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    • EyeNet Magazine
    • / May 2022
    • / MIPS 2019—Table 13: Improvement Activities at a Glance
  • MIPS 2019—Table 13: Improvement Activities at a Glance

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    This content was excerpted from EyeNet’s MIPS 2019; also see the Academy’s MIPS hub page. 


     

    34 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 34 improvement activities that are relevant to ophthalmology. To determine which activities would be right for your practice, review the list below and click on activity titles for detailed activity descriptions and CMS documentation suggestions.

    High-Weighted Activities

    ID#: Improvement Activity Notes
    IA_AHE_1: Engagement of new Medicaid patients and follow-up No EHR required
    IA_AHE_6: Provide education opportunities for new clinicians New,* no EHR required
    IA_BE_6: Collection and follow-up on patient experience and satisfaction data on beneficiary engagement No EHR required
    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
    IA_PM_7: Use of QCDR for feedback reports that incorporate population health Facilitated by IRIS Registry–EHR integration
    IA_PM_17: Participation in population health research New,* no EHR required
    IA_PSPA_11: Participation in CAHPS [Consumer Assessment of Healthcare Providers and Systems] or other supplemental questionnaire No EHR required

    Medium-Weighted Activities

    ID#: Improvement Activity Notes
    IA_AHE_4: Leveraging a QCDR for use of standard questionnaires New,* IRIS Registry–EHR questionnaire (in development)
    IA_AHE_7: Comprehensive eye exams New,† no EHR required
    IA_BE_4: Engagement of patients through implementation of improvements in patient portal  
    IA_BE_13: Regularly assess the patient experience of care through surveys, advisory councils, and/or other mechanisms No EHR required
    IA_BE_16: Evidence-based techniques to promote self-management into usual care New,* no EHR required
    IA_BE_17: Use of tools to assist patient self-management No EHR required
    IA_BE_21: Improved practices that disseminate appropriate self-management materials New,* no EHR required
    IA_BE_22: Improved practices that engage patients pre-visit New,* no EHR required
    IA_BMH_2: Tobacco use No EHR required
    IA_CC_1: Implementation of use of specialist reports back to referring clinician or group to close referral loop No EHR required
    IA_CC_2: Implementation of improvements that contribute to more timely communication of test results No EHR required
    IA_CC_4: TCPI participation [CMS Transforming Clinical Practice Initiative]  
    IA_CC_6: Use of QCDR [Qualified Clinical Data Registry] to promote standard practices, tools, and processes in practice for improvement in care coordination Facilitated by IRIS Registry–EHR integration
    IA_CC_8: Implementation of documentation improvements for practice/process improvements No EHR required
    IA_CC_13: Practice improvements for bilateral exchange of patient information  
    IA_EPA_2: Use of telehealth services that expand practice access New,* no EHR required
    IA_EPA_3: Collection and use of patient experience and satisfaction data on access No EHR required
    IA_EPA_5: Participation in user testing of the Quality Payment Program website: https://qpp.cms.gov New,* no EHR required
    IA_PM_10: Use of QCDR data for quality improvement such as comparative analysis reports across patient populations Facilitated by IRIS Registry–EHR integration
    IA_PSPA_2: Participation in MOC Part IV No EHR required; IRIS Registry–EHR integration required for Academy/ABO option
    IA_PSPA_5: Annual registration in the Prescription Drug Monitoring Program No EHR required, must be in PDMP for 6 months
    IA_PSPA_7: Use of QCDR data, for ongoing practice assessment and improvements Facilitated by IRIS Registry–EHR integration
    IA_PSPA_12: Participation in private payer clinical practice improvement activities New,* no EHR required
    IA_PSPA_15: Implementation of an antibiotic stewardship program No EHR required
    IA_PSPA_16: Use of decision support and standardized treatment protocols No EHR required
    IA_PSPA_18: Measurement and improvement at the practice and panel level No EHR required
    IA_PSPA_20: Leadership engagement in regular guidance and demonstrated commitment for implementing practice improvement changes No EHR required

    * Newly added to IRIS Registry for 2019; not a new improvement activity.

    † Newly added to IRIS Registry for 2019; a newly developed improvement activity.

    Previous: Improvement Activities: 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© 2019, 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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