The guys in the back gave me a thumbs up and said we should start. So we will do that. Thank you for working your way upstairs and down the hall and still finding this lovely location. For those of us that were here for the GLEAM session yesterday, we were in this exact same space so it's very familiar to us. The people sitting back there in the corner won't even know that there are people sitting back here in the corner. We'll try to make amends of that when it's time for the questions. We really do want to keep this pretty informal. I'm Sue Sadori, the CEO at the American College of Emergency Physicians and also the president as of the end of this meeting of CMSS and most curiously came into the association space to develop the clinical registry at Otolaryngology in 1997, which I think probably some of you might not have been around yet. And boy has a lot changed when we think about our clinical registries and what we do then. We were at that point in time working on trying to develop our registry as something we could put on a CD and send out to practices so that they could collect data, right? Very, very, very different world. And so what we really wanted to do in this session today is bring together a variety of ways that we're all thinking about doing things differently with our registries. When the program committee saw some of these presentations that came in, these were not together as a panel. They were all individual submissions and we said, you know what? They all fit into this broader category of there's a lot of things we can do with our registries so let's just talk about this random stuff that we can do with our registries and then open it up to conversation and question and that's really what we've built today. So I will introduce the panel members and then they're going to each sort of spend about five to seven minutes talking about what is unique to what they do with their registries and then we really do want to have this a very interactive and engaging conversation with you all in the room. I will also make a note that several of these folks are substitutes for people that should have been here but are sick. So we will give them some grace that they will be working with some slides that might not have been there. So the first substitute is Jason Murray who is with the American Academy of Osteo-Orthopedic Surgeons and he is substituting in for Nathan Gluskamp and he's going to be talking about how they are navigating payers, patient reported outcomes measures and prior authorization through what they do with their registry. Next is Debbie Gibson with the American Psychiatric Association and she's going to be talking about PsychPro and what they do with their clinical data registry there and sort of how they're looking at that to think about the future of psychiatry. Next is Carolyn Morgan from the Society of Vascular Surgery who was supposed to be here with Carrie Becela who is with Symmetric Health Solutions which is a partner to the SVS registry and they're going to be talking about how they kind of use the registry to improve capturing of device identification information in those registries. And then last but not least is Rhonda Bowman who is a nurse with the American Society of Clinical Oncology and she's going to talk a little bit about how they kind of work their certification and evaluation programs into what they do. So I'm going to let them go ahead and take the mic and take some time and we're going to kind of go through that obviously if you have any sort of really burning questions you want to kind of hit it at the end of each presentation we can do that but I think it'll be more interesting for us to kind of hold it to the end. So Jason you're up. I'm excited to kick off this session today with talking about our registries and giving you some data reuse opportunities that we have had success with with our registries and helping our members improve the quality of orthopedic care. So first let me just kind of go over our suite of registries here. So we have five registries. The American Spine Registry is a collaborative registry with the American Association of Neurological Surgeons. Our American Joint Replacement Registry is our flagship registry. It's our most mature registry. We have the Shoulder and Elbow Registry the Fracture and Trauma Registry and the Musculoskeletal Tumor Registry. Now data across the registries you can see as I said our American Joint Replacement Registry is our most mature registry with 3.5 million total procedures, 3 million patients and 12,000 total surgeons represented. The rest of our across the registries we're growing. We have a total of 1,400 sites that participate with our registries that represent 14,000 surgeons and over all 50 states. So we all know that collecting data for the sake of collecting data is not a useful exercise. It's how you use that data that determines its usefulness. So I want to give four quick examples on how we're using data from our registries to improve the quality of patient care. So first is our collaboration with the Joint Commission. So the Joint Commission and the AAOS work together to do advanced certifications in total hip and total knee as well as spine surgery. This not only improves the quality of care but offers our participating sites with the opportunity to get the unique distinction of being an advanced certified Joint Commission program. So you can see here are these are some over an overview of the criteria that we use to actually work with the Joint Commission for their advanced certifications. Again we are the sole pathway for gaining these advanced certifications for total hip and knee and spine. Another good use case is our work with the Aetna Institutes of Quality. So the Joint Commission and the AOS work together to distinguish high quality institutions through the Aetna Institutes of Quality. You can see the goals of the program here is to recognize health care states that demonstrate high levels of quality provide qualitative feedback on the institution level to Aetna so sites can report on the quality of care