MIPS 2019—Table 13: Improvement Activities at a Glance
This content was excerpted from EyeNet’s MIPS 2019; also see the Academy’s MIPS hub page.
34 Improvement Activities—At a Glance
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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.
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High-Weighted Activities
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| 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
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| 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 |
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| 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] |
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| 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 |
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| 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 |
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* Newly added to IRIS Registry for 2019; not a new improvement activity.
† Newly added to IRIS Registry for 2019; a newly developed improvement activity.
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