Pejman Kharazi

Saint Mary's Regional Medical Center NPI1669763488

Performance

Public Reporting for Performance Scores

More Details

Final MIPS Score

89.52 out of 100

Score Breakdown

Quality Category Score 100
PI Category Score 55

 

IA Category Score 0
Cost Category Score 0
Total Patients: 36
Source of Scores: individual

Performance Details

Measure Code Measure Title Performance Rate Patient Count Star Value Five Star Benchmark Collection Type
MIPS_EC_001_overall Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) 35 233 EHR
MIPS_EC_128_overall Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan 30 1406 2 98 EHR
MIPS_EC_226_overall Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 63 167 3 100 EHR
MIPS_EC_130_overall Documentation of Current Medications in the Medical Record 99 3407 4 100 EHR
MIPS_EC_226_screenedForUse Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 75 961 EHR
MIPS_EC_226_tobacco Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 69 961 EHR
MIPS_EC_236_overall Controlling High Blood Pressure 66 387 EHR
MIPS_EC_317_overall Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented 25 2648 2 64 EHR
PI_EC_EP_1 e-Prescribing 92 7763 3 100 ATT
PI_EC_LVITC_2 Support Electronic Referral Loops By Receiving and Reconciling Health Information Exclusion
PI_EC_EP_2 Query of the Prescription Drug Monitoring Program (PDMP)
PI_EC_HIE_1 Support Electronic Referral Loops By Sending Health Information 1 124 1 100 ATT
PI_EC_ONCACB_1 ONC-ACB Surveillance Attestation
PI_EC_PEA_1 Provide Patients Electronic Access to Their Health Information 64 1697 3 100 ATT
PI_EC_PHCDRR_1 Immunization Registry Reporting
PI_EC_ONCDIR_1 ONC Direct Review Attestation
PI_EC_PHCDRR_2_EX_3 Syndromic Surveillance Reporting Exclusion
PI_EC_PHCDRR_3_EX_3 Electronic Case Reporting Exclusion
PI_EC_PHCDRR_4_EX_3 Public Health Registry Reporting Exclusion
PI_EC_PPHI_1 Security Risk Analysis
PI_EC_PHCDRR_5_EX_3 Clinical Data Registry Reporting Exclusion