Two executives from the well-known DaVita Kidney Care network share some advice for preparing your MIPS entries.
Robert Provenzano, MD, DaVita Kidney Care vice president of medical affairs, and Adam Weinstein, MD, DaVita Kidney Care vice president of medical affairs-clinical IT services, caution that “all situations are unique and need to be evaluated as such,” and that they’re speaking in their individual capacities and their opinions and views are their own. Nonetheless, it looks like sound advice.
Pick measures that are “within the boundaries of practice capabilities” -- by which Provenzano says they mean that the practice provides the service that is being measured at a rate that makes it measurable. “For instance, if you don't provide diabetic care, don't pick measures that look at of A1c measurement rates,” he says.
Understand which clinical improvement opportunities your practice is already doing. “Many practices have informal or formal quality improvement efforts, like getting in new patients in under 48 hours or other efforts that may apply toward improvement activities,” says Provenazo. “Looking for points of overlap is a quick win.” Also, check to see if your physician incentive program has some overlap with MIPS measures.
Know where your data comes from within the workflow of the practice. Make sure everyone in the practice knows what data they are responsible for entering and where they enter it. For example, front desk is probably responsible for some demographics (is this a Part B patient?), while clinical staff who room the patients are responsible for vitals, smoking status, etc. “Knowing and educating staff as to which of these data are integral to denominator or numerator inclusions for quality measures makes the staff in these roles aware of what data they need to consistently and cleanly collect,” says Provenzano.
Do oversight in real time or as close to it as is practicable.
Assign a “data wrangler” to track the completeness and quality of the data and fix issues as they arise, not retrospectively.
Cross-check and validate your data before submission.
Keep a copy of all data in case of audit.