MACRA Boosts the Power, Relevance of Registries

With its focus on clinical improvement activities and increased use of technology, CMS' Quality Payment Program, otherwise known as MACRA, has given a boost to clinical registries serving as data collection and reporting tools to study patient populations and quality of care.

There are approximately 120 Qualified Clinical Data Registries (QCDRs) approved by CMS for the 2017 reporting period. Through the Merit-based Incentive Payment System (MIPS), CMS offers physicians bonuses for participating in QCDRs, which can send physician reporting data directly to CMS. But figuring out how to get data from an EHR to a QCDR can be an additional burden for physicians trying to come to grips with MIPS.

“In MACRA there was a specific push to get clinicians to use QCDRs,” said Emily Richardson, MD, chief quality officer for Encompass Healthcare Data Solutions, a practice management services company. Richardson, who serves as co-chair of the Physician Consortium for Performance Improvement’s National Quality Registry Network QCDR Committee, said that because of the way the MIPS categories are structured, QCDRs are a good value proposition.

Physicians participating in a QCDR first must capture the data for the quality component of MIPS and send that data to the registry. “There are 13 Improvement Activities based on QCDR participation,” Richardson said. “A lot of those are built on the quality data you are already sending to the registry, and there are also bonus points for using a QCDR in the Advancing Care Information category.”

The American College of Cardiology (ACC) is exploring ways in which its PINNACLE and Diabetes Collaborative Registries can leverage the 13 Improvement Activities related to QCDRs, according to Adeela Khan, associate director of the National Cardiovascular Data Registry’s Outpatient Registries. For example, registry participants can easily attest to using the registries to promote standard practice, tools, and processes for quality improvement. Participants can also use drill-down capabilities to look at provider- and patient-level data to assess and track quality improvement projects. (The PINNACLE Registry and the Diabetes Collaborative Registry have more than 55 million patient encounters from more than 12,000 physicians combined.)

“We have developed a new MIPS dashboard available to our participants, by which they can select improvement activities,” Khan said. “Providers will self-attest to meeting any improvement activities and then we will submit that data for them.” She added that while the registries are integrated with the EHRs, many of the improvement activities are not linked to data elements that can be captured in a standard way, but when improvement activities are tied to data elements, it’s easy for ACC to track and verify them.

Indeed, getting the data out of an EHR to send to a registry can be difficult. The pool of electronic clinical quality measures that enterprise EHR vendors can report on may be too small, especially for specialists. To do quality reporting, clinicians may need to integrate with a third party or middleware group that can extract that information from the EHR.

Sheila Heitzig, JD, director of practice and policy for the American Academy of Allergy, Asthma & Immunology, said her academy's members have had mixed luck working with EHR vendors on integrating with its registry. “We have had some people who had fantastic partnerships with their EHR vendor,” she said. “Others have been told by EHR companies that this is not possible, and still others have been told they don’t need a QCDR and that the EHR vendor would report data directly to CMS for them and actually dissuaded them from using the registry.”

The American Academy of Ophthalmology (AAO) makes access to its IRIS Registry a free member benefit, and it has worked with EHR vendors to map out where the data elements the registry needs reside in the EHR databases so that the data extraction can happen automatically. In just three years since its launch, the IRIS Registry has accumulated 16,700 registered users with 147 million patient encounters from 37 million unique patients.

The main purpose for creating the registry was quality improvement, but the IRIS Registry also helps physicians report for mandates like PQRS and now MIPS, said Michael Chiang, MD, a professor of ophthalmology at Oregon Health Sciences University and chair of the AAO’s Medical Information Technology Committee.

Clinicians can use the IRIS Registry dashboard to look at how they are doing on performance measures and how they compare to national benchmarks. “One tangible benefit of the IRIS Registry is that you can improve your MIPS score very significantly,” Chiang said, “but another benefit that is as significant but perhaps more difficult to quantify is that by allowing doctors access to data about their own quality, it helps them understand the field better and hopefully that will allow them to reflect more on the barriers to their own improvement. It is a cultural change.”

Although most medical societies such as the AAO or the American Society of Anesthesiologists (ASA) have created QCDRs, others have been created by software companies who saw a business opportunity. A large portion of anesthesiologists in the country use the ASA’s registry, Richardson said, but there are other anesthesia QCDRs available. “There are billing and practice management companies that have built QCDRs because of these data flow issues,” she said. “If you already are in control of the billing data, it makes sense to try to create your own registry.”

For physicians, Richardson recommends studying whether the measure list the registry uses is meaningful to your practice and consider the logistics of getting that data. “If a society creates a bunch of measures and even if Medicare approves them, if it is very difficult to get the data, it is not going to be helpful for those clinicians,” she said. “That is why some of these other software companies have done well - because they have built the measures around the work flow.”

Many AAAAI members have shown strong interest in using the registry, but for others, “no amount of information is going to be enough to get past their preconceptions about whether this is relevant to them in their practice,” Heitzig said. “We are continually trying to make the registry more accessible and more relevant in terms of performance improvement. We want to provide a meaningful opportunity to engage not just in the Quality Payment Program but in the larger shift to value-based payment.”

Looking ahead to Year 2 of the Quality Payment Program. Christine Perez, ACC’s associate director for Medicare payment and quality policy, said that from the proposed rule, it appears that CMS intends to maintain flexibility, which means that clinicians who take the time this year to become familiar with their measures and set up their data collection and reporting systems should be set for next year.