|
What does it take to get an improvement activities performance category score of 100%? See “Improvement Activities: An Overview.”
Which improvement activities should you perform? The IRIS Registry supports reporting of 62 improvement activities—16 of those are high-weighted and 46 are medium-weighted.
Select your improvement activities carefully. To determine which improvement activities would be right for your practice, review the list below and click on activity titles for detailed activity descriptions and CMS documentation suggestions.
Update. In Spring 2020, after EyeNet's MIPS Manual had gone to press, CMS announced a new high-weighted improvement activity: COVID-19 Clinical Trial. You may attest to this improvement activity if you treat patients diagnosed with COVID-19 and report their data to a Qualified Clinical Data Registry (QCDR), such as the IRIS Registry.
|
|
High-Weighted Activities
|
| Activity ID#: Improvement Activity |
Notes |
| Achieving Health Equity |
| IA_AHE_1: Engagement of new Medicaid patients and follow-up |
No EHR required, high-weighted |
| IA_AHE_3: Promote use of patient-reported outcome tools |
No EHR required, high-weighted |
| IA_AHE_6: Provide education opportunities for new clinicians |
No EHR required, high-weighted |
| Beneficiary Engagement |
| IA_BE_6: Collection and follow-up on patient experience and satisfaction data on beneficiary engagement |
No EHR required, high-weighted |
| IA_BE_14: Engage patients and families to guide improvement in the system of care |
No EHR required, high-weighted |
| Emergency Response and Preparedness |
| IA_ERP_2: Participation in a 60-day or greater effort to support domestic or international humanitarian needs |
No EHR required, high-weighted |
| IA_ERP_3: COVID-19 Clinical Trial |
High-weighted |
| Expanded Practice Access |
| IA_EPA_1: Provide 24/7 access to MIPS eligible clinicians or groups who have real-time access to patient’s medical record |
No EHR required, high-weighted |
| Patient Safety and Practice Assessment |
| IA_PSPA_6: Consultation of the Prescription Drug Monitoring Program |
No EHR required, high-weighted |
| IA_PSPA_11: Participation in CAHPS or other supplemental questionnaire |
No EHR required, high-weighted |
| IA_PSPA_22: CDC Training on CDC’s guideline for prescribing opioids for chronic pain* |
No EHR required, high-weighted |
| IA_PSPA_23: Completion of CDC training on antibiotic stewardship* |
No EHR required, high-weighted |
| IA_PSPA_31: Patient medication risk education |
No EHR required, high-weighted |
| IA_PSPA_32: Use of CDC guideline for clinical decision support to prescribe opioids for chronic pain via clinical decision support |
High-weighted |
| Population Management |
| IA_PM_3: Rural Health Clinic (RHC), Indian Health Service Medium Management (HIS), or Federally Qualified Health Center (FQHC) quality improvement activities |
No EHR required, high-weighted |
| IA_PM_7: Use of QCDR for feedback reports that incorporate population health |
Facilitated by IRIS Registry—EHR, high-weighted integration |
| * You can only select IA_PSPA_22 once every four years. The same is true for IA_PSPA_23. |
|
Medium-Weighted Activities
|
| Activity ID#: Improvement Activity |
Notes |
| Achieving Health Equity |
| IA_AHE_5: MIPS eligible clinician leadership in clinical trials or CBPR [community-based participatory research] |
No EHR required, medium-weighted |
| IA_AHE_7: Comprehensive eye exams |
No EHR required, medium-weighted, substantive changes to measure description |
| Beneficiary Engagement |
| IA_BE_1: Use of certified EHR to capture patient reported outcomes |
Medium-weighted |
| IA_BE_3: Engagement with QIN-QIO to implement self-management training programs [Quality Innovation Network-Quality Improvement Organization] |
No EHR required, medium-weighted |
| IA_BE_4: Engagement of patients through implementation of improvements in patient portal |
Medium-weighted, substantive changes to measure description |
| IA_BE_5: Enhancements/regular updates to practice websites/tools that also include considerations for patients with cognitive disabilities |
No EHR required, medium-weighted |
| IA_BE_12: Use evidence-based decision aids to support shared decision-making |
No EHR required, medium-weighted |
| IA_BE_13: Regularly assess the patient experience of care through surveys, advisory councils, and/or other mechanisms |
No EHR required, medium-weighted |
| IA_BE_15: Engagement of patients, family, and caregivers in developing a plan of care |
Medium-weighted |
| IA_BE_16: Evidence-based techniques to promote self-management into usual care |
