David Robert Downey

South Peninsula Hospital NPI1306882360

Performance

Public Reporting for Performance Scores

More Details

Final MIPS Score

100 out of 100

Score Breakdown

Quality Category Score 98.02
PI Category Score 100

 

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_039_overall Screening for Osteoporosis for Women Aged 65-85 Years of Age 58 57 3 100 REG
MIPS_EC_047_overall Advance Care Plan 73 106 3 100 REG
MIPS_EC_112_overall Breast Cancer Screening 49 107 3 93 EHR
MIPS_EC_113_overall Colorectal Cancer Screening 57 155 3 92 EHR
MIPS_EC_128_overall Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan 49 226 3 98 EHR
MIPS_EC_130_overall Documentation of Current Medications in the Medical Record 97 818 4 100 EHR
MIPS_EC_134_overall Preventive Care and Screening: Screening for Depression and Follow-Up Plan 20 251 1 96 EHR
MIPS_EC_226_screenedForUse Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 87 285 EHR
MIPS_EC_226_tobacco Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 86 285 EHR
MIPS_EC_309_overall Cervical Cancer Screening 44 160 2 98 EHR
MIPS_EC_317_overall Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented 39 389 3 64 EHR
MIPS_EC_318_overall Falls: Screening for Future Fall Risk 24 96 1 100 EHR
MIPS_EC_374_overall Closing the Referral Loop: Receipt of Specialist Report 37 63 2 88 EHR
PI_EC_HIE_5 Health Information Exchange(HIE) Bi-Directional Exchange
PI_EC_EP_1 e-Prescribing 96 561 3 100 EHR
PI_EC_ONCACB_1 ONC-ACB Surveillance Attestation
PI_EC_PHCDRR_4 Public Health Registry Reporting
PI_EC_ONCDIR_1 ONC Direct Review Attestation
PI_EC_PEA_1 Provide Patients Electronic Access to Their Health Information 99 355 5 99 EHR
PI_EC_PHCDRR_5 Clinical Data Registry Reporting
PI_EC_PPHI_1 Security Risk Analysis