Luann Aquino

Hilton Head Regional Medical Center NPI1659399566

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: 124
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%) 20 116 EHR
MIPS_EC_112_overall Breast Cancer Screening 93 548 5 93 EHR
MIPS_EC_117_overall Diabetes: Eye Exam 63 116 3 100 EHR
MIPS_EC_113_overall Colorectal Cancer Screening 95 811 5 92 EHR
MIPS_EC_128_overall Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan 76 1410 4 98 EHR
MIPS_EC_119_overall Diabetes: Medical Attention for Nephropathy 93 116 4 100 EHR
MIPS_EC_130_overall Documentation of Current Medications in the Medical Record 97 3519 4 100 EHR
MIPS_EC_134_overall Preventive Care and Screening: Screening for Depression and Follow-Up Plan 98 1111 5 96 EHR
MIPS_EC_226_overall Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 83 42 4 100 EHR
MIPS_EC_226_screenedForUse Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 99 1310 EHR
MIPS_EC_317_overall Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented 30 1267 2 64 EHR
MIPS_EC_226_tobacco Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 99 1310 EHR
MIPS_EC_236_overall Controlling High Blood Pressure 70 845 EHR
PI_EC_EP_1 e-Prescribing 99 8451 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_ONCDIR_1 ONC Direct Review Attestation
PI_EC_PEA_1 Provide Patients Electronic Access to Their Health Information 91 1428 4 99 EHR
PI_EC_PHCDRR_5 Clinical Data Registry Reporting
PI_EC_PHCDRR_4 Public Health Registry Reporting
PI_EC_PPHI_1 Security Risk Analysis