Dr. Gibel Soraya Cedeno

Hendrick Medical Center NPI1730301615

Performance

Public Reporting for Performance Scores

More Details

Final MIPS Score

100 out of 100

Score Breakdown

Quality Category Score 95.38
PI Category Score 94

 

IA Category Score 40
Cost Category Score 0
Total Patients: 56
Source of Scores: individual

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
IA_EC_PSPA_21 Implementation of fall screening and assessment programs
MIPS_EC_001_overall Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) 47 240 EHR
MIPS_EC_110_overall Preventive Care and Screening: Influenza Immunization 51 778 3 85 EHR
MIPS_EC_112_overall Breast Cancer Screening 36 321 2 93 EHR
MIPS_EC_117_overall Diabetes: Eye Exam 13 240 1 100 EHR
MIPS_EC_128_overall Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan 30 1057 2 98 EHR
MIPS_EC_119_overall Diabetes: Medical Attention for Nephropathy 87 240 4 100 EHR
MIPS_EC_130_overall Documentation of Current Medications in the Medical Record 96 3703 4 100 EHR
MIPS_EC_134_overall Preventive Care and Screening: Screening for Depression and Follow-Up Plan 4 754 1 96 EHR
MIPS_EC_226_overall Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 36 25 2 100 EHR
MIPS_EC_226_screenedForUse Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 23 946 EHR
MIPS_EC_238_overall Use of High-Risk Medications in Older Adults 12 484 3 100 EHR
MIPS_EC_226_tobacco Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 22 946 EHR
MIPS_EC_236_overall Controlling High Blood Pressure 63 572 EHR
MIPS_EC_309_overall Cervical Cancer Screening 12 373 1 98 EHR
MIPS_EC_317_overall Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented 34 1398 3 64 EHR
MIPS_EC_318_overall Falls: Screening for Future Fall Risk 13 484 1 100 EHR
MIPS_EC_374_overall Closing the Referral Loop: Receipt of Specialist Report 14 674 1 88 EHR
PI_EC_EP_1 e-Prescribing 97 18968 4 100 EHR
PI_EC_HIE_5 Health Information Exchange(HIE) Bi-Directional Exchange
PI_EC_ONCDIR_1 ONC Direct Review Attestation
PI_EC_ONCACB_1 ONC-ACB Surveillance Attestation
PI_EC_PHCDRR_4 Public Health Registry Reporting
PI_EC_PEA_1 Provide Patients Electronic Access to Their Health Information 86 1103 4 99 EHR
PI_EC_PPHI_1 Security Risk Analysis
PI_EC_PHCDRR_5 Clinical Data Registry Reporting