Ryan Bergeson

Ascension Seton Williamson NPI1154460152

Performance

Public Reporting for Performance Scores

More Details

Final MIPS Score

95.38 out of 100

Score Breakdown

Quality Category Score 92.51
PI Category Score 90

 

IA Category Score 40
Cost Category Score 0
Total Patients: 13
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_18 Measurement and Improvement at the Practice and Panel Level
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%) 54 68 EHR
MIPS_EC_110_overall Preventive Care and Screening: Influenza Immunization 16 492 1 85 EHR
MIPS_EC_047_overall Advance Care Plan 22 463 1 100 REG
MIPS_EC_112_overall Breast Cancer Screening 20 255 1 93 EHR
MIPS_EC_117_overall Diabetes: Eye Exam 9 68 1 100 EHR
MIPS_EC_119_overall Diabetes: Medical Attention for Nephropathy 82 68 4 100 EHR
MIPS_EC_113_overall Colorectal Cancer Screening 23 497 2 92 EHR
MIPS_EC_130_overall Documentation of Current Medications in the Medical Record 99 1631 4 100 EHR
MIPS_EC_128_overall Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan 22 847 1 98 EHR
MIPS_EC_134_overall Preventive Care and Screening: Screening for Depression and Follow-Up Plan 92 800 4 96 EHR
MIPS_EC_226_overall Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 58 59 3 100 EHR
MIPS_EC_226_screenedForUse Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 99 652 EHR
MIPS_EC_226_tobacco Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 95 652 EHR
MIPS_EC_238_overall Use of High-Risk Medications in Older Adults 3 458 4 100 EHR
MIPS_EC_236_overall Controlling High Blood Pressure 55 216 EHR
MIPS_EC_309_overall Cervical Cancer Screening 7 182 1 98 EHR
MIPS_EC_317_overall Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented 12 1290 1 64 EHR
MIPS_EC_318_overall Falls: Screening for Future Fall Risk 12 458 1 100 EHR
MIPS_EC_374_overall Closing the Referral Loop: Receipt of Specialist Report 35 390 2 88 EHR
PI_EC_LVPP_1 e-Prescribing Exclusion
PI_EC_HIE_5 Health Information Exchange(HIE) Bi-Directional Exchange
PI_EC_ONCACB_1 ONC-ACB Surveillance Attestation
PI_EC_PEA_1 Provide Patients Electronic Access to Their Health Information 75 885 4 99 EHR
PI_EC_ONCDIR_1 ONC Direct Review Attestation
PI_EC_PHCDRR_4 Public Health Registry Reporting
PI_EC_PHCDRR_5 Clinical Data Registry Reporting
PI_EC_PPHI_1 Security Risk Analysis