Others titles

  • Advancing Care Information and Cost
  • MIPS Data Validation and Auditing 2017
  • MIPS Data Validation and Auditing 2018
  • MIPS Data Validation and Auditing 2019
  • MIPS Data Validation and Auditing 2020

Keywords

  • Data Validation and Auditing
  • Data Validation Criteria
  • Improvement Activities

MIPS Data Validation Criteria

This dataset includes the MIPS Data Validation Criteria. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) streamlines a patchwork collection of programs with a single system where provider can be rewarded for better care. Providers will be able to practice as they always have, but they may receive higher Medicare payments based on their performance.

Log in to download
Complexity

Get The Data

For getting access to data download links please read and accept the end-user license agreement.
Your Data License
  • Research
    Non-Commercial, Share-Alike, Attribution Free Forever
  • Commercial
    Commercial Use, Remix & Adapt, White Label Log in to download

John Snow Labs Standard End User License Agreement

Last updated:January 20, 2021

This Data Library End User License Agreement (“EULA”) applies to academic researchers, educators, and students using any product of John Snow Labs in John Snow Labs’ Data Library as defined below (hereinafter referred to “you”). This EULA is between you and John Snow Labs Inc., a Delaware corporation (“John Snow Labs”, “we” or “us”).

By downloading and/or using (as applicable) Data Library of John Snow Labs (as defined below), you automatically agree to be bound by, and use it in compliance with, this EULA. This EULA, together with additional terms and conditions and/or policies referenced herein or located on https://www.johnsnowlabs.com and/or conveyed to you by John Snow Labs, is a legally binding contract between you and John Snow Labs.

PLEASE READ THIS EULA CAREFULLY BEFORE DOWNLOADING OR USING DATA LIBRARY.

We may make changes to this EULA from time to time. When we do so, we will revise the “last updated” date given above. The then-current version of this EULA will supersede all earlier versions. You agree that your continued use of Data Library after such changes have been published to our EULA will constitute your acceptance of such revised EULA.

Definitions

“Data Library” means a data library provided by John Snow Labs and located at https://www.johnsnowlabs.com/marketplace/;

“Website” means https://www.johnsnowlabs.com being owned and operated by John Snow Labs.

Important Notice

By downloading and using any product from the Data Library, you acknowledge that the use of Data Library can be subject to the restrictions and controls imposed by United States export regulations.

You represent and warrant that you do not intend to use Data Library for any purpose prohibited by United States export regulations, including, without limitation, terrorism, cyber-attacks, cyber-crimes, money-laundering, industrial espionage, or nuclear, chemical or biological weapons proliferation. Further, you represent and warrant that you are not listed as a denied party on any list governing United States exports.

Eligibility

Our Data Library can be used by an individual.

In the event you have entered into a separate written agreement with John Snow Labs regarding Data Library that contemplates terms that are inconsistent with this EULA, the written agreement shall control and this EULA will not apply to you to the extent inconsistent with such written agreement, or, if such written agreement is contemplated to be in lieu of this EULA, then this EULA shall not apply at all

License Granted

Subject to your compliance with this EULA, as well as any other applicable policies, John Snow Labs grants you non-exclusive, non-transferable, revocable, license to download, access to, modify, and use of, Data Library worldwide (subject to applicable export laws) during the term of this EULA (as described below) under the following conditions:

  • The license can be used solely for research, private study and personal use of Data Library for unlimited period, or unless terminated under this EULA.were made;
  • This license is personal to you and is limited by all terms and conditions set forth in this EULA;
  • The license is granted as a non-commercial, attribution, share-alike and no-derivate-work license as more detailed below;
  • Under the attribution license, you must give the appropriate name of the creator and a copyright notice of John Snow Labs, provide link to this license and indicate if changes
  • Under the share-alike license, you can distribute modified works only under a license identical to this EULA;
  • Under the no-derivate-work license, you can perform only verbatim copies of Data Library, not derivate works or remixes based on it;
  • If the license is used for academic research purpose, the publication shall be made under the open-access, open-source and open-data license.

You can download any dataset from the Data Library from the Website.

