2020 MIPS IA_PSPA_7: Use of QCDR data for ongoing practice assessment and improvements

Activity ID

IA_PSPA_7

Activity Weighting

Medium

Subcategory Name

Patient Safety and Practice Assessment

Activity Description

Participation in a Qualified Clinical Data Registry (QCDR) and use of QCDR data for ongoing practice assessment and improvements in patient safety, including:

  • Performance of activities that promote use of standard practices, tools and processes for quality improvement (for example, documented preventative screening and vaccinations that can be shared across MIPS eligible clinician or groups);
  • Use of standard questionnaires for assessing improvements in health disparities related to functional health status (for example, use of Seattle Angina Questionnaire, MD Anderson Symptom Inventory, and/or SF-12/VR-12 functional health status assessment);
  • Use of standardized processes for screening for social determinants of health such as food security, employment, and housing;
  • Use of supporting QCDR modules that can be incorporated into the certified EHR technology; or
  • Use of QCDR data for quality improvement such as comparative analysis across specific patient populations for adverse outcomes after an outpatient surgical procedure and corrective steps to address adverse outcomes.

Validation

Use of QCDR data for ongoing practice assessment and improvements in patient safety (e.g., evidence of intended improvements in patient safety for specific targeted populations)

Suggested Documentation

Participation in QCDR that promotes ongoing improvements in patient safety (e.g., regular feedback reports provided by the QCDR that demonstrate ongoing practice assessment and improvements in patient safety). The MIPS eligible clinician or group should document how the practice is using QCDR data, and intended improvements in patient safety for the specific populations targeted (e.g., documentation of standard tools, processes for screening, use of standard questionnaires, or use of QCDR data that is used for quality improvement, such as population-level analysis to assess for adverse outcomes).

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