Mrs. Carla Canavire Weber

North Shore University Hospital NPI1578632899

Performance

Public Reporting for Performance Scores

More Details

Final MIPS Score

100 out of 100

Score Breakdown

Quality Category Score 100
PI Category Score 68

 

IA Category Score 40
Cost Category Score 0
Total Patients: 57
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_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%) 43 1085 EHR
MIPS_EC_110_overall Preventive Care and Screening: Influenza Immunization 13 3725 1 85 EHR
MIPS_EC_107_overall Adult Major Depressive Disorder (MDD): Suicide Risk Assessment 0 206 1 89 EHR
MIPS_EC_119_overall Diabetes: Medical Attention for Nephropathy 84 1085 4 100 EHR
MIPS_EC_112_overall Breast Cancer Screening 69 1331 3 93 EHR
MIPS_EC_113_overall Colorectal Cancer Screening 26 2396 2 92 EHR
MIPS_EC_117_overall Diabetes: Eye Exam 4 1085 1 100 EHR
MIPS_EC_128_overall Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan 55 5798 3 98 EHR
MIPS_EC_130_overall Documentation of Current Medications in the Medical Record 94 17933 4 100 EHR
MIPS_EC_134_overall Preventive Care and Screening: Screening for Depression and Follow-Up Plan 56 5461 3 96 EHR
MIPS_EC_226_screenedForUse Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 46 5081 EHR
MIPS_EC_226_tobacco Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 45 5081 EHR
MIPS_EC_226_overall Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 66 144 3 100 EHR
MIPS_EC_238_overall Use of High-Risk Medications in Older Adults 14 965 2 100 EHR
MIPS_EC_317_overall Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented 48 10721 4 64 EHR
MIPS_EC_236_overall Controlling High Blood Pressure 74 2226 EHR
MIPS_EC_239_BMI Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents 100 294 EHR
MIPS_EC_239_nutrition Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents 86 294 EHR
MIPS_EC_239_physicalActivity Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents 83 294 EHR
MIPS_EC_309_overall Cervical Cancer Screening 65 2682 3 98 EHR
PI_EC_EP_1 e-Prescribing 100 22811 5 100 EHR
MIPS_EC_374_overall Closing the Referral Loop: Receipt of Specialist Report 17 1311 1 88 EHR
MIPS_EC_318_overall Falls: Screening for Future Fall Risk 7 965 1 100 EHR
MIPS_EC_370_18+ Depression Remission at Twelve Months 12 25 EHR
PI_EC_HIE_5 Health Information Exchange(HIE) Bi-Directional Exchange
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 19 6205 1 99 EHR
PI_EC_PHCDRR_5 Clinical Data Registry Reporting
PI_EC_PHCDRR_4 Public Health Registry Reporting
PI_EC_PPHI_1 Security Risk Analysis