they deliver and to assist with the internal quality tracking and monitoring. So AJRR and our spine registry both have metrics within them that are used for performance measures for this Institutes of Quality and we provide one report per three year cycle for submission to Aetna on behalf of the participants. Another good data reuse opportunity is for federal reporting. So the CMS inpatient quality reporting program is one that in 2025 will require hospitals to report on patient reported outcome measures for total hip and total knee for their Medicare patients. So we are preparing to help reduce the administrative burden of actually reporting that data back to CMS to meet the requirements of the program. So you can see here that we have added an extractable performance report and three new data elements to serve the participating sites. This is a quick overview of the reporting process for the CMS IQR program. So you can see that the site would elect to report. They would submit the data that's necessary for this and we would collate that data and allow them two options either they can download and extract the data on their own and send it in to CMS or they can submit the Excel file. We can submit the Excel file to CMS on their behalf. Prior authorization. This is obviously an evergreen topic for all of us. So this is a good opportunity for registry data to change the landscape a little bit and prior auth. We are talking with a number of payers right now to get this underway but we do have a relationship in place with a company called Cohere Health. They are a digital health care company and they're putting together a collaborative program for prior authorization. So you can see the goals of our pilot with Cohere Health on the left hand side. This is the actual roadmap that we're going to take with the pilot to try to green light participants for gold carding. That said if you if you would like more information on AOS registries please visit AOS.org forward slash registries. Thank you. So the registry lead at the American Psych Pro Registry clinical lead is Dr. Nitin Gokde. He's here today as well and he's my my boss. So today I'm just going to provide a quick overview of a couple of things. One being sort of the future of psychiatry and how Psych Pro fits into that and the challenges we've been having up until today with our registry vendors and then you know how we kind of got together as a team at APA to strategically develop solutions for the way forward. So you know currently psychiatry is in a place where it faces many challenges right as it moves into the future. But you know with that there is an opportunity although lots of challenges it opens up the space for how do we solve for those challenges. So last year's president 2022 president had a work group on a presidential work group on the future of psychiatry and so some of the things that are challenged as we move into the future with psychiatry are of course things like data for mental health research personal medicine or personalized medicine advances in technology technology etc. And so with that presidential work group there are several recommendations that were grouped in six sections and were approved for implementation by the APA administration and Psych Pro the registry was one of them. So how can Psych Pro make a difference if we think about the future of psychiatry and as a registry. Well we're looking primarily at research and the DSM so the DSM is in its five fifth edition. There's been a text revision but where is the future of DSM. So looking at cross cross dimensional features with other with research research areas that sort of map to the DSM. So there's a lot of work there that the registry can help with in terms of making that into reality and bringing the DSM to into the future with a sixth edition. Of course quality work you know we're looking at access to care issues we're looking at you know safety issues all of that of course needs data and information to help with research to make improvements to patient care just as an aside. So psychiatry was probably as a medical specialty association the last sort of in the registry space Psych Pro was developed in 20 or we started development of Psych Pro in 2017. So that's very recent. We've been up and going for six seven years now. And I think in the beginning when psychiatry got into the registry space, there was a lot of focus on MIPS reporting. So I think when we started and we came out the gate, it was all about MIPS, MIPS, MIPS. And so at this point, because that has not been able to support a lot of the things we wanna do in the future with the registry, we have to kind of sort of take stock of where we are and think about the future and strategically plan for that. So that's where we are right now. So one of the first things we did was actually, we wanted to rebrand things and we wanted to try to change the conversation with respect to psych pro and what it would mean to the APA going forward in the future, which was of course is to sort of not exclude the MIPS sort of thing, but to kind of make that less of a focus. So some of our vendor challenges and many of you who are in the registry space may have a similar, have had a similar experience because we were MIPS focused, our original vendor was very MIPS focused and that's where we started. So when we started to ask for things like measures that weren't QPP or MIPS measures, there was an issue with implementation of those kinds of things or development of measures that we might not necessarily be thinking of for implementation in MIPS. Collecting data from sites who weren't interested in participating in MIPS was a challenge because the data that we collected was targeted for MIPS. So in 2021, we decided to change vendors and we had a broader scope with our new vendor to of course develop dashboards and other resources and tools that were not MIPS focused, but we were still carrying our QCDR and the idea that we would report MIPS for folks. And so what we have found with that is that becomes, that takes over. It becomes precedent for