Achieving Quality Measures in Encompass EHR

The clinical side of Encompass offers the following reporting methods, or submission mechanisms:

• Claims
• Built-in registry
• American Academy of Ophthalmology (AAO) IRIS^® Registry
• MIPS Value Pathways (MVP)

You may choose multiple reporting methods (e.g., use claims-based reporting for some measures and registry reporting for others). If you submit a measure using multiple methods, CMS will give you credit for your highest-scoring reporting method.

Not every reporting method is available for each measure. The following table lists each of the measures supported by Encompass and which reporting methods are available for each. Click the measure name to learn how to achieve the measure in Encompass.

Measure	Category	High Priority	Claims	Registry	AAO IRIS	MVP
	Choose 1 Outcome measure	Choose 1 high priority if no Outcome is available.	Choose 6 measures from these columns. You may choose measures in different columns.			OR choose 4 from this column.
001. Diabetes: Glycemic Status Assessment > 9%	Intermediate Outcome	Yes
012. Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation (Documentation coming soon)	Process
019. Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care (Documentation coming soon)	Process	Yes
117. Diabetes: Eye Exam	Process
130. Documentation of Current Medications in the Medical Record	Process	Yes
141. Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 20% or Documentation of a Plan of Care	Outcome	Yes
191. Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery (Documentation coming soon)	Outcome	Yes
226. Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention	Process
236. Controlling High Blood Pressure	Intermediate Outcome	Yes
238. Use of High-Risk Medications in Older Adults Documentation coming soon)	Process	Yes
303. Cataracts: Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery (Documentation coming soon)	Patient-Reported Outcome-Based Performance	Yes
304. Cataracts: Patient Satisfaction within 90 Days Following Cataract Surgery (Documentation coming soon)	Patient Engagement/ Experience	Yes
317. Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented	Process
374. Closing the Referral Loop: Receipt of Specialist Report (Documentation coming soon)	Process	Yes
384. Adult Primary Rhegmatogenous Retinal Detachment Surgery: No Return to the Operating Room Within 90 Days of Surgery (Documentation coming soon)	Outcome	Yes
385. Adult Primary Rhegmatogenous Retinal Detachment Surgery: Visual Acuity Improvement Within 90 Days of Surgery (Documentation coming soon)	Outcome	Yes
389. Cataract Surgery: Difference Between Planned and Final Refraction (Documentation coming soon)	Outcome	Yes
499. Appropriate screening and plan of care for elevated intraocular pressure following intravitreal or periocular steroid therapy (Documentation coming soon)	Process
500. Acute Posterior Vitreous Detachment Appropriate Examination and Follow-up (Documentation coming soon)	Process
501. Acute posterior vitreous detachment and acute vitreous hemorrhage appropriate examination and follow-up (Documentation coming soon)	Process

Measure contributes up to 10 points based on performance.

Measure is capped at a maximum of 7 points based on performance.