Dr. Judith Marie Gilbreth

Duncan Regional Hospital, Inc NPI1407823982

Performance

Public Reporting for Performance Scores

More Details

Final MIPS Score

61.82 out of 100

Score Breakdown

Quality Category Score 60.83
PI Category Score 0

 

IA Category Score 40
Cost Category Score 0
Total Patients: 54
Source of Scores: individual, 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_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_18 Measurement and Improvement at the Practice and Panel Level
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%) 39 82 EHR
MIPS_EC_107_overall Adult Major Depressive Disorder (MDD): Suicide Risk Assessment 0 41 1 89 EHR
MIPS_EC_110_overall Preventive Care and Screening: Influenza Immunization 24 441 2 85 EHR
MIPS_EC_112_overall Breast Cancer Screening 17 187 1 93 EHR
MIPS_EC_117_overall Diabetes: Eye Exam 4 82 1 100 EHR
MIPS_EC_113_overall Colorectal Cancer Screening 15 298 1 92 EHR
MIPS_EC_130_overall Documentation of Current Medications in the Medical Record 94 1410 4 100 EHR
MIPS_EC_128_overall Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan 16 598 1 98 EHR
MIPS_EC_119_overall Diabetes: Medical Attention for Nephropathy 66 82 3 100 EHR
MIPS_EC_134_overall Preventive Care and Screening: Screening for Depression and Follow-Up Plan 1 520 1 96 EHR
MIPS_EC_226_screenedForUse Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 25 440 EHR
MIPS_EC_239_BMI Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents 75 110 EHR
MIPS_EC_239_nutrition Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents 40 110 EHR
MIPS_EC_236_overall Controlling High Blood Pressure 57 262 EHR
MIPS_EC_238_overall Use of High-Risk Medications in Older Adults 17 224 2 100 EHR
MIPS_EC_239_physicalActivity Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents 42 110 EHR
MIPS_EC_309_overall Cervical Cancer Screening 38 236 2 98 EHR
MIPS_EC_226_tobacco Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 24 440 EHR
MIPS_EC_318_overall Falls: Screening for Future Fall Risk 5 224 1 100 EHR
MIPS_EC_374_overall Closing the Referral Loop: Receipt of Specialist Report 4 144 1 88 EHR
MIPS_EC_317_overall Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented 23 595 2 64 EHR