everything and every year when you're done MIPS reporting at March 31st, you think, okay, now we can tackle some of the other things we wanna do, but you never can because oh, here comes MIPS again. So we've decided and have conferred with other specialty associations and thought about a way forward and the single end-to-end vendor solution is something we are questioning. So to sort of strategically design our way forward, we've been thinking about the registry in functional areas, right? So data acquisition as the primary function or one of the primary functions is of course key because as we all know, the data is the most important thing because there are a couple of, I don't know, you call them idioms or whatever, but we all know them, junk in, junk out, right? And then the other one is what you measure is what's focused on. So that's the part, the data part, which is extremely important. And so then we get the data, then we have to think about the warehousing and the mapping because everybody, we get data from EHRs. We're also thinking about collaborations that I think you'll hear about later with some of the other registries. So important in psychiatric care are mental health assessments, right? And there's lots of apps and new electronic ways to collect things like the PHQ-9 or other tools to look at symptoms for anxiety and alcohol and substance use screening tools and that kind of thing. So instead of necessarily building that ourselves, we've thought about collaborating and partnering with applications that collect those data and then share the data with PsychPro Registry. And then we have our dashboards because of course we collect data, it has to be meaningful for folks. And so provide reports and feedback mechanisms for them to see their data, have a view into what's going on and to help with improving the quality of care for their patients. And then of course with the database you build, the very important analytics that will help drive the profession into the future by looking at new interventions and new modes of care and things like that. So I mentioned that we met with other specialty societies and we had an RFI. And then the potential approaches of course are, again, the end-to-end vendor, doing everything in-house ourself or some combination in the middle. And so that's where we are right now. We're looking at sourcing multiple vendors along the lines of the functional areas we've identified and see how it works that way. So if things fail in one, we're not completely done. And so just our strategy, immediate midterm and long-term needs also have to be considered. And then in summary, so although we started out with MIPS, it's been good for those who did it before COVID. It's not, it hasn't helped to sort of grow the registry and garner the interest we need in attracting participants to do the things we need to do. So basically we are shifting our focus from MIPS to quality and hopefully develop a future registry that can bring psychiatry into the future. So thanks. Hi, everybody. My name's Carolyn Morgan. I work with the Society for Vascular Surgery and we're gonna talk a little bit about some of the challenges and solutions we've experienced in the collection of devices within our registries. Unfortunately, Carrie can't, couldn't come today. She's not feeling well, but neither Carrie or I have any disclosures to share. So again, we're gonna go with, have a brief overview of what SVS is, a brief overview of symmetric health solutions, and discuss the solutions and successes that we've experienced with this collaboration. So the Vascular Quality Initiative, abbreviated or acronymed as VQI, our mission statement is to improve the quality, safety, and effectiveness, as well as cost of vascular healthcare by collecting and exchanging information. VQI is a component of the Society of Vascular Surgery. And as part of that component, we are a patient safety organization. The general philosophy of a patient safety organization is to encourage honest and honest reporting without fear of any punitive action against anybody, whether it's an industry partner, whether it's a hospital system or the healthcare provider. VQI, we have divided into 18 regional quality improvement groups across the continental United States and Canada. We work with multiple commercial technology partners, and that includes symmetric health solutions. So symmetric health solutions, they are an inventory, inventory management system that works directly with hospitals and their inventory systems. And they use directly, use UDI and DI, as well as GMDN terms to collect device details, including the manufacturer, device names, the device sizes, as well as a lot of other device details. They work closely to maintain compliance and collaboration with our industry partners, as well as CMS and clinical trials. And there's a lot of clinical integration. They work closely to make sure that everybody is aware of recalls and adverse events. And with all of their work and collaboration, they've been able to simplify data entry using their barcode scanning technology. So I don't know how many of you use scanning technology within your healthcare systems, but a lot of times you have to decide which of the two, four, six barcodes you need to scan. The uniqueness with this symmetric scanning system is it'll scan the whole package and their scanning technology will pick the appropriate barcode so that there's no guessing. And it increases efficiency and accuracy of device information. So some of the challenges that SVS had with the manual list. First of all, I just wanna make sure that everybody knows, device collection is only part of our quality improvement and patient safety. We need to collect the devices to support the device efficacy and safety to our patients and help guide us into the proper direction for quality improvement. So currently, devices are collected within SVS in six different registries and they are manually entered one by one by me. It becomes burdensome because it's hard. We only enter devices into the registries that are FDA approved. So if