Except for your pre-existing rights and this license granted to you, we and our licensors retain all rights, titles and interests in and to our Data Library, all related intellectual property rights, including trademarks (whether registered or pending), domain and business names. Our Data Library is protected by applicable intellectual property laws, including United States copyright law and international treaties.

John Snow Labs is entitled to revoke the license granted at any time at its sole discretion.

License Restrictions

You will be deemed to have taken any action that you permit, assist or facilitate any person or entity to take related to this EULA, your content or use of Data Library. You are responsible for end users’ use of your content and Data Library. You will ensure that all end users comply with your obligations under this EULA and that the terms of your agreement with each end user are consistent with this EULA. If you become aware of any violation of your obligations under this EULA caused by an end user, you will immediately suspend access to your content and Data Library by such end user.

License Restrictions

You will access or use our Data Library solely via John Snow Labs’ Data Library.

Except as otherwise explicitly provided in this EULA or as may be expressly permitted by applicable law, you will not, and will not permit or authorize any third party to:

  1. you cannot reproduce, translate, enhance, decompile, disassemble, reverse engineer or create derivative works of Data Library or its technological features or measures;
  2. you cannot rent, lease, sell, resell, loan, distribute, or sublicense access to any of Data Library;
  3. you cannot circumvent or disable any security or technological features or measures of Data Library;
  4. you cannot use our intellectual property rights without our express prior written authorization or in violation of this EULA;
  5. you cannot use Data Library with an intent to build a competitive product or service, or copy or substantially copy any ideas, features, functions, organization, structure, application program interface, graphics, or user interface of Data Library;
  6. you cannot copy, distribute, or resell any of the information; audio, visual, and audiovisual works, or other content made available on Data Library (collectively, “Content”) or compile or collect any Content as part of a database or other work;
  7. you cannot use any automated tool (e.g., robots, spiders) to access or use Data Library, or to store, copy, modify, distribute, or resell any Content;
  8. you cannot circumvent or disable any rights management, usage rules, or other security features of Data Library;
  9. you cannot use Data Library in a manner that overburdens, or that threatens the integrity, performance, or availability of, Data Library; or
  10. you cannot remove, alter, or obscure any proprietary notices (including copyright and trademark notices) on any portion of Data Library or any Content.

If you breach any of this EULA, the above license will terminate automatically.

Fees and Taxes

This license is for non-commercial use. If you wish to use our Data Library for commercial use, please contact us at support@JohnSnowLabs.com.

Support and Updates

Under this EULA, support services are excluded.

From time to time John Snow Labs can perform updates to our software. If available, such updates may include bug fixes, new features and/or enhancements. You are solely responsible for deploying such updates at your own risk and liability.

Term and Termination

This EULA will become effective as of the date of your order of Data Library and shall be in effect until terminated.

John Snow Labs may suspend or terminate your right to use Data Library, if you or your end user’s use of Data Library:

  1. is in breach of this EULA;
  2. poses a security risk to Data Library;
  3. could adversely impact our systems, Data Library or other customers;
  4. could subject us, our affiliates, or any third party to liability; or
  5. could be fraudulent.

We may also suspend or terminate your right to use Data Library, if you have ceased to operate in the ordinary course, made an assignment for the benefit of creditors or similar disposition of your assets, or become the subject of any bankruptcy, reorganization, liquidation, dissolution or similar proceeding.

You will cease use of Data Library during any period of suspension, or upon termination of this EULA.

All provisions which by their nature are intended to survive termination shall survive termination of this EULA.

Access to Data Library

We do not provide you with the equipment to access Data Library. You are responsible for all fees charged by third parties related to your access and use of Data Library (e.g., charges by Internet service providers).

You are responsible for monitoring your use of Data Library, including payment of all fees and/or taxes related to such access and use. You agree that John Snow Labs is permitted to request and you hereby consent to provide John Snow Labs information related to your use of Data Library for auditing purposes.

You also certify that you are legally permitted to use Data Library, and take full responsibility for the selection and use of Data Library. This EULA is void where prohibited by law, and the right to use Data Library is revoked in such jurisdictions. John Snow Labs makes no claim that Data Library may be lawfully used outside of the United States. If you use Data Library from outside of the United States, you do so at your own risk and you are responsible for compliance with the laws of jurisdiction.

