Where can I find it?
Clinical: Reports > MIPS Dashboard
What do I need to know?
The system has been updated with a MIPS Dashboard that will allow MIPS Eligible Clinicians (ECs) to report their MIPS quality measures with ease. ECs can track their progress throughout their MIPS performance period and make any necessary corrections before submitting their data.
When you access the MIPS Dashboard, you can select, add, edit, and delete various Configurations where you set the eligible clinicians and the various parameters for each of the four categories for of the MIPS program: Quality, Advancing Care Information, Improvement Activities, and Cost. Do note that the Cost category is not available for 2017.
After a Configuration is set up and selected, you will have access to each of the categories to select various parameters for those categories, as well as calculate scores based on the parameters set and your data entered to date. Each of the categories will have a last calculated/modified date so you will easily know if you need to run these again. Likewise, you can also view MIPS Requirements and the system will calculate an Estimated MIPS total composite score.
Prior to configuring and running any data in the MIPS Dashboard you must select a Configuration in the corresponding field. Configurations can be added by clicking the Add button to the right of this field. Likewise, you can edit and delete a configuration by selecting the desired Configuration, and then clicking the Edit or Delete button to the right.
In the MIPS Dashboard Configuration dialog, you can enter a Configuration name, select the Performance period (which needs to be 90 days or more), select the Eligible clinicians (NPI) (which needs to be a single clinician, or all clinicians in the practice), and then select the parameters for the Quality Reporting, Advancing Care Information Exemption, and Improvement Activity Adjustments. Do note, that by default, Quality Reporting is weighted as 60%, Advancing Care Information (ACI) as 25%, and Improvement Activity (IA) is 15%. If a user is configured to be exempt from reporting for ACI, the Quality category will be weighted as 85% and ACI will be 0% and disabled.
Once a configuration is selected in the MIPS Dashboard, you can access the Quality Measures dialog to select the quality measures for your performance period, calculate your estimated score, run a reconciliation report, and generate a file for submission by clicking the Quality button.
In the Quality Measures dialog, in the left pane, the existing 29 quality measures will be listed, like the Meaningful Use Dashboard, but here are re-categorized as Outcome Measures, High Priority Measures, or Other Measures. You can select as many measures as desired, however, at least one outcome or high priority measure must be selected. The selected measures will appear in the right pane as a single row for each selected measure. Once the applicable measures are selected, you can calculate your estimated score by clicking the Calculate button, and after the system is done collecting and running data for the performance period, a Total score will appear at the bottom. After the total score has been calculated you can run a Reconciliation Report and Generate Files for Submission via the corresponding buttons at the bottom of the dialog. Clicking the OK button will save the selected quality measures and maintain any scores.
When calculating quality measure scores, the standard Numerator and Denominator information will be displayed along with a percentage result and a final score. The score starts as a base 3 points for all measures. If the measure has 20 or more in the denominator and at least 1 patient is marked as having Medicare as an insurance during an encounter, the measure is eligible for additional benchmark points. Benchmark points are determined by information provided by CMS, however, not all quality measures have a benchmark. Double clicking a row within the grid will display the benchmark breakdown and bonus points if they exist.
Only the top 6 best performing measures will be counted in the score, if more than 6 measures are calculated. Measures that are not included in the score will be marked with a gray background and reordered to the bottom of the grid. The top 6 measures are then eligible for 1 additional bonus point each for submitting through an EHR (for a maximum of 6 points). One outcome or high priority measure is required, however for each additional outcome 2 bonus points are awarded and 1 for each additional high priority measure (for a maximum of 6 points). Double clicking a row within a grid will also show the bonus points awarded.
When generating files for submission, as QRDA file will be generated that will include all measures that are selected, not just the 6 top performing measures.
If the total score is greater than 60, a warning text will appear indicating that the final score is capped. Clicking the OK button will automatically update the main dashboard view with the final capped score and the weighted score and update the total MIPS score.
If you chose to use the Reporting through the STI Quality Reporting Registry option in the MIPS Dashboard Configuration dialog (see figure 10 above), when you click the Quality button in the MIPS Dashboard, a Quality Score dialog will appear allowing you to manually enter the Quality score from the registry.
With a configuration is selected in the MIPS Dashboard, you can access the Advancing Care Information dialog to select the Advancing Care Information (ACI) options for your performance period, calculate your estimated Base Score, Performance Score, and Bonus Points, run a reconciliation report for your Performance Score, and Print your Performance Score information by clicking the Advancing Care Information button.
The Advancing Care Information dialog is broken up into three areas for Base Score, Performance Score, and Bonus Points. The Base Score must be completed before any other section of the ACI will count. Performance and Bonus sections will automatically be in a disabled state (although measures can be calculated but will show as gray rows and their score will not be added to the total) if Base Score credit is not awarded, and warning text will appear at the bottom to indicate that base credit was not met.
In the Base Score section, you must first check the Performed a security risk analysis option, followed by getting a 1 in the numerator after calculating the 3 base performance measures. You also have the option to select Include controlled substances in the E-Prescribing measure. As an exemption, a user with less than 100 in the denominator for E-Prescribing will count even if they do not have at least 1 in the numerator. To run the base performance measures, click the corresponding Calculate button. Once these conditions are met, the rest of the dialog will be enabled.
The Performance Score section contains a Submitted data for immunization registry reporting option that allows you to indicate immunization registry use for 10 points. In addition, 6 measures can be calculated for an additional 0 to 10 points each, two of which are worth double points, where scoring is based on the performance percentage per CMS requirements and guidelines. Once the applicable options are selected, you can calculate your estimated score by clicking the Calculate button, and after the system is done collecting and running data for the performance period, the results and applicable scores will appear in the corresponding columns in the grid. After the scores have been calculated, you can run a Reconciliation Report and Print the results via the corresponding buttons.
The Bonus Points section has a Submitted data to one or more public health or clinical data registries option that is worth 5 points. Likewise, you may also receive 10 points by making any selection in the ACI Bonus tab of the Improvement Activities dialog which will be described further below.
The final score (points) is listed at the bottom as a breakdown of Base Score plus the Performance Score plus any Bonus Points.
Clicking the OK button will save any calculated scores and selections, and will automatically update the MIPS Dashboard view and the Estimated MIPS total composite score.
With a configuration is selected in the MIPS Dashboard, you can access the Improvement Activities dialog to select an improvement activities that you qualify for during your performance period, by clicking the Improvement Activities button.
The Improvement Activities dialog is broken into three tabs: ACI Bonus, High Weighted, and Medium Weighted activities. Each tab will display the applicable list of activities with a link for More Information and a Yes/No selection drop-down box. High Priority activities are worth 20 points and medium weight are worth 10 points.
If you chose the Small practice, rural area, or non-patient facing clinician option in the Improvement Activity Adjustments section of the MIPS Dashboard Configuration dialog, you will receive double points for each selection. If you selected the Patient Centered Medical Home or equivalent option, you will receive full credit automatically (40 points), but can still make other choices. If you selected the Other approved Alternative Payment Model, you will receive half credit (20 points) automatically.
If you make any selection from the ACI Bonus section, 10 points will be given to the ACI total.
The Total score (capped at 40 points) is listed at the bottom. Clicking the OK button will save any selections and scores, and will automatically update the MIPS Dashboard view and the Estimated MIPS total composite score.
How do I use it?
Upon upgrading the ChartMaker Medical Suite, the MIPS Dashboard will be accessible by clicking Reports > MIPS Dashboard. In the MIPS Dashboard you can then create Configurations as needed, and then select and calculate the applicable options for Quality Measures, Advancing Care Information, and Improvement Activities as outlined above.