a device is still under investigation, we don't collect that because it's not an approved device. And currently, we only collect US approved devices. In the past, before our collaboration, our data managers who were the people, boots on the ground, they're doing all the data abstraction, they were required to assign device attributes to our devices. Is it a stent? Is it a balloon? Is it a cutting device? Is it drug coded? Is it a bare metal stent? Is it a stent graft? And the list goes on and on and on. And I mean, it's a good thing that our devices are changing and advancing so quickly, but it's also hard for our data managers to keep up with all the technologies. And we wanna make sure that the information going into our registries is clean and accurate. So we had been using just solely access good ID as our repository to pull our device identification or UDIs and our device details. But what we found is within good ID, there were a number of different descriptors for devices, for instance, for balloons, or I'm gonna go out to stents. Stents are many times mounted on a balloon catheter, and then it's also a stent, so it has two descriptors. How do we know which one to pull in to the device? Then we had a number of companies that merged. So devices that were put in seven years ago into good ID, under one manufacturer's name is now a different manufacturer, and maybe the library isn't updated. And then there might be devices never had sizing put in. So there were a lot of gaps that we identified. And again, we wanna. So our solution, in July of 2022, SBS and VQI launched a partnership with Symmetric Health. We also worked with our partner, Fivos Health Solutions, to enhance our device collection tool within the embedded directly into the electronic data collection form to make the capture devices more streamlined. But the partnership with Symmetric allowed real-time... good I.D. There were approximately 70. Symmetric uses over The partnership with Symmetric allowed for nightly data refreshes instead of quarterly, manually entered device refreshes. And it eliminated, again, the manual maintenance and increased the number of device attributes or data points that can be captured. So this is our success story. We've only launched it in one registry right now, which is a PVI registry. We capture well over 35,000 devices with the Peripheral Vascular Intervention Registry. What had been just 70 device attributes stent and not just a bare metal stent. So between Fivose Health and Symmetric, we've made some positive strides. has brought to SVS, we've made great strides. Good afternoon, everyone. I'm Rhonda Bowman. I'm an oncology nurse and I work for the American Society of Clinical Oncology, or ASCO. And I'm sorry, this is two weeks of stuff that's still like, not COVID, nobody worry. It's just, it's hard to get rid of, I apologize. About our certification programs and really the evolution of the assessment and improvement of cancer care delivery. So no disclosures to report. From a learning objectives or what I'd like to accomplish is to provide some information about ASCO, the American Society of Clinical Oncology, as well as our certification programs. And also review the demonstration and practice culture and a commitment of continual quality improvement through certification. And then understanding care delivery certification. This designation adds value to patients, payers, and the medical community. I realized when I put this slide deck together, this is new for me. I've never attended a CMS meeting. All of you are new friends to me and I'm sort of like a little blown away by all of this that I'm hearing. But I thought, I don't even have a slide in here about ASCO. It's like, you guys probably don't know what ASCO is. When I'm in my oncology world, everybody knows what ASCO is. So just to give you a little bit of background, we're a big membership. We have 45,000 oncology professionals that are domestic as well as international. We have a significant international membership. Our mission of conquering cancer through research, education, and promotion of the highest quality and equitable patient care. We are the world's leading organization and professional organization for cancer care as well as we have 18 standing volunteer committees. We have a lot of activity that's going on through the committees with our volunteers and advancing programs, resources, and services. And then we have a successful certification program that began in 2010. And we have a new certification program that really is further development of this COPE certification. I'm going to go ahead and just like flash this thing totally. So this is the evolution and I would say as I am a kid growing up in oncology because I've been in oncology my whole life, I started on the left side of this continuum. I've been around a really long time. So our practice, actually Brian Barbosa in the corner is my colleague. We worked together in a practice that started all of this because there was a physician with a vision who said, we're going to start looking at quality initiatives. So the first pass at this was COPE. And so quality oncology practice initiative, somewhat of a registry. We could put it in that category because I know that I'm with all these registry friends here, but the idea being that we could look at medical records and abstract certain quality measures to do some trending and benchmarking against others and then develop continual quality improvement initiatives. We did that for a long time. It was a manual abstraction and you were guaranteed to have a migraine by the time you were done doing it. So we always looked forward to that. Every six months we had to dig into those records. That evolved to the yellow highlight of COPE certification program in 2010. So there was an idea that it's not enough to look at the medical record, but that we need to take a look at practice. And so there was a development of specific standards that were met by the practice and they invited surveyors to come in and evaluate their practice against those standards. And I'm one