Mrs. Cindy Nicole Burnett

Family St Marys Regional Medical Center NPI1699308544

Performance

Public Reporting for Performance Scores

More Details

Final MIPS Score

94.91 out of 100

Score Breakdown

Quality Category Score 83.43
PI Category Score 100

 

IA Category Score 40
Cost Category Score 0
Total Patients: 39
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
IA_EC_PSPA_6 Consultation of the Prescription Drug Monitoring Program
MIPS_EC_001_overall Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) 22 158 EHR
MIPS_EC_119_overall Diabetes: Medical Attention for Nephropathy 83 158 4 100 EHR
MIPS_EC_130_overall Documentation of Current Medications in the Medical Record 95 2121 4 100 EHR
MIPS_EC_236_overall Controlling High Blood Pressure 64 474 EHR
MIPS_EC_238_overall Use of High-Risk Medications in Older Adults 8 201 3 100 EHR
MIPS_EC_309_overall Cervical Cancer Screening 35 463 2 98 EHR
MIPS_EC_374_overall Closing the Referral Loop: Receipt of Specialist Report 42 306 2 88 EHR
PI_EC_EP_1 e-Prescribing 99 5157 4 100 EHR
PI_EC_EP_2 Query of the Prescription Drug Monitoring Program (PDMP)
PI_EC_ONCACB_1 ONC-ACB Surveillance Attestation
PI_EC_HIE_5 Health Information Exchange(HIE) Bi-Directional Exchange
PI_EC_PEA_1 Provide Patients Electronic Access to Their Health Information 89 2332 4 99 EHR
PI_EC_ONCDIR_1 ONC Direct Review Attestation
PI_EC_PHCDRR_5 Clinical Data Registry Reporting
PI_EC_PHCDRR_4 Public Health Registry Reporting
PI_EC_PPHI_1 Security Risk Analysis