Dr. James Michael Fay

St David's Medical Center NPI1083818645

Performance

Public Reporting for Performance Scores

More Details

Final MIPS Score

90.59 out of 100

Score Breakdown

Quality Category Score 78.03
PI Category Score 100

 

IA Category Score 40
Cost Category Score 0
Total Patients: 72
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_PM_16 Implementation of medication management practice improvements
IA_EC_CC_13 Practice Improvements for Bilateral Exchange of Patient Information
IA_EC_PSPA_16 Use of decision support and standardized treatment protocols
MIPS_EC_001_overall Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) 100 28 EHR
IA_EC_PSPA_6 Consultation of the Prescription Drug Monitoring Program
MIPS_EC_110_overall Preventive Care and Screening: Influenza Immunization 0 832 1 85 EHR
MIPS_EC_113_overall Colorectal Cancer Screening 0 729 1 92 EHR
MIPS_EC_117_overall Diabetes: Eye Exam 0 28 1 100 EHR
MIPS_EC_119_overall Diabetes: Medical Attention for Nephropathy 71 28 3 100 EHR
MIPS_EC_128_overall Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan 20 1347 1 98 EHR
MIPS_EC_130_overall Documentation of Current Medications in the Medical Record 85 4461 3 100 EHR
MIPS_EC_226_screenedForUse Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 0 1139 EHR
MIPS_EC_226_tobacco Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 0 1139 EHR
MIPS_EC_236_overall Controlling High Blood Pressure 49 338 EHR
MIPS_EC_238_overall Use of High-Risk Medications in Older Adults 6 712 4 100 EHR
MIPS_EC_317_overall Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented 15 4058 1 64 EHR
MIPS_EC_374_overall Closing the Referral Loop: Receipt of Specialist Report 27 131 2 88 EHR
PI_EC_EP_2 Query of the Prescription Drug Monitoring Program (PDMP)
PI_EC_EP_1 e-Prescribing 100 308 5 100 EHR
PI_EC_HIE_5 Health Information Exchange(HIE) Bi-Directional Exchange
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 78 1439 4 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