2021 MIPS Improvement Activity IA_PSPA_7: Use of QCDR data for ongoing practice assessment and improvements

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.
Activity ID Activity Weighting Sub-Category Name
IA_PSPA_7 Medium Patient Safety and Practice Assessment


Anesthesiology-2021, IA_2021, Podiatry-2021