Privacy Policy

We may collect, store and receive personal and other information about you through our Products. Our collection and use of this information is governed by our Privacy Policy available at https://www.JohnSnowLabs.com/privacy/ which may be amended from time to time.

Links and Third Party Content

Data Library may display, or contain links to, third party products, services, and websites. Any opinions, advice, statements, services, offers, or other information that constitutes part of the content expressed, authored, or made available by other users or other third parties, or which is accessible through or may be located using Data Library (collectively, “Third Party Content”) are those of the respective authors or producers and not of us or our shareholders, directors, officers, employees, agents, or representatives.

We do not control Third Party Content and do not guarantee the accuracy, integrity or quality of such Third Party Content. We are not responsible for the performance of, we do not endorse, and we are not responsible or liable for, any Third Party Content or any information or materials advertised in any Third Party Content. By using Data Library, you may be exposed to content that is offensive, indecent, or objectionable. We are not responsible or liable, directly or indirectly, for any damage or loss caused to you by your use of or reliance on any goods, services, or information available on or through any third party service or Third Party Content. It is your responsibility to evaluate the information, opinion, advice, or other content available on and through our Products.

Proprietary Rights

John Snow Labs will not obtain any rights under this EULA from you (or your licensors) to your content.

Data Library is and remains the exclusive property of John Snow Labs and its licensors. Except for the access and use rights expressly set forth in this EULA, no license or other rights in or to Data Library or John Snow Labs trademark(s) and other intellectual property rights therein, are granted to you, and all such licenses and rights are expressly reserved. You will not remove, alter, or obscure any proprietary notices (including copyright and trademark notices) on any portion of Data Library or any Content.

Trademarks

“John Snow Labs,” the John Snow Labs logo, and any other product, business or service name or slogan, whether registered or pending, displayed on Data Library are trademarks of John Snow Labs, Inc. or its suppliers or licensors, and may not be copied, imitated or used, in whole or in part, without the prior written permission of John Snow Labs or the applicable trademark holder. You may not use any metatags or any other “hidden text” utilizing “John Snow Labs” or any other name, trademark or product, business or service name of John Snow Labs without our prior written permission. In addition, the look and feel of Data Library, including all page headers, custom graphics, button icons and scripts, is the service mark, trademark and/or trade dress of John Snow Labs may not be copied, imitated or used, in whole or in part, without our prior written permission. All other trademarks, pending trademarks, registered trademarks, product names and company names or logos mentioned in Data Library are the property of John Snow Labs Inc. and/or their respective owners. Reference to any products, services, processes or other information, by trade name, trademark, manufacturer, supplier, or otherwise does not constitute or imply endorsement, sponsorship, or recommendation thereof by us.

Disclaimer of Warranties

YOUR USE OF DATA LIBRARY IS AT YOUR SOLE RISK. THE PRODUCTS AND CONTENT EACH ARE PROVIDED ON AN “AS IS” AND “AS AVAILABLE” BASIS. WE AND OUR SUPPLIERS AND LICENSORS EXPRESSLY DISCLAIM ALL WARRANTIES OF ANY KIND, WHETHER EXPRESS OR IMPLIED, INCLUDING, BUT NOT LIMITED TO THE IMPLIED WARRANTIES OF MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, TITLE, AND NON-INFRINGEMENT. WE DO NOT GUARANTEE THE ACCURACY, COMPLETENESS, OR USEFULNESS OF THE PRODUCTS OR ANY CONTENT, AND YOU RELY ON THE PRODUCTS AND CONTENT AT YOUR OWN RISK. ANY MATERIAL THAT YOU ACCESS OR OBTAIN THROUGH OUR PRODUCTS IS DONE AT YOUR OWN DISCRETION AND RISK AND YOU WILL BE SOLELY RESPONSIBLE FOR ANY DAMAGE TO YOUR COMPUTER OR LOSS OF DATA THAT RESULTS FROM THE DOWNLOAD OF ANY MATERIAL THROUGH OUR PRODUCTS. NO ADVICE OR INFORMATION, WHETHER ORAL OR WRITTEN, OBTAINED BY YOU FROM US OR THROUGH OR FROM OUR PRODUCTS WILL CREATE ANY WARRANTY NOT EXPRESSLY STATED IN THIS EULA. SOME STATES MAY PROHIBIT A DISCLAIMER OF WARRANTIES AND YOU MAY HAVE OTHER RIGHTS THAT VARY FROM STATE TO STATE.