of those surveyors. I oversee the certification program. I love that program because it's an opportunity for practices to have a standardized way to assure safety and quality in drug preparation and administration. Lots of double checks. Nothing's going to get out the door if the practices are following the standards. That's a misadministration from my perspective. So we travel along with that and it was thought that you know we need to expand this to care delivery. It needs to be pulled up a little bit more. So that was kind of the idea of these oncology medical home standards. Standards that cover diagnosis treatment survivorship end of life care but then also include the chemotherapy safety standards. It was a big lift. It was about a five year project but just was launched just a couple of weeks ago at our annual quality care symposium. So we now have a full fledged care delivery certification called ASCO certified ASCO kind of does this thing of using our name as our brand and everybody loves it. So that worked for us. It's very specific to these patient centered cancer care standards. So a couple of things I noticed that folks start asking about the why because there's this guy on LinkedIn that says you should do that. So I want to make sure that I always address the why. And for me this is when I was practicing as I shared I've been around for a while but that why was there chemotherapy safety standards that were developed because there was a young woman who died from a misadministration and this woman was someone who was well known. Some of you may have heard about this but when we heard about it in our practice it was shocking but believable because where I worked we would pile drugs up in order of what they were and then we would just grab and go. There was no labeling there was no verification. So what was born from that are these chemotherapy safety standards and really the rationale behind that. So next I'm thinking about a why. And this goes to that care delivery standards is that value based care has been talked about a lot and I'm sure for all of you we want to provide a solution for our members and our practices of how can we help them to meet all the competing priorities all the needs that everybody's asking them to fulfill. So on the right is the care delivery system which is the ASCO certified standards and then on the left are the payment models that are out there that everybody wants our practices and our institutions to meet which include oncology care model which is just wrapped up and then the succession of it enhancing oncology model and then all the payers are out there that have all their different value based care models as well. So we did a head to head review and the standards within ASCO certified the oncology medical home standards and all of the payment models on the left meter exceed. So from our perspective and what we want to promote for our practices that when they have this designation they're going to be prepared and ready for any value based care program so you guys are looking on the right whatever side you're looking at of the wheel. So here's the standard. So there's seven domains and within those are 17 medical home standards or care delivery standards starting at the 12 o'clock position with patient engagement. Each one of these domains have standards and standard elements within them that equal to the 17 medical home and then 22 chemotherapy safety standards have remained at the 11 o'clock position. So the end result is and we'll talk about the pilot I'm doing a little bit reverse because I want to share about the program and then we'll talk about what the pilot and what we learned but that we are certifying outpatient oncology practices and institutions. So the idea is there's a single set of standards that practices know what the roadmap is. It covers everything from diagnosis to supportive care and survivorship. What it offers for the practices is a single set of standards that they can then reach out to teach their team and together reach the standards. We did demonstrate through a pilot that it was a value and success and then we have also identified that there's objective measure for high value patient centered care but also that there is early payer engagement which is kind of the good news that all this effort was worth something in regards to recognition besides an asterisk behind the practice name. So I wanted to give a shout out to our 12 pilot practices. If you know them in any way and you talk to them tell them congratulations. They took a chance on us when we looked at the practices we by design would like to have different types and sizes and that's what we got. And this was really folks that came and said we're interested. We had three academic sites. We have a big public health system in South Florida and then eight community practices that range from a couple of rural practices that were smaller and their H.R. manager was implementing their telephone triage because they just had everybody doing different jobs to the state of Tennessee which has 33 sites and 150 providers. Wanted to just talk through a couple of slides of what we found out from the pilot. So what was the value and benefit to the practice. So the recognition of being high quality and patient centered and that was through the society. So it was an objective party that is giving them that recognition. The single set of standards that were evidence based I didn't mention that the standards had gone through the evidence based review at ASCO which is very thorough in regards to literature review as well as expert opinion. And then this this fostering culture of continual quality improvement. We were on a panel. We've been on multiple panels this fall with our practices and they can't stop talking about how now they see things so differently because everything has to change. Everything has to be improved based off of the data that they're finding for continual quality improvement. One of the outputs we didn't plan on but happened is a learning collaborative. So these practices we meet every month by