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…