Limitation of Liability

WE AND OUR SUPPLIERS AND LICENSORS WILL NOT BE LIABLE FOR ANY DIRECT, INDIRECT, INCIDENTAL, SPECIAL, CONSEQUENTIAL, OR EXEMPLARY DAMAGES, INCLUDING BUT NOT LIMITED TO, DAMAGES FOR LOSS OF PROFITS, GOODWILL, USE, DATA, OR OTHER INTANGIBLE LOSSES (EVEN IF WE HAVE BEEN ADVISED OF THE POSSIBILITY OF THESE DAMAGES), RESULTING FROM YOUR USE OF OUR PRODUCTS AND CONTENT. UNDER NO CIRCUMSTANCES WILL THE TOTAL LIABILITY OF US AND OUR SUPPLIERS AND LICENSORS OF ALL KINDS ARISING OUT OF OR RELATED TO YOUR USE OF THE PRODUCTS AND CONTENT (INCLUDING BUT NOT LIMITED TO WARRANTY CLAIMS), REGARDLESS OF THE FORUM AND REGARDLESS OF WHETHER ANY ACTION OR CLAIM IS BASED ON CONTRACT, TORT, OR OTHERWISE, EXCEED THE AMOUNTS, IF ANY, THAT YOU HAVE PAID FOR YOUR USE OF THE PRODUCTS AND CONTENT. BECAUSE SOME STATES DO NOT ALLOW THE EXCLUSION OR LIMITATION OF LIABILITY FOR CONSEQUENTIAL OR INCIDENTAL DAMAGES, THE ABOVE LIMITATION MAY NOT APPLY TO YOU.

Indemnity

To the full extent permitted by applicable law, you shall defend, indemnify and hold harmless John Snow Labs, its affiliates and its licensors, and each of their respective employees, officers, directors, and representatives from and against any claims, damages, losses, liabilities, costs, and expenses (including reasonable attorney’s fees) arising out of or relating to any third party claim concerning: (a) your use of Data Library; (b) breach of this EULA or violation of applicable law by you; (c) any content or the combination of such content with other software, content or processes, including any claim involving alleged infringement or misappropriation of third-party rights by such content or combination; or (d) breach of any obligation or duty you owe to a third party.

Legal Notices

Enforcement of this EULA will be governed by the laws of the State of Delaware, excluding its conflict and choice of law principles. The exclusive jurisdiction and venue for any claims arising out of or related to this EULA or your use of Data Library will lie in the state and federal courts located in Sussex County, within the State of Delaware, and you irrevocably agree to submit to the jurisdiction of such courts. Our failure to enforce any right or provision in this EULA will not constitute a waiver of such right or provision unless acknowledged and agreed by us in writing. In the event that a court of competent jurisdiction finds any provision of this EULA to be illegal, invalid, or unenforceable, the remaining provisions will remain in full force and effect.

Notifications

We may use your contact information to notify you if we have any legitimate interest or if we need to notify you on any important information related to your use of Data Library. We will not send you newsletters unless you expressly consented to such notifications.

Contacting Us

If you have any questions or concerns about Data Library or this EULA, you may contact us by email at support@JohnSnowLabs.com.

Description

The Quality Payment Program Final Rule with comment requires CMS to provide the criteria we will use to audit and validate measures and activities for the transition year of MIPS for the Quality, Advancing Care Information and Improvement Activities performance categories.

By definition, data validation is the process of ensuring that a program operates on accurate and useful data. MIPS requires all-payer data for all data submission mechanisms with the exception of claims and the CMS Web Interface. The data from payers, other than Medicare, will be used for informational purposes to improve future validation efforts and will not be the only source of data used to make final determinations on whether you pass or fail an audit in the transition year.

