Thuy-Trang Pham

Foot & Ankle Surgery St John's Episcopal Hospital At South Shore NPI1760839658

Performance

Public Reporting for Performance Scores

More Details

Final MIPS Score

97.30 out of 100

Score Breakdown

Quality Category Score 88.38
PI Category Score 79

 

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_2 Tobacco use
IA_EC_BMH_4 Depression screening
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
IA_EC_PSPA_21 Implementation of fall screening and assessment programs
MIPS_EC_001_overall Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) 69 131 EHR
MIPS_EC_110_overall Preventive Care and Screening: Influenza Immunization 30 164 2 85 EHR
MIPS_EC_112_overall Breast Cancer Screening 26 72 2 93 EHR
MIPS_EC_117_overall Diabetes: Eye Exam 2 131 1 100 EHR
MIPS_EC_119_overall Diabetes: Medical Attention for Nephropathy 88 131 4 100 EHR
MIPS_EC_130_overall Documentation of Current Medications in the Medical Record 85 685 3 100 EHR
MIPS_EC_128_overall Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan 24 288 1 98 EHR
MIPS_EC_134_overall Preventive Care and Screening: Screening for Depression and Follow-Up Plan 18 255 1 96 EHR
MIPS_EC_226_screenedForUse Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 36 283 EHR
MIPS_EC_226_tobacco Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 35 283 EHR
MIPS_EC_236_overall Controlling High Blood Pressure 43 143 EHR
MIPS_EC_238_overall Use of High-Risk Medications in Older Adults 1 118 4 100 EHR
MIPS_EC_309_overall Cervical Cancer Screening 25 85 2 98 EHR
MIPS_EC_318_overall Falls: Screening for Future Fall Risk 14 118 1 100 EHR
MIPS_EC_374_overall Closing the Referral Loop: Receipt of Specialist Report 3 35 1 88 EHR
PI_EC_EP_1 e-Prescribing 90 101 1 100 EHR
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 34 328 2 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