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    • EyeNet Magazine
    • / June 2022
    • / MIPS 2021—Improvement Activities: Table: Improvement Activities at a Glance
  • MIPS 2021—Improvement Activities: Table: Improvement Activities at a Glance

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    This content is excerpted from EyeNet’s MIPS 2021; also see the Academy’s MIPS hub page.


    62 Improvement Activities at a Glance

    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

    Previous: How to Select, Perform, and Document Your Activities

    Next: Cost: An Overview 

    DISCLAIMER AND LIMITATION OF LIABILITY: Meeting regulatory requirements is a complicated process involving continually changing rules and the application of judgment to factual situations. The Academy does not guarantee or warrant that regulators and public or private payers will agree with the Academy’s information or recommendations. The Academy shall not be liable to you or any other party to any extent whatsoever for errors in, or omissions from, any such information provided by the Academy, its employees, agents, or representatives.

    COPYRIGHT© 2021, American Academy of Ophthalmology, Inc.® All rights reserved. No part of this publication may be reproduced without written permission from the publisher. American Academy of Ophthalmic Executives® and IRIS® Registry, among other marks, are trademarks of the American Academy of Ophthalmology®.

    All of the American Academy of Ophthalmology (AAO)–developed quality measures are copyrighted by the AAO’s H. Dunbar Hoskins Jr., MD, Center for Quality Eye Care (see terms of use).


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