Diana L Fairfax

Sturdy Memorial Hospital NPI1023016953

Performance

Public Reporting for Performance Scores

More Details

Final MIPS Score

100 out of 100

Score Breakdown

Quality Category Score 100
PI Category Score 99

 

IA Category Score 40
Cost Category Score 0
Total Patients: 116
Source of Scores: individual

Performance Details

Measure Code Measure Title Performance Rate Patient Count Star Value Five Star Benchmark Collection Type
IA_EC_AHE_6 Provide Education Opportunities for New Clinicians
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_CC_11 Care transition standard operational improvements
IA_EC_CC_2 Implementation of improvements that contribute to more timely communication of test results
IA_EC_EPA_2 Use of telehealth services that expand practice access
IA_EC_EPA_3 Collection and use of patient experience and satisfaction data on access
IA_EC_PSPA_20 Leadership engagement in regular guidance and demonstrated commitment for implementing practice improvement changes
MIPS_EC_110_overall Preventive Care and Screening: Influenza Immunization 100 1530 5 100 REG
MIPS_EC_047_overall Advance Care Plan 100 672 5 100 REG
MIPS_EC_111_overall Pneumococcal Vaccination Status for Older Adults 88 509 4 99 REG
MIPS_EC_130_overall Documentation of Current Medications in the Medical Record 100 3305 5 100 REG
MIPS_EC_137_overall Melanoma: Continuity of Care Recall System 100 92 REG
MIPS_EC_265_overall Biopsy Follow-Up 98 65 REG
MIPS_EC_402_overall Tobacco Use and Help with Quitting Among Adolescents 100 281 REG
PI_EC_EP_1 e-Prescribing 100 682 5 100 REG
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_PEA_1 Provide Patients Electronic Access to Their Health Information 99 741 4 100 REG
PI_EC_ONCDIR_1 ONC Direct Review Attestation
PI_EC_PHCDRR_5_MULTI Clinical Data Registry Reporting for Multiple Registry Engagement
PI_EC_PHCDRR_5 Clinical Data Registry Reporting
PI_EC_PPHI_1 Security Risk Analysis