About this Dataset

Data Info

Date Created

2017-08-10

Last Modified

2020-03-01

Version

2020-03-01

Update Frequency

Annual

Temporal Coverage

2017-2020

Spatial Coverage

United States

Source

John Snow Labs; Quality Payment Program Resource Library;

Source License URL

Source License Requirements

N/A

Source Citation

N/A

Keywords

Data Validation and Auditing, Data Validation Criteria, Improvement Activities

Other Titles

Advancing Care Information and Cost, MIPS Data Validation and Auditing 2017, MIPS Data Validation and Auditing 2018, MIPS Data Validation and Auditing 2019, MIPS Data Validation and Auditing 2020

Data Fields

Name Description Type Constraints
Activity_IDUnique Activity Identification Numberstring-
Subcategory_NameCategory Complete Namestring-
Activity_NameProvided Activity Namestring-
Activity_DescriptionDetail Description of Activitystring-
Activity_WeightingShows Activity weighting (High and Normal)string-
ValidationDetailed validation reportstring-
Suggested_DocumentationSuggested/ Required documents for activitiesstring-
First_Program_YearFirst yearof MIPS data validationnumber-
Additional_NotesExamples of Additional Activities that Qualify for Attestation. Completing these alternate activities can fulfill the requirements of this Improvement Activity; and Notes.string-

