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•Use the right data; that is, data drawn from medical
records, backed by research, that track patients post-discharge, and are continuously updated
•Verify with outside experts through external peer review
Registries: Increasingly relevant
Meeting these standards and helping to ease the
financial and administrative burdens that many
surgeons are experiencing in today’s highly regulated health care environment are the underpinnings of our database software redesign project.
More specifically, the ACS recognizes that Fellows
need coordinated quality measurement systems
and registries to comply with increasing demands
for public reporting, performance-based payment
reforms, and Maintenance of Certification (MOC)
requirements.
A range of public reporting websites are now available, including the Centers for Medicare & Medicaid Services (CMS) Physician Compare program and
ProPublica’s so-called Surgeon Scorecard. The College has significant concerns regarding both of these
public reporting systems because they use Medicare
billing data to measure performance and surgeon
complication rates rather than risk-adjusted clinical
data, such as the information used to generate ACS
NSQIP outcomes reports. The College maintains that
risk-adjusted clinical data are a better reflection of
performance and other complicating factors that may
affect patient outcomes.
The College has worked closely with CMS to
ensure that information collected in the SSR is com-
patible with CMS’ Physician Quality Reporting Sys-
tem (PQRS). The SSR has been approved as a PQRS
registry for individual eligible providers (EPs) to par-
ticipate in traditional registry-based reporting, and
the MBSAQIP has been approved as a Qualified Clini-
cal Data Registry. Physicians and other EPs who fail
to satisfy PQRS reporting requirements face penalties
on their Medicare Part B billings.
As the Medicare program transitions to implementation of the Medicare Access and CHIP (
Children’s Health Insurance Program) Reauthorization
Act (MACRA), new payment systems will be put in
motion. However, the Merit-based Incentive Payment System and alternative payment models that
are set for implementation in 2019 will likely rely
on outcome measures and registries to determine
reimbursement. As a result, surgeon participation
in the ACS clinical data registries will remain eminently important.
In addition, the Health Information Technology for Economic and Clinical Health (HITECH)
Act authorizes the U.S. Department of Health and
Human Services to provide incentives to EPs who
meet meaningful use criteria for the use of electronic
health records (EHRs) and to penalize those who do
not meet the program’s objectives. Many surgeons,
particularly those in small practices, find it difficult
to meet the meaningful use criteria and can ill-afford
to take any additional financial hits for noncompliance. Furthermore, PQRS has an EHR-based reporting option as well.
Moreover, the American Board of Surgery and
other surgical boards have been gradually implementing MOC mandates. Part 4 of MOC focuses on
assessment of practice performance. The SSR provides surgeons with information about procedure-specific outcomes in their own practices and allows
them to benchmark their performance against the
results of other participants in the national database.
This feedback will help surgeons self-evaluate and
identify areas for improvement.
A collaborative effort
The newly reimagined ACS quality database system
responds to all of these concerns. It will not only
allow the ACS to migrate all of our clinical registries
