First national urology-wide registry gathers steam

The AUA-sponsored AQUA Registry is gaining momentum as more U.S. urologists choose to sign on with the first national urology-wide registry for quality reporting and more.

Dr. WolfThe overarching goal of the AQUA Registry (AUA Quality Registry) is to enhance the quality of urologic care, says J. Stuart Wolf, Jr, MD, who chairs the AUA’s Science and Quality Council.

“There are secondary goals also. We hope it can be used to provide insight into urologic practice. We hope to inform some of our policy decisions based upon what’s happening with managing certain diseases. There’s an educational aspect to it too,” said Dr. Wolf, professor and associate chair for clinical integration and operations in the department of surgery and perioperative care at Dell Medical School of the University of Texas, Austin.

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The Centers for Medicare & Medicaid Services (CMS) has approved the AQUA Registry as a Qualified Clinical Data Registry (QCDR) since 2016, which means urologists can use it to satisfy federal reporting requirements (Physician Quality Reporting System [PQRS] in 2016 and the Merit-Based Incentive Payment System [MIPS] in 2017).

“The AQUA Registry should make meeting those requirements as easy as possible. I don’t think anyone would consider this an easy process, but on the other hand, compared to some of the alternatives, certainly [the AQUA Registry is] easier and more meaningful,” said J. Quentin Clemens, MD, who until the end of May 2017 is chair of the AUA Data Committee, which oversees the AQUA Registry.

Dr. ClemensAdvanced Alternative Payment Models (APMs), which offer another way of meeting these requirements, are generally what hospitals and other health care systems or groups use to manage patient populations. APMs assess their quality of care and the cost, according to Dr. Clemens.

“Those tend to be for larger groups and the quality measures tend to be more broad-frankly, not really focusing on urology,” said Dr. Clemens, professor of urology at the University of Michigan Medical Center, Ann Arbor.

An example of how urologists might use the AQUA Registry in practice is to measure PSA testing at certain intervals after prostatectomy, according to Dr. Wolf. The registry will track a provider’s practice for that measure and post the results periodically on the practice dashboard. If a provider only has obtained PSAs on 65% of surgical patients and the national average is 85%, that provider might up his or her game, Dr. Wolf said.

Next: Expanding conditions, applications

Expanding conditions, applications

The registry started with a focus on prostate cancer but has been expanding into other urologic conditions.

“We now have measures for BPH, kidney stones, female urology, and nonmuscle-invasive bladder cancer,” Dr. Wolf said. “We have ongoing standing committees whose job is to assess guidelines and other clinical directives and turn those into measures for the AQUA Registry.”

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Dr. CooperbergMatthew Cooperberg, MD, MPH, associate professor of urology and epidemiology and biostatistics at the University of California, San Francisco, who is a senior physician adviser for the AQUA Registry, said the registry has a menu of more than 30 measures. Practices choose nine measure on which they want to report for the purposes of PQRS reporting or six measures for future MIPS reporting.

“The traditional way of getting a new quality measure into PQRS was extremely difficult and burdensome, and you had to go through this multispecialty committee that may or may not really understand the condition for which the measure is being developed. Now, with AQUA, we have the latitude to develop whatever measures we believe are important. As the AUA updates its guidelines, the guidelines’ working groups are helping develop new quality measures. As long as CMS accepts the measures, we get those straight into the QCDR,” Dr. Cooperberg said.

“So, quality reporting is going to become much easier and much more relevant for urologists than it traditionally has been.”

Participation in AQUA also helped urologists get credit for EHR Meaningful Use in 2016 and potentially will help them get credit for Advancing Care Information for MIPS reporting as of 2017. In the near future, participation is expected to help satisfy maintenance of certification requirements, too, according to Dr. Cooperberg.

AQUA will never send patient-level data out to any third party. But the AUA expects to offer aggregate analysis services on behalf of interested third parties, including academic researchers, Dr. Cooperberg says.

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As of April 2017, about 70 urologic practices, representing more than 900 urologists, were fully on board with the registry, according to Dr. Wolf. That means they’ve signed up and taken the necessary steps to integrate the AQUA Registry into their EHRs. In total, 448 practices have signed up to start AQUA; of those, 153 practices, or 1,594 physicians, started the mapping or the process of collecting data with the AQUA Registry.

“We’re increasing that number every month,” Dr. Wolf said.