Data Preview

Activity IDSubcategory NameActivity NameActivity DescriptionActivity WeightingValidationSuggested DocumentationFirst Program YearAdditional Notes
IA_EPA_1Expanded Practice AccessProvide 24/7 Access to MIPS Eligible Clinicians or Groups Who Have Real-Time Access to Patient's Medical RecordProvide 24/7 access to MIPS eligible clinicians, groups, or care teams for advice about urgent and emergent care (For example, eligible clinician and care team access to medical record, cross-coverage with access to medical record, or protocol-driven nurse line with access to medical record) that could include one or more of the following:• Expanded hours in evenings and weekends with access to the patient medical record (For example, coordinate with small practices to provide alternate hour office visits and urgent care);• Use of alternatives to increase access to care team by MIPS eligible clinicians and groups, such as telehealth, phone visits, group visits, home visits and alternate locations (For example, senior centers and assisted living centers); and/or• Provision of same-day or next-day access to a consistent MIPS eligible clinician, group or care team when needed for urgent care or transition management.HighDemonstration of patient care provided outside of normal business hours through 24/7 or expanded practice hours with access to medical records or ability to increase access through alternative access methods or same-day or next-day visits1) Patient Record from EHR - A patient record from an EHR with date and timestamp indicating services provided outside of normal business hours for that clinician (a certified EHR may be used for documentation purposes, but is not required unless attesting for the Promoting Interoperability [formerly ACI] bonus); or2) Patient Encounter/Medical Record/Claim - Patient encounter/medical record claims indicating patient was seen or services provided outside of normal business hours for that clinician including use of alternative visits; or3) Same or Next Day Patient Encounter/Medical Record/Claim - Patient encounter/medical record claims indicating patient was seen same-day or next-day to a consistent clinician for urgent or transitional care.2017
IA_EPA_2Expanded Practice AccessUse of telehealth services that expand practice accessUse of telehealth services and analysis of data for quality improvement, such as participation in remote specialty care consults or teleaudiology pilots that assess ability to still deliver quality care to patients.MediumDocumented use of telehealth services and participation in data analysis assessing provision of quality care with those servicesNOTE: For the purposes of this IA, telehealth services include a “real time” interaction and may be obtained over the phone, online, etc. and are not limited to the Medicare reimbursed telehealth service criteria.1) Use of Telehealth Services - Documented use of telehealth services through: a) claims adjudication (may use G codes to validate); b) EHR or c) other medical record document showing specific telehealth services, consults, or referrals performed for a patient; and 2) Analysis of Assessing Ability to Deliver Quality of Care - Participation in or performance of quality improvement analysis showing delivery of quality care to patients through the telehealth medium (e.g. Excel spreadsheet, Word document or others). NOTE: For the purposes of this IA, telehealth services include a “real time” interaction and may be obtained over the phone, online, etc. and are not limited to the Medicare reimbursed telehealth service criteria.2017
IA_EPA_3Expanded Practice AccessCollection and use of patient experience and satisfaction data on accessCollection of patient experience and satisfaction data on access to care and development of an improvement plan, such as outlining steps for improving communications with patients to help understanding of urgent access needs. MediumDevelopment and use of access to care improvement plan based on collected and stratified patient experience and satisfaction data 1) Access to Care Patient Experience and Satisfaction Data - Patient experience and satisfaction data on access to care; and2) Improvement plan - Access to care improvement plan. 2017Please note: CMS examples of stratification may include, patient demographics such as race/ethnicity, disability status (if available), sexual orientation (if available), sex, gender identity (if available), and geography
IA_EPA_4Expanded Practice AccessAdditional improvements in access as a result of QIN/QIO TAAs a result of Quality Innovation Network-Quality Improvement Organization technical assistance, performance of additional activities that improve access to services or improve care coordination (for example, investment of on-site diabetes educator).MediumImplementation of additional processes, practices, resources or technology to improve access to services or improve care coordination, as a result of receiving QIN/QIO technical assistance1) Relationship with QIN/QIO Technical Assistance - Confirmation of technical assistance and documentation of relationship with QIN/QIO; and2) Improvement Activities - Documentation of activities that improve access or improve care coordination, including support on additional services offered.2017
IA_EPA_5Expanded Practice AccessParticipation in User Testing of the Quality Payment Program Website (https://qpp.cms.gov/)User participation in the Quality Payment Program website testing is an activity for eligible clinicians who have worked with CMS to provide substantive, timely, and responsive input to improve the CMS Quality Payment Program website through product user-testing that enhances system and program accessibility, readability and responsiveness as well as providing feedback for developing tools and guidance thereby allowing for a more user-friendly and accessible clinician and practice Quality Payment Program website experience.MediumEvidence of user participation and implementation of website testing for the Quality Payment Program (QPP)1) Documentation of input to improve the CMS Quality Payment Program website through product user-testing aimed at enhancing system and program accessibility, readability and responsiveness and2) Provide feedback for developing tools and guidance for a more efficient and accessible clinician and practice QPP website experience. 2018
