Dr. Cathy Ann Donovan

Mille Lacs Health System NPI1427023191

Performance

Performance Details

Measure Code Measure Title Performance Rate Patient Count Star Value Five Star Benchmark Collection Type
IA_EC_BE_19 Use group visits for common chronic conditions (e.g., diabetes).
IA_EC_BE_13 Regularly assess the patient experience of care through surveys, advisory councils and/or other mechanisms.
IA_EC_CC_12 Care coordination agreements that promote improvements in patient tracking across settings
IA_EC_PM_13 Chronic Care and Preventative Care Management for Empaneled Patients
IA_EC_EPA_1 Provide 24/7 Access to MIPS Eligible Clinicians or Groups Who Have Real-Time Access to Patient's Medical Record
IA_EC_PSPA_21 Implementation of fall screening and assessment programs
MIPS_EC_001_overall Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) 33 105 EHR
MIPS_EC_107_overall Adult Major Depressive Disorder (MDD): Suicide Risk Assessment 0 116 1 89 EHR
MIPS_EC_110_overall Preventive Care and Screening: Influenza Immunization 54 374 3 85 EHR
MIPS_EC_117_overall Diabetes: Eye Exam 43 105 2 100 EHR
MIPS_EC_119_overall Diabetes: Medical Attention for Nephropathy 87 105 4 100 EHR
MIPS_EC_113_overall Colorectal Cancer Screening 35 416 2 92 EHR
MIPS_EC_112_overall Breast Cancer Screening 46 261 2 93 EHR
MIPS_EC_128_overall Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan 18 680 1 98 EHR
MIPS_EC_130_overall Documentation of Current Medications in the Medical Record 99 1429 4 100 EHR
MIPS_EC_134_overall Preventive Care and Screening: Screening for Depression and Follow-Up Plan 93 481 4 96 EHR
MIPS_EC_226_screenedForUse Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 75 460 EHR
MIPS_EC_236_overall Controlling High Blood Pressure 78 324 EHR
MIPS_EC_239_BMI Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents 2 41 EHR
MIPS_EC_239_nutrition Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents 0 41 EHR
MIPS_EC_238_overall Use of High-Risk Medications in Older Adults 7 327 3 100 EHR
MIPS_EC_226_tobacco Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 75 460 EHR
MIPS_EC_239_physicalActivity Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents 2 41 EHR
MIPS_EC_309_overall Cervical Cancer Screening 44 229 2 98 EHR
MIPS_EC_318_overall Falls: Screening for Future Fall Risk 82 327 4 100 EHR
MIPS_EC_317_overall Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented 36 659 3 64 EHR
PI_EC_EP_2 Query of the Prescription Drug Monitoring Program (PDMP)
PI_EC_EP_1 e-Prescribing 99 2085 4 100 ATT
PI_EC_LVITC_2 Support Electronic Referral Loops By Receiving and Reconciling Health Information Exclusion
PI_EC_LVOTC_1 Support Electronic Referral Loops By Sending Health Information Exclusion
PI_EC_ONCACB_1 ONC-ACB Surveillance Attestation
PI_EC_PHCDRR_1 Immunization Registry Reporting
PI_EC_ONCDIR_1 ONC Direct Review Attestation
PI_EC_PEA_1 Provide Patients Electronic Access to Their Health Information 87 311 4 100 ATT
PI_EC_PHCDRR_2_EX_2 Syndromic Surveillance Reporting Exclusion
PI_EC_PPHI_1 Security Risk Analysis