Dr. Thomas M Facelle

Centura Health-St Anthony Hospital NPI1114227501

Performance

Public Reporting for Performance Scores

More Details

Final MIPS Score

100 out of 100

Score Breakdown

Quality Category Score 100
PI Category Score 100

 

IA Category Score 40
Cost Category Score 0
Total Patients: 111
Source of Scores: individual

Performance Details

Measure Code Measure Title Performance Rate Patient Count Star Value Five Star Benchmark Collection Type
IA_EC_AHE_1 Engagement of New Medicaid Patients and Follow-up
IA_EC_BE_22 Improved Practices that Engage Patients Pre-Visit
IA_EC_EPA_3 Collection and use of patient experience and satisfaction data on access
MIPS_EC_001_overall Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) 100 30 EHR
MIPS_EC_111_overall Pneumococcal Vaccination Status for Older Adults 90 509 4 98 EHR
MIPS_EC_112_overall Breast Cancer Screening 86 51 4 93 EHR
MIPS_EC_113_overall Colorectal Cancer Screening 91 552 4 92 EHR
MIPS_EC_128_overall Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan 27 993 2 98 EHR
MIPS_EC_119_overall Diabetes: Medical Attention for Nephropathy 93 30 4 100 EHR
MIPS_EC_130_overall Documentation of Current Medications in the Medical Record 97 1571 4 100 EHR
MIPS_EC_236_overall Controlling High Blood Pressure 49 106 EHR
MIPS_EC_309_overall Cervical Cancer Screening 87 39 4 98 EHR
PI_EC_EP_1 e-Prescribing 97 236 4 100 EHR
PI_EC_LVOTC_1 Support Electronic Referral Loops By Sending Health Information Exclusion
PI_EC_EP_2 Query of the Prescription Drug Monitoring Program (PDMP)
PI_EC_ONCACB_1 ONC-ACB Surveillance Attestation
PI_EC_ONCDIR_1 ONC Direct Review Attestation
PI_EC_PHCDRR_2_EX_1 Syndromic Surveillance Reporting Exclusion
PI_EC_PEA_1 Provide Patients Electronic Access to Their Health Information 96 351 4 99 EHR
PI_EC_PHCDRR_1_EX_1 Immunization Registry Reporting Exclusion
PI_EC_PPHI_1 Security Risk Analysis
PI_EC_PHCDRR_5 Clinical Data Registry Reporting