Saundra Rae Anderson

Yoakum Community Hospital NPI1861553067

Performance

Public Reporting for Performance Scores

More Details

Final MIPS Score

100 out of 100

Score Breakdown

Quality Category Score 100
PI Category Score 97

 

IA Category Score 40
Cost Category Score 0
Total Patients: 56
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_2 Tobacco use
IA_EC_BMH_5 MDD prevention and treatment interventions
IA_EC_BMH_4 Depression screening
IA_EC_PM_16 Implementation of medication management practice improvements
IA_EC_PSPA_16 Use of decision support and standardized treatment protocols
IA_EC_PSPA_18 Measurement and Improvement at the Practice and Panel Level
MIPS_EC_001_overall Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) 33 208 EHR
IA_EC_PSPA_21 Implementation of fall screening and assessment programs
MIPS_EC_110_overall Preventive Care and Screening: Influenza Immunization 34 1583 2 85 EHR
MIPS_EC_047_overall Advance Care Plan 92 449 4 100 REG
MIPS_EC_112_overall Breast Cancer Screening 64 434 3 93 EHR
MIPS_EC_117_overall Diabetes: Eye Exam 22 208 1 100 EHR
MIPS_EC_113_overall Colorectal Cancer Screening 64 688 3 92 EHR
MIPS_EC_119_overall Diabetes: Medical Attention for Nephropathy 82 208 4 100 EHR
MIPS_EC_134_overall Preventive Care and Screening: Screening for Depression and Follow-Up Plan 26 1324 2 96 EHR
MIPS_EC_130_overall Documentation of Current Medications in the Medical Record 99 3317 4 100 EHR
MIPS_EC_226_screenedForUse Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 99 1287 EHR
MIPS_EC_236_overall Controlling High Blood Pressure 52 751 EHR
MIPS_EC_226_overall Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 60 149 3 100 EHR
MIPS_EC_226_tobacco Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 94 1287 EHR
MIPS_EC_309_overall Cervical Cancer Screening 43 609 2 98 EHR
MIPS_EC_317_overall Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented 33 1603 3 64 EHR
MIPS_EC_318_overall Falls: Screening for Future Fall Risk 19 436 1 100 EHR
PI_EC_HIE_1 Support Electronic Referral Loops By Sending Health Information 41 172 2 100 ATT
PI_EC_EP_1 e-Prescribing 96 1427 4 100 ATT
PI_EC_EP_2 Query of the Prescription Drug Monitoring Program (PDMP)
PI_EC_ONCACB_1 ONC-ACB Surveillance Attestation
PI_EC_ONCDIR_1 ONC Direct Review Attestation
PI_EC_PHCDRR_4 Public Health Registry Reporting
PI_EC_PHCDRR_4_MULTI Public Health Registry Reporting for Multiple Registry Engagement
PI_EC_PEA_1 Provide Patients Electronic Access to Their Health Information 97 775 4 100 ATT
PI_EC_PHCDRR_2_EX_3 Syndromic Surveillance Reporting Exclusion
PI_EC_PPHI_1 Security Risk Analysis