No EHR required, medium-weighted |
| IA_BE_17: Use of tools to assist patient self-management |
No EHR required, medium-weighted |
| Care Coordination |
| IA_CC_1: Implementation of use of specialist reports back to referring clinician or group to close referral loop |
No EHR required, medium-weighted |
| IA_CC_2: Implementation of improvements that contribute to more timely communication of test results |
No EHR required, medium-weighted |
| IA_CC_7: Regular training in care coordination |
No EHR required, medium-weighted |
| IA_CC_8: Implementation of documentation improvements for practice/process improvements |
No EHR required, medium-weighted |
| IA_CC_9: Implementation of practices/processes for developing regular individual care plans |
No EHR required, medium-weighted |
| IA_CC_12: Care coordination agreements that promote improvements in patient tracking across settings |
No EHR required, medium-weighted |
| IA_CC_13: Practice improvements for bilateral exchange of patient information |
Medium-weighted |
| IA_CC_14: Practice improvements that engage community resources to support patient health goals |
No EHR required, medium-weighted |
| IA_CC_18: Relationship-centered communication |
No EHR required, medium-weighted |
| Emergency Response and Preparedness |
| IA_ERP_1: Participation on Disaster Medical Assistance Team, registered for 6 months |
No EHR required, medium-weighted |
| Expanded Practice Access |
| IA_EPA_2: Use of telehealth services that expand practice access |
No EHR required, medium-weighted |
| IA_EPA_3: Collection and use of patient experience and satisfaction data on access |
No EHR required, medium-weighted |
| IA_EPA_4: Additional improvements in access as a result of QIN/QIO TA [Quality Innovation Network-Quality Improvement Organization technical assistance] |
No EHR required, medium-weighted |
| IA_EPA_5: Participation in User Testing of the Quality Payment Program Website |
No EHR required, medium-weighted |
| Patient Safety and Practice Assessment |
| IA_PSPA_1: Participation in an AHRQ-listed patient safety organization |
Medium-weighted |
| IA_PSPA_2: Participation in MOC Part IV |
No EHR required; IRIS Registry—EHR integration required for Academy/ABO option, medium-weighted |
| IA_PSPA_4: Administration of the AHRQ Survey of Patient Safety Culture |
No EHR required, medium-weighted |
| IA_PSPA_7: Use of QCDR data for ongoing practice assessment and improvements |
Facilitated by IRIS Registry—EHR integration, medium-weighted |
| IA_PSPA_8: Use of patient safety tools |
No EHR required, medium-weighted |
| IA_PSPA_9: Completion of the AMA STEPS Forward program |
No EHR required, medium-weighted |
| IA_PSPA_12: Participation in private payer CPIA [clinical practice improvement activities] |
No EHR required, medium-weighted |
| IA_PSPA_13: Participation in Joint Commission Evaluation Initiative |
No EHR required, medium-weighted |
| IA_PSPA_16: Use of decision support and standardized treatment protocols |
No EHR required, medium-weighted |
| IA_PSPA_17: Implementation of analytic capabilities to manage total cost of care for practice population |
No EHR required, medium-weighted |
| IA_PSPA_18: Measurement and improvement [of quality] at the practice and panel level |
No EHR required, medium-weighted |
| IA_PSPA_19: Implementation of formal quality improvement methods, practice changes, or other practice improvement processes |
No EHR required, medium-weighted |
| IA_PSPA_20: Leadership engagement in regular guidance and demonstrated commitment for implementing practice improvement changes |
No EHR required, medium-weighted |
| IA_PSPA_21: Implementation of fall screening and assessment programs |
No EHR required, medium-weighted |
| IA_PSPA_25: Cost display for laboratory and radiographic orders |
No EHR required, medium-weighted |
| IA_PSPA_26: Communication of unscheduled visit for adverse drug event and nature of event |
No EHR required, medium-weighted |
| IA_PSPA_28: Completion of an accredited safety or quality improvement program |
No EHR required, medium-weighted |
| Population Management |
| IA_PM_5: Engagement of community for health status improvement |
No EHR required, medium-weighted |
| IA_PM_6: Use of toolsets or other resources to close healthcare disparities across communities |
No EHR required, medium-weighted |
| IA_PM_11: Regular review practices in place on targeted patient population needs |
No EHR required, medium-weighted |
| IA_PM_17: Participation in population health research |
No EHR required, medium-weighted |