacity to receive the information electronically, then this objective would not apply.” (75 FR Page 44365)
Exclusions for EPs, eligible hospitals, and CAHs would apply. See Section 495.6 Meaningful use objectives and measures for EPs, eligible hospitals, and CAHs below. (FR Pages 44566-70)
(a) Stage 1 criteria for EPs—
(1) General rule regarding Stage 1 criteria for meaningful use for EPs. Except as specified in paragraphs (a)(2) and (a)(3) of this section, EPs must meet all objectives and associated measures of the Stage 1 criteria specified in paragraph (d) of this section and five objectives of the EP’s choice from paragraph (e) of this section to meet the definition of a meaningful EHR user.
(2) Exclusion for non-applicable objectives.
(i) An EP may exclude a particular objective contained in paragraphs (d) or (e) of this section, if the EP meets all of the following requirements:
(A) Must ensure that the objective in paragraph (d) or (e) of this section includes an option for the EP to attest that the objective is not applicable.
(B) Meets the criteria in the applicable objective that would permit the attestation.
(C) Attests.
(ii) An exclusion will reduce (by the number of exclusions applicable) the number of objectives that would otherwise apply. For example, an EP that has an exclusion from one of the objectives in paragraph (e) of this section must meet four (and not five) objectives of the EP’s choice from such paragraph to meet the definition of a meaningful EHR user.
(3) Exception for Medicaid EPs who adopt, implement or upgrade in their first payment year. For Medicaid EPs who adopt, implement, or upgrade certified EHR technology in their first payment year, the meaningful use objectives and associated measures of the Stage 1 criteria specified in paragraphs (d) and (e) apply beginning with the second payment year, and do not apply to the first payment year.
(b) Stage 1 criteria for eligible hospitals and CAHs—
(1) General rule regarding Stage 1 criteria for meaningful use for eligible hospitals or CAHs. Except as specified in paragraphs (b)(2) and (b)(3) of this section, eligible hospitals and CAHs must meet all objectives and associated measures of the Stage 1 criteria specified in paragraph (f) of this section and five objectives of the eligible hospital’s or CAH’s choice from paragraph (g) of this section to meet the definition of a meaningful EHR user.
(2) Exclusions for non-applicable objectives.
(i) An eligible hospital or CAH may exclude a particular objective that includes an option for exclusion contained in paragraphs (f) or (g) of this section, if the hospital meets all of the following requirements:
(A) The hospital meets the criteria in the applicable objective that would permit an exclusion.
(B) The hospital so attests.
(ii) An exclusion will reduce (by the number of exclusions received) the number of objectives that would otherwise apply. For example, an eligible hospital that is excluded from one of the objectives in paragraph (g) of this section must meet four (and not five) objectives of the hospital’s choice from such paragraph to meet the definition of a meaningful EHR user.
What if my submission failed?
CMS Final Rules state: “A failed attempt would meet the measure. We highly encourage EPs, eligible hospitals, and CAHs to work with their vendor and the receiving entity with whom they tested to identify the source of the failure and develop remedies, but for Stage 1 of meaningful use a failed attempt would meet the requirements. We had indicated in the proposed rule that only one test is required for EPs practicing in a group setting that shares the same certified EHR technology. We maintain that proposal for the final rule.” (75 FR Page 44365)
Where can I test my immunization message submission?
We recommend that your hospital use the Center for Disease Control PHIN Message Quality Framework (MQF) to assist in testing your initial immunization message submission.
How do I attest for meeting Meaningful Use?
CMS and Medi-Cal will accept a yes/no attestation to verify that eligible hospitals or CAHs have fulfilled the objective and measure of submitting electronic immunization information in the first year reporting period. For auditing purposes, CMS also states that “all providers attesting to receive an EHR incentive payment for either Medicare or Medicaid EHR Incentive Programs should retain ALL relevant supporting documentation (in either paper or electronic format used in the completion of the Attestation Module responses). Documentation to support the attestation should be retained for six years post-attestation. Documentation to support payment calculations (such as cost report data) should continue to follow the current documentation retention processes.”
For hospitals in jurisdictions where the LHD can accept messages via their designated immunization registry, please contact the LHD for proper documentation.
For hospitals in jurisdictions where the LHD cannot accept messages via their designated immunization registry, CDPH recommends printing the California Public Health Capacity to Receive Immunization Information (PDF) document This list will be continually updated as LHDs acquire the capability to accept messages. The list may serve as supporting documentation that the LHD in your jurisdiction could not accept messages at the time your immunization message was sent.
Medicare Hospitals and CAHs
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Visit the
CMS website for more information on attestation.
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CMS has prepared a
Meaningful Use Attestation Calculator to assist you prior to submitting your attestation to see if you would be able to meet all of the necessary measures to successfully demonstrate meaningful use and qualify for an EHR incentive payment.
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Also, review the CMS
Attestation User Guide (PDF, 6.4 MB)for hospitals and CAHs to provide step-by-step instructions for login and completing attestation. For the public health objectives, see pages 19 to 23 of the user guide.
Medi-Cal Hospitals and Critical Access Hospitals
Who do I send my attestation to?
Medicare providers and hospitals must demonstrate Meaningful Use through the CMS web-based Registration and Attestation System.
Medi-Cal providers and hospitals, please submit your attestation to the Department of Health Care Services.
What do I do if I do not administer immunizations?
CMS Final Rules state: “We acknowledge that this objective is not relevant to all EPs, eligible hospitals or CAHs. Therefore, in this final rule, we clarify that this objective and its associated measure apply only to EPs, eligible hospitals or CAHs that administer one or more immunizations during the EHR reporting period.” (75 FR Page 44364)
I have heard that States can change the requirements for submitting immunization information as an objective for the Medi-Cal Incentive Program. Has California changed any requirements for submission of immunization information?
While States do have the option to modify requirements for public health objectives/measures such as immunization information submission under the Medi-Cal Incentive Program, California has not modified any requirements to date.
Additional Resources and FAQs Regarding Meaningful Use:
- Office of the National Coordinator for Health Information Technology (ONC): ONC is at the forefront of the administration’s health IT efforts and is a resource to the entire health system to support the adoption of health information technology and the promotion of nationwide health information exchange to improve health care.
ONC Regulations Frequently Asked Questions
- Centers for Medicare and Medicaid Services (CMS): The CMS has oversees the Medicare and Medicaid EHR Incentive Programs which provide a financial incentive for the "meaningful use" of certified EHR technology to achieve health and efficiency goals.
CMS Frequently Asked Questions
- The Centers for Disease Control and Prevention (CDC): The CDC is engaged in EHR policy decisions to improve care for individuals and provide leadership to leverage Meaningful Use for public health. Currently, we are collaborating with and providing input to ONC and CMS for consideration of public health priorities within Meaningful Use now and in the future. CDC incorporates partner feedback in our input through our engagement with national public health organizations (e.g., ASTHO, NACCHO, APHL, etc.). In an effort to educate stakeholders, CDC is also working to provide consolidated information to its programs and partners as well as through forums to the general public.
CDC Meaningful Use Website
CDC Meaningful Use Frequently Asked Questions
- Association of State and Territorial Health Officials (ASTHO): ASTHO is a national nonprofit organization representing the public health agencies of the United States, the U.S. Territories, and the District of Columbia, as well as the 120,000 public health professionals these agencies employ. ASTHO members, the chief health officials of these jurisdictions, are dedicated to formulating and influencing sound public health policy and to assuring excellence in state-based public health practice.
ASTHO Frequently Asked Questions About Meaningful Use
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