Gail A Besson

St John's Episcopal Hospital At South Shore NPI1639287055

Performance

Public Reporting for Performance Scores

More Details

Final MIPS Score

97.30 out of 100

Score Breakdown

Quality Category Score 88.38
PI Category Score 79

 

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

Performance Details

Measure Code Measure Title Performance Rate Patient Count Star Value Five Star Benchmark Collection Type
IA_EC_BE_4 Engagement of patients through implementation of improvements in patient portal
IA_EC_BMH_2 Tobacco use
IA_EC_BMH_4 Depression screening
IA_EC_CC_13 Practice Improvements for Bilateral Exchange of Patient Information
IA_EC_PM_16 Implementation of medication management practice improvements
IA_EC_PSPA_16 Use of decision support and standardized treatment protocols
MIPS_EC_110_overall Preventive Care and Screening: Influenza Immunization 20 273 1 85 EHR
MIPS_EC_112_overall Breast Cancer Screening 60 99 3 93 EHR
MIPS_EC_128_overall Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan 21 271 1 98 EHR
MIPS_EC_130_overall Documentation of Current Medications in the Medical Record 62 1224 1 100 EHR
MIPS_EC_226_screenedForUse Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 10 439 EHR
MIPS_EC_226_tobacco Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 9 439 EHR
MIPS_EC_236_overall Controlling High Blood Pressure 38 71 EHR
MIPS_EC_309_overall Cervical Cancer Screening 80 424 4 98 EHR
MIPS_EC_317_overall Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented 47 1116 3 64 EHR
MIPS_EC_374_overall Closing the Referral Loop: Receipt of Specialist Report 1 156 1 88 EHR
PI_EC_HIE_5 Health Information Exchange(HIE) Bi-Directional Exchange
PI_EC_EP_1 e-Prescribing 98 262 4 100 EHR
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 62 580 3 99 EHR
PI_EC_PHCDRR_4 Public Health Registry Reporting
PI_EC_PHCDRR_5 Clinical Data Registry Reporting
PI_EC_PPHI_1 Security Risk Analysis