phone. So they become friends with each other. We have academic and community practices talking to each other. We have subgroups of EMRs and they share with each other what their best practices are. For example last week I got an email from someone who said hey do you know anyone that's looking at oral and clinic adherence and so I plugged her in with someone else. So it really has become a supportive group for each other and wanting to share information and then preparing the team for reformation or for the transition to value based care and then the early recognition by the payers. We did take a look at value to the patients because that's really at the end point patient centered. That's what this is about. So it is required for a patient satisfaction survey to be able to collect data look at any nugget that you can find in those experience surveys but also wanted to encourage a patient family advisory council so there's face time with patients and for patients to review what's happening in real time and that seems to be really where it's all at. If you can talk to a patient or their family and ask about workflow process and then overall from an insurer's perspective we had two insurers that participated in the pilot with us. One was Anthem Elevance the other was Cigna public information so I can say it Elevance has has valued this in a way that they now practices who are certified are recognized into their value based care programs meaning that they don't have to go through the assessment of the vetting process but that they're automatically entered into their value based care program because the medical director understands what the value of this is. So it's a little win. You know we'll take it. It's a marathon with the payers as you all know of trying to educate in regards to this being the universal sign of quality and acceptance into their programs and then talk about how this opens the door for practices to move forward and together with payers even though it seems adversarial at times or there's tension between payers in our practices still how can they come together then overall you know the consistency and clarity and being transparent about what quality is in cancer care and this independent mark piece so that it's not that it's you have a mark from a health from a pair but that it's from the societies and then the other thing that's different about this is it's ongoing assessment improvement we meet with the practices on an annual basis. We go back to see them every two to three years. So they can't let up. They're also submitting quality measures on an annual basis. So ongoing staying on top of continual quality improvement I'm going to close with just the fact that this is cool enough that we were able to present it to the National Cancer Plan panel. So this is the moonshot initiative and our CEO and our president was able to present ASCO certified with really good discussion in regards to what this high quality care delivery is and then how does it meet what the National Cancer Plan goals are. So we say we went to the White House you know we just wanted to like at least make it public of all the great things that we're doing for cancer patients. So there's a little QR code there. We're cool like that. And so you can hit that and then you'll be able to go to our Web site to be able to connect if anyone's interested in any other information. Thank you. So we definitely want to open it up to questions. The room's small enough you probably can can shout it out if folks don't have some I've certainly got some that I'm thinking about but but let's open it let's open it up. Yeah, he asked, kind of timing in terms of pilot to launch and then how long is the pilot and then how long is it sort of taken to kind of concept to end. So I'll share that and Brian, please chime in if I'm off base on this, but I'd say it's been five years in total of what the pilot concept is and that concept was going to stakeholders. It wasn't just like, hey, we have an idea, let's do this. There was stakeholder engagement. So talking to everybody, does this seem like a good idea? Would this be a value? We started the pilot in July of 2021 and just wrapped it up June of 2023. We made it a two-year pilot. The idea being that we did recruitment, the beginning of 2021, mind you, COVID was sort of just like still simmering and we were able to recruit those practices within that timeframe of January to June of 2021. So July 1st, practices had the standards and they needed to demonstrate that they were implementing the standards fall of 2021. So we went out to see all 12 sites as surveyors and did kind of the objective gap analysis Of the practices, none met all the standards and that was interesting for us because some of them were pretty high profile practices that had asked to be engaged. It was anywhere from like 85% of the standards to 65% of the standards were met. One practice only had implemented the standards for their OCM patients, but that was just how they approached OCM, so they carried that over. So they needed to figure out how to expand their workflow process to all patients. So we give some time for compliance work because you have to meet all the standards. So the idea is within a year's timeframe that you're certified, which is what 10 of our 12, 11 of our, 10 of our 12 practices met that. So July 1st starts the pilot site visit fall of 2021. We give them the report around Christmas time of 2021 and then they were meeting the standards by June, July of 2022. We did have two outliers of our 10 pilot group that were academic sites that had enterprise issues, which, which takes it up another notch when you're community practice, you're a little bit more nimble, but for them, that group, they had a few issues that were carry over from COVID, but also some carry over of resource for some things that they wanted to do with the standards. That help? Okay. Yeah, so originally the organization really made a heavy investment We're lucky in that we have a pretty healthy reserve at the Academy We did eventually get industry support as well. So