Outrunning The MIPS Bear: Improvement Activities Portion (Article 4 of 5)

Outrunning the MIPS Bear – Article (4 of 5)

MIPS: Improvement Activities

Improvement Activities (IA) is a brand new category, and so ironically while it counts least in terms of the Quality Payment Program (QPP) score, it’s going to be the hardest to wrap our brains around: it’s new. However, here we go: at least this is, essentially, the last category as Cost data is automatically collected from claims so we don’t have to worry about that one.

A critical piece of information about IA: it’s self-attest. Now that’s like having the wind at your back, like taking a multiple choice quiz: however, in the event of an audit you’ve gotta be able to back it up with reports and/or screen shots. But it’s nice: when you’re logged into your EIDM account, you’ll just click “Yes, I performed these activities” and move on.

As stated previously, there are 4 categories to consider while running away from Da Bear:

  1. Quality
  2. Promoting Interoperability (PI)
  3. Improvement Activities (IA)
  4. Cost

Of the 4, Improvement Activities (IA) represents 15% of the final score, third to Promoting Interoperability at 25%: I see the sequential pattern – I can be taught!

All right, then, CMS defines (qpp.cms.gov), IA as: “improve your care processes, enhance patient engagement in care, and increase access to care”.

Ok – you had me at “gauging”, and I’ve got to play anyway, so… for 90 days, I’ve got to pick one of the following 3 combos:

  • 2 high-weighted activities
  • 1 high-weighted, 2 medium-weighted activities
  • 4 medium-weighted activities

And the wrinkle? If I qualify for any of the Special Status categories I get double the points! So give me one big green check; my practice is Small (less than 15 physicians); I get double the points, double the Wintergreen chewing gum pleasure (I’m dating myself on that one), right?

Again at qpp.cms.gov, working the filters, an old hand at this by now, I come up with a combination of weighted activities that best suit my practice and EHR reporting capability when it comes to IA.

I pick a combination of the following activities:


Activity Weight CMS/NQF EHR Documentation process
Provide 24/7 access to MIPS eligible clinicians High N/A Caretracker operator access logs, Direct email logs
Depression Medium CMS2v6 Medical record>HX
Tobacco Use Medium CMS138v5 Medical record>HX


And there’s my Improvement Activities, 2nd combo (1 high weighted, 2 medium weighted). The reason I picked Depression and Tobacco use categories: I know exactly where in the EMR I can both document and produce the relevant reports when necessary: good on me, no?

Done!… with this caveat: implied in the word improvement is that I can indeed demonstrate improvement, year over year, in the categories I have chosen. This is an area that I will have to monitor and will demand significant adjustment moving forward (I recommend spending time perusing the measures), but IA, step #3, handled, some brain damage sustained but not too bad. A drink in my easy chair (after hours, or course!), some cheese and crackers, I might actually recover from outrunning Da MIPS Bear.

Best thing to do now? Get my EIDM (Enterprise Identity Data Management) Account up and running so I can submit and track my status.

What’s that? You asked “What’s an EIDM?” Ah ha! Good question! That’s a subject for yet another post! Stay tuned…

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Brad Sclar has founded several successful Healthcare IT companies within the last 20 years in the Denver area — PRS Network, Phasis Group, and MD-IT. In addition to multiple IT certifications he supports voice recognition software into multiple EMR environments nationwide, serves as the CIO of the PRS IT Division, overseeing template development, maintenance of client LAN installations, custom software development, HL7 interfaces between EMRs, and the installation of the Health Record portion of the EMR software packages that PRS represents. Currently, he is involved in launching a Urology focused MSO.