Next: What it takes to get on board

What it takes to get on board

Dr. SuhUrologist Ronald Suh, MD, of Urology of Indiana in Indianapolis, said his group practice was the 30th practice to sign up for the registry. While most of the work setting up the interface to build a connection between a practice’s EHR and the AQUA dashboard and registry is done by FigMD (www.figmd.com), the company the AUA commissioned to do the work, there is some work involved on the part of the practice during the start-up process.

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In essence, FigMD makes the connection with a practice’s data, including charts, which is stored in servers. That can be easy or difficult depending on how restrictive a practice EHR is in terms of allowing access to structured data, Dr. Suh said.

After FigMD makes the initial connection, there might be back and forth with the practice to refine from where the software pulls the data.

“You then go back and have a conference with them. We did it over the phone through a webinar. And they basically sign on and watch you use your EHR system, and they look and see where you’re documenting,” Dr. Suh said.

It took Dr. Suh’s IT department about 30 minutes to build the connection and allow FigMD’s software into the practice’s firewall to extract the data from its system, according to Dr. Suh.

While the process might not require much time, it does require physician participation. Each practice needs a physician champion who understands the clinical side, quality measures that are being captured, and how the practice, in general, is using its EHR to sit down and go through that process with FigMD, Dr. Suh explained.

The software for the AQUA Registry pulls data from Dr. Suh’s practice weekly. While daily dashboard updates are an option, Dr. Suh and his partners decided they didn’t want the process to potentially disrupt their servers during the work week.

“The secret sauce to this registry is that it’s all EHR based,” Dr. Wolf said.

Therefore, participating in the registry costs less because urologists don’t have to employ staff to do manual data input. It’s seamless. Urologists use their EHRs as they normally would, once it’s up and running, according to Dr. Wolf.

For now, Dr. Suh said, the AQUA Registry’s draw for many urologists is that it can satisfy some of the CMS reporting ­requirements.

“I don’t know that I can say that by participating in the AQUA Registry that we’ve elevated the level of care,” Dr. Suh said. “But I think that it definitely has the potential. I get to focus on reporting urologic quality measures, instead of reporting measures that are really meant for more of a primary care environment, like influenza vaccinations and follow-up of hypertension. By having the opportunity to measure and track urologic quality outcomes in the AQUA Registry as a Qualified Clinical Data Registry, that at least gives me a chance in this new environment to improve the urologic care we provide and, ultimately, the urologic care we provide.”

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There is a cost for joining the AQUA Registry. For the first few years of the registry, the AUA bore physician practice costs for joining. That will be changing soon. Going forward, the AUA will subsidize the registry but will not pay for it completely. That cost, Dr. Wolf said, wasn’t formally announced at this writing, but urologists can find out more by going to the AUA’s website (www.auanet.org/AQUA) and clicking on the “Sign up for AQUA” tab.

Next: Real-world results

Real-world results

Dr. Cooperberg recently presented a plenary presentation on AQUA-generated prostate cancer data at the AUA annual meeting in Boston.

“We already have over two million patients in the registry, including over 35,000 men with prostate cancer,” he said.

While Dr. Cooperberg and colleagues were still finalizing their update on practice patterns for prostate cancer in the U.S. at press time, he shared that AQUA data is shedding light on the issue of overtreatment of prostate cancer.

“Recent studies, including one we did at UCSF through the CaPSURE registry, have shown a major rise in the rate of active surveillance for low-risk disease. It has been unclear whether we would see that at the national level as well, and in fact we are. It’s great news,” Dr. Cooperberg said.

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In essence, AQUA is already helping to validate findings from more select data sources.

“I think it’s the broadest sample of what we have been able to collect yet in what is really going on in prostate cancer,” he said. “There’s still a lot of variation in care. Whether you get surveillance, radiation or surgery still depends pretty heavily on which urologist you see. That’s always going to be true to an extent, but I do think we need to work to reduce that variation.”

Dr. SheltonJeremy B. Shelton, MD, MSHS, assistant professor of urology at UCLA, received an AUA Data Grant to study optimal uses for the AQUA Quality Dashboard.

“We’re going to focus on four early adopter sites,” Dr. Shelton said, “and conduct a pilot implementation trial of how to optimize the AQUA Quality Dashboard. We’ll look at fully participating practices that have access to the dashboard, and figure out ways that we can optimize its use within each clinical practice to drive improvements in quality of care.”

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