MVP ID: G0057
Most applicable medical specialty(s):
Emergency Medicine
The Adopting Best Practices and Promoting Patient Safety within Emergency Medicine MVP focuses on important assessors of the care emergency clinicians provide to patients with undifferentiated high-risk conditions. By focusing on these specific measures and activities, emergency clinicians can reduce clinical variability, improve the quality of emergency care and potentially lower costs.
Quality
Report 4 quality measures (one must be an outcome or a high priority measure):
- Quality ID: 065 - Appropriate Treatment for Upper Respiratory Infection (URI)
- Quality ID: 116 - Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis
- Quality ID: 254 - Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal Pain
- Quality ID: 321 - CAHPS for MIPS Clinician/Group Survey
- Quality ID: 331 - Adult Sinusitis: Antibiotic Prescribed for Acute Viral Sinusitis (Overuse)
- Quality ID: 415 - Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older
- Quality ID: 416 - Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 Through 17 Years
- Quality ID: 487 - Screening for Social Drivers of Health
- Quality ID: ACEP50 - ED Median Time from ED arrival to ED departure for all Adult Patients
- Quality ID: ACEP52 - Appropriate Emergency Department Utilization of Lumbar Spine Imaging for Atraumatic Low Back Pain
- Quality ID: ECPR46 - Avoidance of Opiates for Low Back Pain or Migraines
- Quality ID: HCPR24 - Appropriate Utilization of Vancomycin for Cellulitis
Improvement Activities
Report Two medium-weighted improvement activities or One high- weighted improvement activity:
- Activity ID: IA_AHE_12 - Practice Improvements that Engage Community Resources to Address Drivers of Health
- Activity ID: IA_BE_4 - Engagement of patients through implementation of improvements in patient portal
- Activity ID: IA_BE_6 - Regularly Assess Patient Experience of Care and Follow Up on Findings
- Activity ID: IA_BMH_12 - Promoting Clinician Well-Being
- Activity ID: IA_CC_2 - Implementation of improvements that contribute to more timely communication of test results
- Activity ID: IA_MVP - Practice-Wide Quality Improvement in MIPS Value Pathways
- Activity ID: IA_PCMH - Electronic submission of Patient Centered Medical Home accreditation
- Activity ID: IA_PSPA_1 - Participation in an AHRQ-listed patient safety organization.
- Activity ID: IA_PSPA_15 - Implementation of an ASP
- Activity ID: IA_PSPA_7 - Use of QCDR data for ongoing practice assessment and improvements
Cost
Calculated by CMS using administrative claims data:
Population Health Measures
Select one population health measure to be scored by CMS using administrative claims data:
- #479: Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment Program (MIPS) Groups (Administrative Claims)(!!)
- #484: Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions (Administrative Claims) (!!)
Promoting Interoperability
Report on the same PI measures required under traditional MIPS unless qualified for automatic reweighting or approved hardship exception:
- Prevention of Information Blocking
- e-Prescribing
- Query of the Prescription Drug Monitoring Program (PDMP) (Optional)
- Provide Patients Electronic Access to Their Health Information
- Support Electronic Referral Loops By Sending Health Information AND
- Support Electronic Referral Loops By Receiving and Reconciling Health Information OR
- Health Information Exchange (HIE) Bi-Directional Exchange
- Enabling Exchange Under the Trusted Exchange Framework and Common Agreement (TEFCA)
- Immunization Registry Reporting
- Syndromic Surveillance Reporting
- Electronic Case Reporting
- Public Health Registry Reporting
- Clinical Data Registry Reporting
- Security Risk Analysis
- Safety Assurance Factors for EHR Resilience Guide (SAFER Guide)
- ONC Direct Review
MVP Registration
- MVP Participants must register between April 1 – December 2, 2024 to report an MVP in 2024.
- To register, MVP Participants must select:
- The MVP they intend to report.
- 1 population health measure included in the MVP.
- Any outcomes-based administrative claims measures on which the MVP Participant intends to be scored (if available).
- If reporting as a subgroup, registration must also include:
- A list of Taxpayer Identification Numbers (TINs)/National Provider Identifiers (NPIs) in the subgroup;
- A plain language name for the subgroup (which will be used for public reporting);
- A description of the composition of the subgroup, which may be selected from a list or described in a narrative.
- MVP Participants won’t be able to:
- Submit/make changes to the MVP they select after the close of the registration period (December 2, 2024).
- Report on an MVP they didn’t register for during the 2024 performance year.
- Report on more than one MVP.