Denisse Menendez Sangha

Cardiovascular Disease Methodist Hospital NPI1437415031

Performance

Public Reporting for Performance Scores

More Details

Final MIPS Score

100 out of 100

Score Breakdown

Quality Category Score 100
PI Category Score 97

 

IA Category Score 40
Cost Category Score 0
Total Patients: 188
Source of Scores: individual

Performance Details

Measure Code Measure Title Performance Rate Patient Count Star Value Five Star Benchmark Collection Type
IA_EC_CC_1 Implementation of Use of Specialist Reports Back to Referring Clinician or Group to Close Referral Loop
IA_EC_PM_16 Implementation of medication management practice improvements
IA_EC_PSPA_16 Use of decision support and standardized treatment protocols
IA_EC_PSPA_21 Implementation of fall screening and assessment programs
MIPS_EC_001_overall Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) 27 99 EHR
MIPS_EC_110_overall Preventive Care and Screening: Influenza Immunization 2 686 1 85 EHR
MIPS_EC_119_overall Diabetes: Medical Attention for Nephropathy 70 99 3 100 EHR
MIPS_EC_226_overall Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 95 80 4 100 EHR
MIPS_EC_226_screenedForUse Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 99 892 EHR
MIPS_EC_226_tobacco Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 99 892 EHR
MIPS_EC_236_overall Controlling High Blood Pressure 40 735 EHR
MIPS_EC_317_overall Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented 92 1260 5 64 EHR
MIPS_EC_318_overall Falls: Screening for Future Fall Risk 100 762 5 100 EHR
MIPS_EC_374_overall Closing the Referral Loop: Receipt of Specialist Report 93 252 5 88 EHR
PI_EC_EP_1 e-Prescribing 96 621 3 100 EHR
PI_EC_LVOTC_1 Support Electronic Referral Loops By Sending Health Information Exclusion
PI_EC_ONCDIR_1 ONC Direct Review Attestation
PI_EC_PHCDRR_1_EX_1 Immunization Registry Reporting Exclusion
PI_EC_PEA_1 Provide Patients Electronic Access to Their Health Information 100 584 5 99 EHR
PI_EC_PPHI_1 Security Risk Analysis
PI_EC_PHCDRR_4 Public Health Registry Reporting