Leslie M. Golden

Watertown Memorial Hospital NPI1336401736

Performance

Public Reporting for Performance Scores

More Details

Final MIPS Score

100 out of 100

Score Breakdown

Quality Category Score 100
PI Category Score 0

 

IA Category Score 40
Cost Category Score 0
Total Patients: 38
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
IA_EC_PSPA_18 Measurement and Improvement at the Practice and Panel Level
MIPS_EC_001_overall Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) 21 154 EHR
MIPS_EC_107_overall Adult Major Depressive Disorder (MDD): Suicide Risk Assessment 1 228 1 89 EHR
MIPS_EC_110_overall Preventive Care and Screening: Influenza Immunization 36 1134 2 85 EHR
MIPS_EC_113_overall Colorectal Cancer Screening 62 636 3 92 EHR
MIPS_EC_119_overall Diabetes: Medical Attention for Nephropathy 94 154 4 100 EHR
MIPS_EC_128_overall Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan 21 1132 1 98 EHR
MIPS_EC_117_overall Diabetes: Eye Exam 42 154 2 100 EHR
MIPS_EC_112_overall Breast Cancer Screening 64 411 3 93 EHR
MIPS_EC_130_overall Documentation of Current Medications in the Medical Record 96 2887 4 100 EHR
MIPS_EC_134_overall Preventive Care and Screening: Screening for Depression and Follow-Up Plan 54 1086 3 96 EHR
MIPS_EC_226_overall Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 37 132 2 100 EHR
MIPS_EC_236_overall Controlling High Blood Pressure 78 482 EHR
MIPS_EC_226_screenedForUse Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 82 1231 EHR
MIPS_EC_238_overall Use of High-Risk Medications in Older Adults 5 374 4 100 EHR
MIPS_EC_309_overall Cervical Cancer Screening 42 608 2 98 EHR
MIPS_EC_226_tobacco Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 75 1231 EHR
MIPS_EC_318_overall Falls: Screening for Future Fall Risk 59 374 3 100 EHR
MIPS_EC_317_overall Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented 41 1545 3 64 EHR
MIPS_EC_374_overall Closing the Referral Loop: Receipt of Specialist Report 36 443 2 88 EHR