Dr. Florencio Tudela Lizama

Guam Memorial Hospital Authority NPI1538220553

Performance

Public Reporting for Performance Scores

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Final MIPS Score

87.67 out of 100

Score Breakdown

Quality Category Score 82.99
PI Category Score 94

 

IA Category Score 40
Cost Category Score 0
Total Patients: 45
Source of Scores: group, 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_BMH_4 Depression screening
IA_EC_BMH_6 Implementation of co-location PCP and MH services
IA_EC_PM_16 Implementation of medication management practice improvements
MIPS_EC_001_overall Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) 11 197 EHR
MIPS_EC_110_overall Preventive Care and Screening: Influenza Immunization 57 563 3 85 EHR
MIPS_EC_111_overall Pneumococcal Vaccination Status for Older Adults 59 333 3 98 EHR
MIPS_EC_113_overall Colorectal Cancer Screening 2 379 1 92 EHR
MIPS_EC_119_overall Diabetes: Medical Attention for Nephropathy 95 197 4 100 EHR
MIPS_EC_128_overall Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan 21 650 1 98 EHR
MIPS_EC_130_overall Documentation of Current Medications in the Medical Record 88 2166 3 100 EHR
MIPS_EC_226_screenedForUse Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 77 570 EHR
MIPS_EC_226_overall Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 8 71 1 100 EHR
MIPS_EC_226_tobacco Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 65 570 EHR
MIPS_EC_236_overall Controlling High Blood Pressure 66 522 EHR
MIPS_EC_238_overall Use of High-Risk Medications in Older Adults 6 334 4 100 EHR
MIPS_EC_317_overall Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented 18 2166 2 64 EHR
PI_EC_EP_1 e-Prescribing 93 1060 2 100 EHR
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_ONCDIR_1 ONC Direct Review Attestation
PI_EC_PEA_1 Provide Patients Electronic Access to Their Health Information 94 152 4 99 EHR
PI_EC_PHCDRR_4 Public Health Registry Reporting
PI_EC_PHCDRR_2_EX_1 Syndromic Surveillance Reporting Exclusion
PI_EC_PPHI_1 Security Risk Analysis