Dr. Naveed Hasan

Critical Care Medicine Saint Agnes Hospital NPI1023274511

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: 24
Source of Scores: individual

Performance Details

Measure Code Measure Title Performance Rate Patient Count Star Value Five Star Benchmark Collection Type
IA_EC_BE_13 Regularly assess the patient experience of care through surveys, advisory councils and/or other mechanisms.
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_EPA_5 Participation in User Testing of the Quality Payment Program Website (https://qpp.cms.gov/)
MIPS_EC_001_overall Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) 62 42 EHR
MIPS_EC_110_overall Preventive Care and Screening: Influenza Immunization 37 180 2 85 EHR
MIPS_EC_107_overall Adult Major Depressive Disorder (MDD): Suicide Risk Assessment 0 35 1 89 EHR
MIPS_EC_111_overall Pneumococcal Vaccination Status for Older Adults 35 123 2 98 EHR
MIPS_EC_119_overall Diabetes: Medical Attention for Nephropathy 86 42 4 100 EHR
MIPS_EC_128_overall Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan 22 245 1 98 EHR
MIPS_EC_130_overall Documentation of Current Medications in the Medical Record 99 463 4 100 EHR
MIPS_EC_134_overall Preventive Care and Screening: Screening for Depression and Follow-Up Plan 1 165 1 96 EHR
MIPS_EC_226_screenedForUse Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 91 198 EHR
MIPS_EC_226_tobacco Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 85 198 EHR
MIPS_EC_226_overall Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 58 36 3 100 EHR
MIPS_EC_238_overall Use of High-Risk Medications in Older Adults 0 123 5 100 EHR
MIPS_EC_236_overall Controlling High Blood Pressure 70 115 EHR
MIPS_EC_318_overall Falls: Screening for Future Fall Risk 75 123 4 100 EHR
MIPS_EC_317_overall Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented 29 154 2 64 EHR
PI_EC_EP_1 e-Prescribing 87 237 1 100 EHR
PI_EC_EP_2 Query of the Prescription Drug Monitoring Program (PDMP)
PI_EC_LVITC_2 Support Electronic Referral Loops By Receiving and Reconciling Health Information Exclusion
PI_EC_ONCACB_1 ONC-ACB Surveillance Attestation
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 97 116 4 99 EHR
PI_EC_PHCDRR_4 Public Health Registry Reporting
PI_EC_PHCDRR_3 Electronic Case Reporting
PI_EC_PHCDRR_2_EX_2 Syndromic Surveillance Reporting Exclusion
PI_EC_PPHI_1 Security Risk Analysis
PI_EC_PHCDRR_1 Immunization Registry Reporting