Jimena C Burnett

Hilton Head Regional Medical Center NPI1356314793

Performance

Public Reporting for Performance Scores

More Details

Final MIPS Score

100 out of 100

Score Breakdown

Quality Category Score 100
PI Category Score 100

 

IA Category Score 40
Cost Category Score 0
Total Patients: 94
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_4 Depression screening
IA_EC_BMH_2 Tobacco use
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_21 Implementation of fall screening and assessment programs
IA_EC_PSPA_16 Use of decision support and standardized treatment protocols
MIPS_EC_001_overall Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) 9 226 EHR
MIPS_EC_113_overall Colorectal Cancer Screening 89 1648 4 92 EHR
MIPS_EC_112_overall Breast Cancer Screening 88 1074 4 93 EHR
MIPS_EC_110_overall Preventive Care and Screening: Influenza Immunization 79 1615 4 85 EHR
MIPS_EC_119_overall Diabetes: Medical Attention for Nephropathy 97 226 4 100 EHR
MIPS_EC_117_overall Diabetes: Eye Exam 73 226 3 100 EHR
MIPS_EC_128_overall Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan 94 2583 4 98 EHR
MIPS_EC_130_overall Documentation of Current Medications in the Medical Record 100 5262 5 100 EHR
MIPS_EC_226_overall Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 100 133 5 100 EHR
MIPS_EC_134_overall Preventive Care and Screening: Screening for Depression and Follow-Up Plan 98 2152 5 96 EHR
MIPS_EC_226_screenedForUse Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 100 2091 EHR
MIPS_EC_236_overall Controlling High Blood Pressure 86 1281 EHR
MIPS_EC_226_tobacco Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 100 2091 EHR
MIPS_EC_317_overall Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented 27 2507 2 64 EHR
PI_EC_EP_1 e-Prescribing 98 13725 4 100 EHR
PI_EC_EP_2 Query of the Prescription Drug Monitoring Program (PDMP)
PI_EC_HIE_5 Health Information Exchange(HIE) Bi-Directional Exchange
PI_EC_ONCACB_1 ONC-ACB Surveillance Attestation
PI_EC_PHCDRR_4 Public Health Registry Reporting
PI_EC_ONCDIR_1 ONC Direct Review Attestation
PI_EC_PEA_1 Provide Patients Electronic Access to Their Health Information 85 2628 4 99 EHR
PI_EC_PPHI_1 Security Risk Analysis
PI_EC_PHCDRR_5 Clinical Data Registry Reporting