Dr. Rolf Edward Kirby

Weisbrod Memorial County Hospital NPI1548279532

Performance

Public Reporting for Performance Scores

More Details

Final MIPS Score

88.08 out of 100

Score Breakdown

Quality Category Score 80.92
PI Category Score 0

 

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

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_16 Use of decision support and standardized treatment protocols
MIPS_EC_001_overall Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) 30 56 EHR
MIPS_EC_110_overall Preventive Care and Screening: Influenza Immunization 49 344 3 85 EHR
MIPS_EC_117_overall Diabetes: Eye Exam 7 56 1 100 EHR
MIPS_EC_112_overall Breast Cancer Screening 50 101 3 93 EHR
MIPS_EC_113_overall Colorectal Cancer Screening 38 199 2 92 EHR
MIPS_EC_130_overall Documentation of Current Medications in the Medical Record 95 713 4 100 EHR
MIPS_EC_119_overall Diabetes: Medical Attention for Nephropathy 82 56 4 100 EHR
MIPS_EC_134_overall Preventive Care and Screening: Screening for Depression and Follow-Up Plan 1 327 1 96 EHR
MIPS_EC_317_overall Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented 19 311 2 64 EHR
MIPS_EC_309_overall Cervical Cancer Screening 28 125 2 98 EHR
PI_EC_EP_2 Query of the Prescription Drug Monitoring Program (PDMP)
PI_EC_EP_1 e-Prescribing 90 355 1 100 EHR
PI_EC_ONCDIR_1 ONC Direct Review Attestation
PI_EC_HIE_5 Health Information Exchange(HIE) Bi-Directional Exchange
PI_EC_ONCACB_1 ONC-ACB Surveillance Attestation
PI_EC_PHCDRR_4 Public Health Registry Reporting
PI_EC_PHCDRR_5 Clinical Data Registry Reporting
PI_EC_PEA_1 Provide Patients Electronic Access to Their Health Information 76 598 4 99 EHR
PI_EC_PPHI_1 Security Risk Analysis