industry does foot the bill for a lot of our registry work The partnership between us and the American Association of Neurological Surgeons for the American Spine Registry Did help kind of split the costs, but it is a very very heavy investment. Yeah, it's very expensive Yes millions of dollars I'm sorry We don't we don't currently know You might be a plant so so my my expertise is actually in clinical practice guidelines not registries I'm filling in for a colleague of mine but this is kind of the Holy Grail for for our team is to take that registry data incorporated in with the published literature that we're using in our systematic literature reviews and and combine it in a way that can be even more impactful for the for the end user with our clinical practice guideline recommendations. We're we're getting close to figuring out how to actually extract the data analyze it based on whatever PICO questions we're asking for the guideline. The problem that we're really running into now is how do we score. So for all the all the evidence that we use in clinical practice guidelines we assess the quality of the studies based on if there are cities or what what potential conflicts they may have. There's no doesn't seem to be a general consensus on how to use registry data and how to assess the quality of registry data because we're looking at it retrospectively but we are. We do have like a prospective question that we're trying to answer. So that's what we're trying to figure out now is how to actually incorporate it in a way that we can address the quality issue along with other evidence that we have. So it is for yes we are also using the data that is input in the registry to support and refresh our guidelines so hopefully we'll be able to use some machine learning or A.I. to do faster turnover because I mean it takes time. You want to get multidisciplinary task force to provide input. But we are heavily into using guideline and appropriate use criteria as well and supporting that with registry data. So for psych pro that is the plan of course as well. The any guidelines written by APA have in them quality measures like that could be calculated. So eventually it would be that those would be done in the registry and then have like kind of like a real time assessment based on the current guidelines and be able to report that to folks in the registry and I'll chime in although my colleagues Brian Bourbeau and Stephanie Jones are here in regards to really looking at quality measures and using data that is from claims based data as well as also looking at the standards and how can we develop quality measures related to the standards really to make them even more robust. So the registry objectives, like the mission and vision for the registry, which is paramount. So I think for us, you know, we thought about, you know, the registry is this thing that's going to, you know, collect data, research, improve patient care, but then we picked a vendor who did MIPS, and then so that didn't really connect with the data we were collecting and what the vision was and that kind of thing. So I think when you start from your objectives, the strategy for the registry and all of that, when you then go to source a vendor, they have to be able to provide the functionality of the pieces that you're going to need to achieve, like, your objective, right? So for us, if it's we're going to need to build a robust database that we could access for analytics and research to look at, you know, the efficacy of treatment and that kind of thing, then they have to be able to collect data, and if it's the EHR data, that we can use to do that, right? So with the focus on MIPS, we couldn't do that because then folks would say, oh, you can't have that data because, yeah, I only want to report these two measures or whatever else, right? So it just has to line up, I think, with your objectives and your vision, and then, you know, you're picking a vendor who can do the things, like, provide the functions that you need to meet those objectives. But they're very good at telling you what they can do, like, the vendors, right, and showing you. So it's kind of, like, sometimes I feel like it's a crapshoot, but so I think that's why we're trying to do more of it ourself and bring it more in-house, like, different pieces so that we have more control. I already told this gentleman that they're very expensive but so you have to have complete buy-in from the board. I mean now we're so far down the tracks that even if we did see a dip in industry funding we would you know compensate with with our reserve funding towards that but we have full buy-in from the board we have full buy-in from from our council and committees who oversee the registries and luckily we we haven't seen too much pullback yet but it's always you know it always fluctuates just like the stock market on on how much industry has to invest any given year you know they may decide to decrease funding halfway through the year when you had projected that you're gonna have that funding but from from our perspective I can't speak for everybody else from our perspective we've proven the value we have the numbers that actually make it reusable in terms of putting research out there and actually affecting the quality of care for orthopedic patients so that's really the baseline so long as your organization is financially healthy enough to sustain any dips that you may see in industry depending on how they're feeling at the moment then we're going to continue forward. If anyone would like to adopt Jason's board members please see him after the meeting. For us that's the question we're challenged with right now is like how are you gonna make this sustainable I think there's we're trying to you know have them understand this like what the ortho board understands it's the focus is patient care right so if you're a healthy organization and your mission is to provide the highest quality care then I expect some of the risk you're gonna take some of that risk to to do that and be the organization to say that we are taking care