Dr. Thomas Howard Bracken

Mille Lacs Health System NPI1154390227

Performance

Public Reporting for Performance Scores

More Details

Final MIPS Score

100 out of 100

Score Breakdown

Quality Category Score 99.00
PI Category Score 0

 

IA Category Score 40
Cost Category Score 0
Total Patients: 22
Source of Scores: group

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_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_PM_13 Chronic Care and Preventative Care Management for Empaneled Patients
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_PSPA_21 Implementation of fall screening and assessment programs
MIPS_EC_001_overall Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) 34 111 EHR
MIPS_EC_110_overall Preventive Care and Screening: Influenza Immunization 56 336 3 85 EHR
MIPS_EC_107_overall Adult Major Depressive Disorder (MDD): Suicide Risk Assessment 0 110 1 89 EHR
MIPS_EC_112_overall Breast Cancer Screening 52 128 3 93 EHR
MIPS_EC_117_overall Diabetes: Eye Exam 32 111 2 100 EHR
MIPS_EC_119_overall Diabetes: Medical Attention for Nephropathy 90 111 4 100 EHR
MIPS_EC_113_overall Colorectal Cancer Screening 35 389 2 92 EHR
MIPS_EC_128_overall Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan 18 723 1 98 EHR
MIPS_EC_130_overall Documentation of Current Medications in the Medical Record 98 1451 4 100 EHR
MIPS_EC_134_overall Preventive Care and Screening: Screening for Depression and Follow-Up Plan 92 576 4 96 EHR
MIPS_EC_226_screenedForUse Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 75 322 EHR
MIPS_EC_226_tobacco Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 75 322 EHR
MIPS_EC_236_overall Controlling High Blood Pressure 63 313 EHR
MIPS_EC_238_overall Use of High-Risk Medications in Older Adults 5 385 4 100 EHR
MIPS_EC_239_nutrition Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents 0 51 EHR
MIPS_EC_239_physicalActivity Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents 6 51 EHR
MIPS_EC_309_overall Cervical Cancer Screening 34 120 2 98 EHR
MIPS_EC_239_BMI Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents 2 51 EHR
MIPS_EC_317_overall Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented 21 714 2 64 EHR
MIPS_EC_318_overall Falls: Screening for Future Fall Risk 91 385 4 100 EHR
PI_EC_EP_1 e-Prescribing 98 1571 4 100 ATT
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_LVOTC_1 Support Electronic Referral Loops By Sending Health Information Exclusion
PI_EC_ONCACB_1 ONC-ACB Surveillance Attestation
PI_EC_ONCDIR_1 ONC Direct Review Attestation
PI_EC_PEA_1 Provide Patients Electronic Access to Their Health Information 80 349 4 100 ATT
PI_EC_PHCDRR_1 Immunization Registry Reporting
PI_EC_PHCDRR_2_EX_2 Syndromic Surveillance Reporting Exclusion
PI_EC_PPHI_1 Security Risk Analysis