Cecilia M Vicuna Keady

Valley Regional Hospital NPI1558334656

Performance

Public Reporting for Performance Scores

More Details

Final MIPS Score

100 out of 100

Score Breakdown

Quality Category Score 100
PI Category Score 0

 

IA Category Score 40
Cost Category Score 0
Total Patients: 61
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_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%) 27 265 EHR
MIPS_EC_110_overall Preventive Care and Screening: Influenza Immunization 44 1416 3 85 EHR
MIPS_EC_113_overall Colorectal Cancer Screening 67 867 3 92 EHR
MIPS_EC_117_overall Diabetes: Eye Exam 28 265 2 100 EHR
MIPS_EC_112_overall Breast Cancer Screening 73 529 4 93 EHR
MIPS_EC_130_overall Documentation of Current Medications in the Medical Record 93 6977 4 100 EHR
MIPS_EC_128_overall Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan 21 1603 1 98 EHR
MIPS_EC_226_overall Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 54 50 3 100 EHR
MIPS_EC_226_screenedForUse Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 14 1620 EHR
MIPS_EC_236_overall Controlling High Blood Pressure 55 744 EHR
MIPS_EC_226_tobacco Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 13 1619 EHR
MIPS_EC_239_nutrition Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents 38 159 EHR
MIPS_EC_239_physicalActivity Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents 42 159 EHR
MIPS_EC_309_overall Cervical Cancer Screening 58 797 3 98 EHR
MIPS_EC_374_overall Closing the Referral Loop: Receipt of Specialist Report 44 532 3 88 EHR
MIPS_EC_239_BMI Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents 78 159 EHR
MIPS_EC_317_overall Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented 31 3082 2 64 EHR
MIPS_EC_370_18+ Depression Remission at Twelve Months 12 65 EHR