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Dr. Kelly Lynn Abate

Elmhurst Memorial Hospital NPI1528141116
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Performance

Public Reporting for Performance Scores

More Details

Final MIPS Score

69.89 out of 100

Score Breakdown

Quality Category Score 78.05
PI Category Score 34

 

IA Category Score 40
Cost Category Score 0
Total Patients: 128
Source of Scores: individual

Performance Details

Measure Code Measure Title Performance Rate Patient Count Star Value Five Star Benchmark Collection Type
IA_EC_BE_18 Provide peer-led support for self-management.
IA_EC_BE_21 Improved Practices that Disseminate Appropriate Self-Management Materials
IA_EC_BE_12 Use evidence-based decision aids to support shared decision-making.
IA_EC_BMH_2 Tobacco use
IA_EC_CC_11 Care transition standard operational improvements
IA_EC_CC_2 Implementation of improvements that contribute to more timely communication of test results
IA_EC_EPA_1 Provide 24/7 Access to MIPS Eligible Clinicians or Groups Who Have Real-Time Access to Patient's Medical Record
IA_EC_CC_12 Care coordination agreements that promote improvements in patient tracking across settings
IA_EC_CC_8 Implementation of documentation improvements for practice/process improvements
IA_EC_CC_1 Implementation of Use of Specialist Reports Back to Referring Clinician or Group to Close Referral Loop
IA_EC_CC_7 Regular training in care coordination
IA_EC_EPA_2 Use of telehealth services that expand practice access
IA_EC_EPA_5 Participation in User Testing of the Quality Payment Program Website (https://qpp.cms.gov/)
IA_EC_PSPA_2 Participation in MOC Part IV
IA_EC_PSPA_12 Participation in private payer CPIA
IA_EC_PSPA_20 Leadership engagement in regular guidance and demonstrated commitment for implementing practice improvement changes
IA_EC_PSPA_6 Consultation of the Prescription Drug Monitoring Program
IA_EC_PSPA_4 Administration of the AHRQ Survey of Patient Safety Culture
MIPS_EC_110_overall Preventive Care and Screening: Influenza Immunization 39 898 2 100 REG
MIPS_EC_111_overall Pneumococcal Vaccination Status for Older Adults 74 416 4 99 REG
MIPS_EC_137_overall Melanoma: Continuity of Care Recall System 55 55 REG
MIPS_EC_130_overall Documentation of Current Medications in the Medical Record 53 2013 1 100 REG
MIPS_EC_265_overall Biopsy Follow-Up 100 23 REG
PI_EC_EP_2 Query of the Prescription Drug Monitoring Program (PDMP)
PI_EC_EP_1 e-Prescribing 100 2128 5 100 REG
PI_EC_LVITC_2 Support Electronic Referral Loops By Receiving and Reconciling Health Information Exclusion
PI_EC_LVOTC_1 Support Electronic Referral Loops By Sending Health Information Exclusion
PI_EC_ONCDIR_1 ONC Direct Review Attestation
PI_EC_PEA_1 Provide Patients Electronic Access to Their Health Information 5 1375 1 100 REG
PI_EC_PPHI_1 Security Risk Analysis
PI_EC_PHCDRR_5 Clinical Data Registry Reporting
PI_EC_PHCDRR_5_MULTI Clinical Data Registry Reporting for Multiple Registry Engagement