of our patients right as well I think there are opportunities to develop programs like what ASCO has right and you know at least have folks pay for those things right and and you know if they see value in it then they're gonna pay for it and at least if we can break even I I think that would be a good thing. SVS is going through the same thing you know we partner a lot with our industry folks to help support us because again this isn't about the registry this is about taking care of our patients and providing evidence-based data providing evidence-based data to say maybe there's a gap somewhere and maybe we can improve something I always go back to this one example that some of our centers were seeing a lot of groin infections after an infrainguinal bypass and it was something as simple as sending that these patients home and it's very sad with a bar of soap and some disposable underwear to get them through the first few days so that their skin can start closing up but this is the value that we we see and then there is a you have to sell you have to provide value back to the centers that are enrolling and you also have to be mindful of the data burden that we're asking our centers yeah yeah so it's job security for me but it's something you always have to keep in the front of your mind and maybe with our advances in technology again machine learning and AI that this will help well that's that's what I'm wondering I mean what what from that last presentation from Mike Howell what excites you like what what about the future of being able to sort of think about this do this differently that there's gonna be some additional support I mean obviously you're all amassing giant quantities of information that you know could be generating a lot of a lot of things so so what what do you see is the next exciting thing so what's exciting right now we've SVS has been talking about this for a long long time but we're finally starting to make movement we heard Dr. Howell talking about building stuff into the foundation we are starting to build our registry variables into the epic foundation so that will automatically populate the data variables and sent over to five O's which will then send it into the pathways electronic data collection form to decrease registry burden and decreased level of effort and increased productivity for everybody yeah yeah so so remove sort of that administrative burden which I think is still at the you know the end of the day one of the things that are driving our physicians crazy right it's that it's that being thought of as a widget as opposed to being able to use this technology to help others I just so I just I just had first a thought about your question in regards to how is this sustained I think that the standards and this certification has opened up tremendous opportunities for our organization and so we have lots of projects if you ask Brian and Stephanie they have a long list we have a ton of things that are coming in the pipeline you know to sustain us and that excites our board I think regarding the AI piece we are we're just starting to get into this and specifically to phone triage so one of the practices that's in our pilot hem was in unable to staff triage team like like you just can't find people to work anymore in particular post COVID and so they actually went out to a vendor who has a bot that does the initial response to the patient in regards to what their symptoms are and then makes an evaluation if that needs to be elevated up to a live APP and then possibly to a home visit so you know it's starting and electronic patient reported outcomes there's things that are starting we just have to get focused on it and then find some resources to help us get it deployed but you know I think it's coming my colleague and I were actually just talking about using machine learning to help do risk calculators based off the data that we have in the registry so we would like to kind of dabble in that area and guidelines we're certainly more than dipping our toe in the water with machine machine learning and large language models to actually identify because so the guideline process is you know you do your literature search you have abstract review full text review quality evaluation data extraction then you bring it back to your multidisciplinary panel and you make guideline recommendations on that so the the abstract and full text review are kind of the time sucks you know we have analysts we're lucky to have analysts on staff who actually day in and day out go through abstracts and extract data I don't know how they do it without going crazy but they do but so we're trying to use large language models we have a whole host of data on previous guidelines to build the model on to more quickly get to which articles are potentially relevant to the Pico question that was being asked so that's ways that we're kind of trying to incorporate some of this emergent technology in our group I think with the emerging technology question so when I was mentioning before about like data and the significance of that like you know AI and machine learning it's on data and it has to be good data right so psychiatry as a field they were not only last with the adoption of registries they were last with the adoption of like EHRs and any kind of documentation standard so I think you know thinking about that in this space is going to be a challenge since those data I think are still not quite there where that's the value is gonna be able to be extracted with with those new technologies but I think there is exciting spaces when you think about things like wearables those data so everybody knows like sleep and different behaviors are associated with behavioral health and so collecting those kind of data are exciting and thinking about how to use that in the future we are at time so I want to thank the panel thank you all for for being here as well and I think we're moving from this to a reception anyway right so I think we can continue the conversation here or there so thank you

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