Tugboats, End Results, and the Professional Obligation to Participate in a Registry

Ernest Codman, an 1895 Harvard Medical School graduate, became a surgeon at the turn of the 20th century. He spent his life on a crusade to reform surgical practice and medical care, formulating what he called the “end result system” in which he followed-up on patients and systematically measured their medical and surgical outcomes. Codman is rightfully considered the father of the quality movement. Standardizing basic practices was a novel concept in the early 1900’s, but support for the idea came from unexpected events. In a 1932 storm, 2 barges were lost because tugboats were not equipped with radios. The tugboat company was found negligent for failing to provide this necessary equipment when it was demonstrated that four other tugs avoided accidents because they had radios. Since then, the process of establishing standards and holding organizations accountable to them has improved the safety of industries from medicine to coal mining.

Codman also initiated one of the first registries – a sarcoma registry, which takes me to why I am in Chicago, at, “The Future of Clinical Registries Summit,” convened by the Council of Medical Specialty Societies (CMSS). This is a photo of the room to show how packed it is.

In 2012, the CMSS identified the establishment of registries as a physician responsibility. Now in 2018, there are 31 specialty societies here with 49 registries, representing an aggregate of $500 Million of investment, nearly all of which was funded by the specialty societies themselves (meaning, by physician member dues). Yes, that’s an average of $10 million per registry.

There is one thing we know for certain – active use of performance comparisons from registry data improves patient quality of care. Many examples were presented from specialty societies – one of which is that of IVC filters. We all believed that they reduced complications from deep venous thrombosis. However, registry data from a Collaborative Quality Initiative (CQI) convened by Blue Cross Blue Shield of Michigan demonstrated that in fact, they increased both morbidity and mortality. Within a year of this revelation, there was a 90% reduction in their use and now they have nearly disappeared.  It typically takes 15 years for new evidence to become standard practice, but registries married to quality improvement programs can change practice fast, particularly when payers are involved.

Interestingly, specialty societies that had registry reporting mandated as a condition of payment (like Cardiology often has) called that mandate, “good luck that sadly, doesn’t last forever.”  Mandatory reporting helped get many physicians and societies past the barriers to participation.

Universally, the 4 biggest barriers faced by societies in implementing a registry are:

  1. Getting doctors to accept the use of measurement
  2. How much the registry will COST the society
  3. Getting relevant outcomes from patients
  4. The burden of registry implementation

Here are 10 things I saw today that nearly all specialty society registries had in common:

  1. MIPS Reporting: they all provided quality data submission to CMS for members
  2. MOC: All used them for Maintenance of board certification
  3. Quality Measure Development: they develop quality measures through their Qualified Clinical Data Registry (QCDR) to fill gaps in the MIPS program
  4. Benchmarking: they use Quality Measure data for benchmarking services to practitioners
  5. Quality Campaigns: they use QM performance to develop campaigns some of which are national in scope and which may involve helping patients find the best care.
  6. Commercialization: they all at least TRY to monetize data via industry agreements
  7. Research: the nearly all publish scholarly papers on their findings
  8. Prediction: they develop risk models to predict outcome and help guide decision making
  9. QI: they are dedicated to using registry data to improve patient outcomes which means changing practice in response to data
  10. Demonstrating Value to Support Payment & Public Policy: they actively share data with payers

That last point is really important. This isn’t just about altruism. In 2017, Blue Cross Blue Shield of Michigan began to pay a differential for quality and outcomes based on the data from their Collaborative. They found that clinicians in the top tier of quality performance had shorter hospital stays, lower costs, and fewer adverse events. Last week the US Wound Registry demonstrated that practitioners who engage in registry reporting have 10% better diabetic foot ulcer and venous leg ulcer healing rates than their non-reporting colleagues. I think by next year we will be able to show that they decrease time in service and cost of care as well. We plan to take that story to the payers.

Dr. Tim Ferris, the Chairman and CEO of the Massachusetts General Physician Organization, home of the Codman Center for Quality initiatives, concluded, “There is a professional obligation to build, maintain and use registries. In fact, it’s an abdication of professional responsibility if a registry exists that’s relevant to your practice, NOT to participate.”  Registries are to medical practice what communications are to tugboats – it is now considered negligent for practitioners to try navigating the treacherous sea of real world practice without a registry to monitor and improve performance. Thanks to Codman, the surgeons had about 100 years head start. We have a lot of catching up to do.

Resources:

https://cmss.org/wp-content/uploads/2016/02/CMSS_Registry_Primer_1.2.pdf

https://cmss.org/wp-content/uploads/2018/04/CMSS-Future-of-Clinical-Registries-Summit_Agenda-_updated_040518.pdf