How do I use the MIPS-Quality Scorecard?

Electronic Clinical Quality Measures (eCQMs) are automatically tracked by RevolutionEHR based on actions a provider takes within the system.

How to Run the MIPS-Quality Scorecard

You can run this report from Reports>Administration>Providers>MIPS - Quality.

Based on your eligibility, run the scorecards with the Provider field set to your name and again with it set to "All Providers".  When run under your name, you are producing "Individual" level data and when run under "All Providers" you are producing "Group" level data.  The level of data that works out best for you statistically is part of considering "how" to report your performance information. See Example

 Video Discussion

Measures

Diabetes: Eye Exam

• Denominator: Patients 18-75 years of age with diabetes and a visit during the performance period.
  • Exclusion: patients who were in Hospice care during the measurement year.
• Numerator: Patients in the denominator who had at least one of the following:
  1. A retinal or dilated eye exam by an eye care professional in the performance period
     • A “retinal or dilated examination” is an encounter where the Fundus test is used to document at least one value
  2. A negative retinal exam (no evidence of retinopathy) by an eye care professional < 12 months prior to the performance period
     • “No evidence of retinopathy” is a Fundus test where both the following are true for both eyes:
     • “Diab Ret Grd ” is “None”; and
     • “DME Y/N” is “N”

Closing the Referral Loop: Receipt of Specialist Report

• Denominator: Number of patients who were both referred by one provider to another during the performance period as documented in the Referrals component and who had a visit during the performance period.
• Numerator: Number of patients in the denominator for whom the referring provider received a report from the provider to whom the patient was referred

Documentation of Current Medications in the Medical Record

• Denominator: All visits occurring during the 12-month performance period for patients aged 18 years and older.
  • An exception is available for medical reasons where the patient is in an urgent or emergent situation where time is of the essence and the delay of treatment would jeopardize the patient’s health status.
• Numerator: Eligible professional attests to documenting, updating or reviewing the patient's current medications using all immediate resources available on the date of the encounter.

Use of High-Risk Medications in the Elderly

• Denominator: Patients 65 years and older who had a visit during the performance period.
  • Exclusion: patients who were in Hospice care during the measurement year.
• Numerator 1: Patients with an order for at least one high-risk medication during the performance period OR an order or at least one high-risk medication with days supply criteria with a cumulative medication duration > 90 days during the performance period.
• Numerator 2: Patients with at least two orders for the same high-risk medication during the performance period OR at least two orders for the same high-risk medication with days supply criteria with a cumulative medication duration > 90 days during the performance period.

Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Surgery

• Denominator: All patients aged 18 years and older who had cataract surgery during but greater than 92 days prior to the end of the performance period as documented within the Surgery History component.
  • Exclusions:
    • Patients with significant ocular conditions that impact the visual outcome of surgery
    • Cataract procedures performed during October 1 – December 31
• Numerator: Patients who had best-corrected visual acuity of 20/40 or better (distance or near) achieved within 90 days following cataract surgery.

Cataracts: Complications within 30 Days Following Cataract Surgery Requiring Additional Surgical Procedures

• Denominator: All patients aged 18 years and older who had cataract surgery during the performance period as documented in the Surgery History component and no significant ocular conditions impacting the surgical complication rate.
  • Exclusion: patients with any one of a specified list of significant ocular conditions that impact the surgical complication rate
• Numerator: Patients who had one or more specified operative procedures for any of the following major complications within 30 days following cataract surgery: retained nuclear fragments, endophthalmitis, dislocated or wrong power IOL, retinal detachment, or wound dehiscence as documented in the Surgery History component.

POAG: Optic Nerve Evaluation

• Denominator: All patients aged 18 years and older with an active diagnosis of primary open-angle glaucoma and one or more office visits during the performance period.
  • An exception is available when a medical reason is provided for not performing an optic nerve head evaluation
• Numerator: Patients who have an optic nerve head evaluation during one or more office visits within the performance period.

Diabetic Retinopathy: Communication with Physician Managing Diabetes Care

• Denominator: All patients aged 18 years and older with an active diagnosis of diabetic retinopathy who had an office visit and dilated macular or fundus exam performed during the performance period.
  • An exception is available when a medical or patient reason is documented for not communicating the findings of the dilated macular or fundus exam to the physician who manages the ongoing care of the patient with diabetes.
• Numerator: Patients with documentation, at least once within the performance period, of the findings of the dilated macular or fundus exam via a communication to the physician who manages the patient's diabetic care.