IA_PM_2Population ManagementAnticoagulant management improvementsIndividual MIPS eligible clinicians and groups who prescribe anti-coagulation medications (including, but not limited to oral Vitamin K antagonist therapy, including warfarin or other coagulation cascade inhibitors) must attest that for 75 percent of their ambulatory care patients receiving these medications are being managed with support from one or more of the following improvement activities: • Participation in a systematic anticoagulation program (coagulation clinic, patient self-reporting program, or patient self-management program);• Patients are being managed by an anticoagulant management service, that involves systematic and coordinated care, incorporating comprehensive patient education, systematic prothrombin time (PT-INR) testing, tracking, follow-up, and patient communication of results and dosing decisions;• Patients are being managed according to validated electronic decision support and clinical management tools that involve systematic and coordinated care, incorporating comprehensive patient education, systematic PT-INR testing, tracking, follow-up, and patient communication of results and dosing decisions;• For rural or remote patients, patients are managed using remote monitoring or telehealth options that involve systematic and coordinated care, incorporating comprehensive patient education, systematic PT-INR testing, tracking, follow-up, and patient communication of results and dosing decisions; or• For patients who demonstrate motivation, competency, and adherence, patients are managed using either a patient self-testing (PST) or patient-self-management (PSM) program.HighDocumented participation of patients being managed by one or more clinical practice improvement activities. Could be supported by claims. Anticoagulation services may consult with patients over the phone, recommending dosage changes and setting dates for follow-up lab work and may also consult with the patient’s personal physician or specialty physicians in complex cases.1) Patients Receiving Anti-Coagulation Medications - Total number of outpatients prescribed oral Vitamin K antagonist therapy; and2) Percentage of that Total Being Managed By a Clinical Practice Improvement Activity - Number of outpatients prescribed oral Vitamin K antagonist therapy and who are being managed by one or more of the four activities in the described in the activity description; and3) Documentation plan to address patients' language and communication needs, literacy level, and cognitive and functional limitations.2017
IA_PM_3Population ManagementRHC, IHS or FQHC quality improvement activitiesParticipating in a Rural Health Clinic (RHC), Indian Health Service Medium Management (IHS), or Federally Qualified Health Center (FQHC) in ongoing engagement activities that contribute to more formal quality reporting, and that include receiving quality data back for broader quality improvement and benchmarking improvement which will ultimately benefit patients. Participation in Indian Health Service (IHS), as an improvement activity, requires MIPS eligible clinicians and groups to deliver care to federally recognized American Indian and Alaska Native populations in the U.S. and in the course of that care implement continuous clinical practice improvement including reporting data on quality of services being provided and receiving feedback to make improvements over time.HighParticipation in RHC, IHS, or FQHC occurs and clinical quality improvement occurs1) Name of RHC, IHS or FQHC - Identified name of RHC, IHS, or FQHC in which the practice participates in ongoing engagement activities; and 2) Continuous Quality Improvement Activities - Documented continuous quality improvement activities that contribute to more formal quality reporting, and that include receiving quality data back for broader quality and benchmarking improvement that ultimately benefits patients.2017
IA_PM_4Population ManagementGlycemic management servicesFor outpatient Medicare beneficiaries with diabetes and who are prescribed antidiabetic agents (e.g., insulin, sulfonylureas), MIPS eligible clinicians and groups must attest to having:For the first performance year, at least 60 percent of medical records with documentation of an individualized glycemic treatment goal that:a) Takes into account patient-specific factors, including, at least 1) age, 2) comorbidities, and 3) risk for hypoglycemia, and b) Is reassessed at least annually.The performance threshold will increase to 75 percent for the second performance year and onward. Clinician would attest that, 60 percent for first year, or 75 percent for the second year, of their medical records that document individualized glycemic treatment represent patients who are being treated for at least 90 days during the performance period.HighReport listing patients who are diabetic and prescribed antidiabetic agents and have documented glycemic treatment goals based on patient-specific factors1) Diabetic Patients Prescribed Antidiabetic Agents - Total number of outpatients who are diabetic and prescribed antidiabetic agents; and 2) Documented Percentage of Total and each demographic group with Glycemic Treatment Goals and Assessed at Least Annually - Number of outpatients, stratified by demographic groups, who are diabetic and prescribed antidiabetic agents, with documented glycemic treatment goals ; and the goals take into account patient-specific factors, including at least age, comorbidities, and risk for hypoglycemia; and are flagged for reassessment in following year.2017Please note: CMS examples of stratification may include, patient demographics such as race/ethnicity, disability status (if available), sexual orientation (if available), sex, gender identity (if available), and geography
IA_PM_5Population ManagementEngagement of community for health status improvementTake steps to improve health status of communities, such as collaborating with key partners and stakeholders to implement evidenced-based practices to improve a specific chronic condition. Refer to the local Quality Improvement Organization (QIO) for additional steps to take for improving health status of communities as there are many steps to select from for satisfying this activity. QIOs work under the direction of CMS to assist MIPS eligible clinicians and groups with quality improvement, and review quality concerns for the protection of beneficiaries and the Medicare Trust Fund. MediumActivity to improve specific chronic condition for specific, identified population within the community is being undertaken1) Documentation of Partnership in the Community - Screenshot of website or other correspondence identifying key partners and stakeholders and relevant initiative including specific chronic condition and target population; and2) Steps for Improving Community Health Status - Report detailing steps being taken to satisfy the activity including, e.g., timeline, purpose, and outcome that is in compliance with the local QIO.2017
IA_PM_6Population ManagementUse of toolsets or other resources to close healthcare disparities across communitiesTake steps to improve healthcare disparities, such as Population Health Toolkit or other resources identified by CMS, the Learning and Action Network, Quality Innovation Network, or National Coordinating Center. Refer to the local Quality Improvement Organization (QIO) for additional steps to take for improving health status of communities as there are many steps to select from for satisfying this activity. QIOs work under the direction of CMS to assist eligible clinicians and groups with quality improvement, and review quality concerns for the protection of beneficiaries and the Medicare Trust Fund.MediumActivity to improve health disparities 1) Resources Used to Improve Disparities - Resources used, e.g., Population Health Toolkit; and2) Documentation of Steps - Report detailing activity as outlined by the local QIO with a statement outlining a plan of action to address specific identified disparities including evidence of disparity targeted and how this disparity is changing over time.2017