CANCER REPORTING IN PI/QPP

The West Virginia Cancer Registry (WVCR) continues to enroll eligible professionals (EPs) and eligible clinicians (ECs) who wish to implement electronic reporting of cancer data from certified electronic health record (EHR) systems under the Promoting Interoperability (PI) Programs (formerly Meaningful Use) or the Quality Payment Program (QPP). (Please note that hospitals cannot conduct cancer reporting under either of these programs.)

The information below provides an overview of the cancer reporting process in West Virginia for the 2019 reporting period. If you meet all eligibility criteria and wish to register, please print the "PI/QPP Cancer Reporting Checklist and Instructions" document, which contains more detailed information regarding each of the steps below. Please use this checklist as you move through the process to achieve ongoing data submission to the West Virginia Cancer Registry.

DECLARATION OF READINESS STATEMENT (posted June 22, 2018): The WVCR will continue accepting cancer registrations for all stages under Meaningful Use/QPP for the 2019 reporting period. It is the registrant's responsibility to know the requirements of the particular Federal Rule under which you are registering and reporting.

IMPORTANT!

It is VERY IMPORTANT that providers keep a record of all communications received from public health throughout the registration, onboarding, testing, and production process, as well as any other documentation that may be needed for attestation or auditing purposes. Examples may include e-mails, screen shots proving date of registration, acknowledgement letters, etc. Due to the large volume of registrants, public health programs will not have the capacity to prepare such a log on your behalf.

ELIGIBILITY CRITERIA

Are you an EP or EC who diagnoses or treats cancer patients? (If you are a hospital or a hospital-based EP/EC, or if you do not diagnose or treat cancer patients, you cannot select cancer reporting. Individual EP/ECs or EP/ECs in group practices may select cancer reporting.)

Do you have an EHR system that is certified for cancer reporting or will be certified for cancer reporting by the end of your 2019 reporting period? If your system will not be certified for cancer reporting by the end of your 2019 reporting period, you should not select cancer.

Contact your EHR vendor to determine if your system is certified or will become certified for cancer, or to discuss alternate public health registry reporting options provided by your software, such as the National Center for Health Statistics' National Ambulatory Medical Care Survey.

REGISTRATION

If you meet both eligibility criteria, you must register your intent to report cancer data to the WVCR using the Meaningful Use Registration System. Download the "Registration System Instructions" to assist with registering. Call or e-mail Myra Fernatt at (304) 356-4953 if you have any questions while completing your registration. Please be aware of the following:

If multiple physicians in a group practice or clinic are moving through PI/QPP concurrently, one registration can be entered under the practice name. Multiple registrations are not required.

If you previously registered for cancer reporting and your registration status was "In Review," "Registered - In Queue," "First or Second Invitation," "Testing and Validation Queue," or "Production" at the end of 2018, you do not have to register again. Your previous registration will continue in 2019. If you are uncertain of your status, please call or e-mail Myra Fernatt at (304) 356-4953.

It is not the responsibility of the West Virginia Cancer Registry to know your certification status, your reporting period registration deadline, or whether your reporting period is the full 2019 calendar year or any 90-day period in 2019.

After you submit your registration, the Registration Status will indicate "In Review" in the Meaningful Use Registration System, and your Primary Contact will receive an e-mail confirmation indicating that the registration was successfully saved. WVCR staff will review the registration information, contact your Primary Contact if more information is needed, and will change the Registration Status to "Registered - In Queue." Your Primary Contact will receive an e-mail confirming that you have been placed in the cancer reporting queue.

TESTING AND VALIDATION

As of 2019, all EPs/ECs must use EHRs that are certified to the ONC 2015 Edition cancer reporting standards in order to use cancer reporting as one of your public health measures for incentive payments. An EHR system that is certified to the 2015 Edition CEHRT for cancer reporting must contain correct vocabulary items as specified in the "HL7 CDA Release 2 Implementation Guide: Reporting to Public Health Cancer Registries from Ambulatory Health Care Providers, Release 1, DSTU Release 1.1 - US Realm."

Your Primary Contact and Technical Contact will eventually receive an e-mail invitation from WVCR staff to begin testing and validation. As soon as a timely response is received to this invitation, WVCR staff will change the Registration Status to "Testing and Validation Queue."

During testing and validation, your office should continue sending paper cancer reports to the WVCR via mail or fax until you have successfully achieved ongoing submission.

As soon as you are added to the Testing and Validation Queue, your Technical Contact must establish a data transport method. Currently the only data transport method offered by the WVCR is secure FTP. Your Technical Contact should e-mail Myra Fernatt for instructions to connect directly to the WVCR via secure FTP.

Once the connection has been established, your Technical Contact should transmit a test HL7 CDA message via the transport route.

Once the test message is received, WVCR staff will perform structure and content validation using the tool "CDA Validation Plus," visual edits, comparison to paper reports, etc.

WVCR staff will contact your Technical Contact and Primary Contact to indicate if the message passes initial validation. If it does not, WVCR staff will provide additional information regarding message issues. Your Technical Contact, Primary Contact, and other office staff must work together to address and correct these isues. Once all issues have been addressed, your Technical Contact should transmit another test CDA message via the transport route. This step will continue until the CDA messages are correct in structure and content.

ACKNOWLEDGEMENT OF 2019 CANCER REPORTING CRITERIA MET

If you meet at least one of the criteria for cancer reporting at the end of your 2019 reporting period (registered and being held in a queue, being in testing and validation, or having achieved ongoing data submission), WVCR staff will send an e-mail to your Primary Contact. The e-mail will contain a link from which the Primary Contact can obtain a PDF document indicating that at least one of the criteria for cancer reporting was met.

At the end of the 2019 reporting period, if you are still waiting for an invitation to begin testing and validation, or if you are actively engaged in testing and validation, you should continue working with WVCR staff to achieve ongoing submission of data.

ONGOING SUBMISSION OF DATA

Once WVCR staff have determined that your CDA messages are correct in structure and content, you will be moved from testing to production, and WVCR staff will change the Registration Status in the Meaningful Use Registration System to "Production."

After achieving ongoing data submission, WVCR will request that you complete a "Provider Site Responsibilities and Contact Information Form" in the event that your ongoing Primary and Technical Contacts are different than those specified during testing and production.

ADDITIONAL QUESTIONS REGARDING PI/QPP?

The Centers for Disease Control's National Program of Cancer Registries (NPCR) PI website contains numerous guidance documents for EHR/EMR vendors and providers.

Please visit the websites for the Centers for Medicare and Medicaid PI Programs and the Quality Payment Program for more information.