Mrs. Lacy Bruster

Sacred Heart Hospital NPI1508233156

Performance

Public Reporting for Performance Scores

More Details

Final MIPS Score

100 out of 100

Score Breakdown

Quality Category Score 95.96
PI Category Score 99

 

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_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%) 41 32 EHR
MIPS_EC_047_overall Advance Care Plan 69 139 3 100 REG
MIPS_EC_110_overall Preventive Care and Screening: Influenza Immunization 34 280 2 85 EHR
MIPS_EC_112_overall Breast Cancer Screening 35 129 2 93 EHR
MIPS_EC_117_overall Diabetes: Eye Exam 16 32 1 100 EHR
MIPS_EC_113_overall Colorectal Cancer Screening 37 232 2 92 EHR
MIPS_EC_128_overall Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan 35 632 2 98 EHR
MIPS_EC_236_overall Controlling High Blood Pressure 62 132 EHR
MIPS_EC_309_overall Cervical Cancer Screening 24 240 1 98 EHR
MIPS_EC_317_overall Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented 32 514 3 64 EHR
MIPS_EC_331_overall Adult Sinusitis: Antibiotic Prescribed for Acute Viral Sinusitis (Overuse) 97 65 1 100 REG
PI_EC_EP_1 e-Prescribing 90 756 1 100 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_PHCDRR_4 Public Health Registry Reporting
PI_EC_PEA_1 Provide Patients Electronic Access to Their Health Information 75 891 4 99 EHR
PI_EC_PPHI_1 Security Risk Analysis
PI_EC_PHCDRR_5 Clinical Data Registry Reporting