Dr. Patti Jean Hook

Mille Lacs Health System NPI1548220940

Performance

Public Reporting for Performance Scores

More Details

Final MIPS Score

100 out of 100

Score Breakdown

Quality Category Score 100
PI Category Score 98

 

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

Performance Details

Measure Code Measure Title Performance Rate Patient Count Star Value Five Star Benchmark Collection Type
IA_EC_BE_19 Use group visits for common chronic conditions (e.g., diabetes).
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_PM_13 Chronic Care and Preventative Care Management for Empaneled Patients
IA_EC_CC_12 Care coordination agreements that promote improvements in patient tracking across settings
IA_EC_PM_16 Implementation of medication management practice improvements
IA_EC_PSPA_21 Implementation of fall screening and assessment programs
MIPS_EC_001_overall Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) 20 41 EHR
MIPS_EC_107_overall Adult Major Depressive Disorder (MDD): Suicide Risk Assessment 0 97 1 89 EHR
MIPS_EC_110_overall Preventive Care and Screening: Influenza Immunization 56 175 3 85 EHR
MIPS_EC_112_overall Breast Cancer Screening 70 97 4 93 EHR
MIPS_EC_113_overall Colorectal Cancer Screening 33 135 2 92 EHR
MIPS_EC_117_overall Diabetes: Eye Exam 41 41 2 100 EHR
MIPS_EC_128_overall Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan 22 290 1 98 EHR
MIPS_EC_119_overall Diabetes: Medical Attention for Nephropathy 88 41 4 100 EHR
MIPS_EC_134_overall Preventive Care and Screening: Screening for Depression and Follow-Up Plan 85 198 4 96 EHR
MIPS_EC_130_overall Documentation of Current Medications in the Medical Record 90 671 4 100 EHR
MIPS_EC_226_screenedForUse Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 81 189 EHR
MIPS_EC_226_tobacco Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 81 189 EHR
MIPS_EC_236_overall Controlling High Blood Pressure 73 120 EHR
MIPS_EC_317_overall Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented 24 283 2 64 EHR
MIPS_EC_309_overall Cervical Cancer Screening 56 94 3 98 EHR
MIPS_EC_238_overall Use of High-Risk Medications in Older Adults 8 161 3 100 EHR
MIPS_EC_318_overall Falls: Screening for Future Fall Risk 88 161 4 100 EHR
PI_EC_EP_2 Query of the Prescription Drug Monitoring Program (PDMP)
PI_EC_EP_1 e-Prescribing 99 1034 4 100 ATT
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 85 163 4 100 ATT
PI_EC_PHCDRR_2_EX_2 Syndromic Surveillance Reporting Exclusion
PI_EC_PHCDRR_1 Immunization Registry Reporting
PI_EC_PPHI_1 Security Risk Analysis