Using IRIS Data to Set Benchmarks for Retina Patients

AAO provides unprecedented access to clinical data.

NIVA DORELL, CONTRIBUTING EDITOR

The IRIS registry (Intelligent Research in Sight) is the American Academy of Ophthalmology’s national registry of ophthalmic ambulatory encounters and the only source of real-time data on ophthalmic care nationwide. Since IRIS’s launch in 2014, demographic and clinical data from approximately 88 million office visits to 13,739 ophthalmologists have been recorded in the IRIS database.¹ According to the American Academy of Ophthalmology, two-thirds of practicing ophthalmologists nationwide have contracted to send data to IRIS. “The goal is to be able to capture data for every single eye patient examined by every single ophthalmologist in the country,” says Michael Chiang, MD.

So, what is holding some people back from signing up? Perhaps not everyone is aware of the fact that the IRIS registry is free to AAO members and fulfills several important functions that affect every ophthalmologist in the United States.

QUALITY IMPROVEMENT TOOL

While empathy, compassion and kindness might rank highest with patients in general, competence and effectiveness are no less important in defining what constitutes a good doctor,² but perhaps challenging to measure — until, for ophthalmologists, now. IRIS allows individual ophthalmologists to measure their performance against composite benchmarks that reflect the performance of their peers around the country. “For example, if you’re doing cataract surgery,” explains Dr. Chiang, MD, a professor of ophthalmology and biomedical informatics and clinical epidemiology at the OHSU Casey Eye Institute and a trustee-at-large, “what fraction of your patient have 20/40 for better vision within a certain time frame after the surgery? Or what fraction of your patients had surgical complications that required a return to the OR within a month after the cataract surgery? An individual ophthalmologist submits their data to the registry, the registry calculates those quality benchmarks and the doctor goes to a dashboard and looks at how they’re performing compared to all the other ophthalmologists around the country. The idea is that for the areas where you recognize yourself as not doing well, you can then identify them and take steps to improve.”

George Williams, MD, AAO’s Secretary for Federal Affairs and Chair of the ophthalmology department at Oakland University’s Beaumont School of Medicine in Michigan, whose practice also participates in IRIS, uses the registry to see how his performance compares to his peers for various criteria. “There’s one quality measure that involves reporting back to the primary care physician for the management of diabetic retinopathy,” says Dr. Williams. “We can look to see how our practice as a whole is performing, then we can break down the data to see if we have a problem with an individual who is not filling that requirement. That has direct implications on our quality measurements, and that of course has direct implications on our patients.”

Furthermore, because of the vast amounts of data in the IRIS registry, doctors can look at specific processes, for example to determine how likely it is overall that an individual operation will necessitate further treatment, such as a return to the operating room. “We can also look to see how many drugs patients get, what percentage of people are only treated with one drug, what percentage of people are receiving two drugs, what percentage of people receive three drugs, or if one drug is associated more with a higher rate of complications, such as retinal detachment,” Dr. Williams explains. “We can literally have millions of projections analyzed and come up with very powerful data.”

SIMPLIFICATION OF SUBMISSIONS

In the past 10 years, ophthalmologists and other doctors have had to report to a number of health care quality improvement incentive programs like the Physician Quality Reporting System (PQRS), initiated by the Centers for Medicare and Medicaid Services (CMS). Whereas traditionally the paradigm in the US was that doctors get paid for volume of care, the pay-for-performance model offers financial incentives to physicians, hospitals, medical groups, and other healthcare providers for meeting certain performance measures, as well as penalizes health care providers for poor outcomes, medical errors, or increased costs.

Unfortunately, the rules for submitting to PQRS often change, making it time-consuming and cumbersome for doctors to review their charts, keep track of all the rules, and submit for paper performance programs on their own. However, if an ophthalmologist belongs to the IRIS registry, the AAO takes care of all of that in the background and submits to PQRS, or any other relevant paper performance programs, on his/her behalf in a variety of specific measurements.³

Measurement of quality is becoming increasingly important from a federal reimbursement perspective. Because IRIS registries, Big Data and electronic health records are intimately tied to quality of care, they affect how doctors are going to be paid moving forward.

MAINTENANCE OF CERTIFICATION

Ophthalmologists have to recertify every 10 years by working with the American Board of Ophthalmology (ABO) to see if their path as an ophthalmologist is in line with national benchmarks. While more of a long-term goal, maintenance of certification is another way that ophthalmologists will be able to utilize the IRIS registry in the future.

The AAO is currently collaborating with the ABO to harmonize these maintenance of certification exercises together with what’s in the IRIS registry with the ultimate goal of using the IRIS registry as a mechanism to submit for maintenance of certification and track quality improvement from a board certification perspective.⁴ The goal is to have it in place in 2017.

CLINICAL RESEARCH

The IRIS registry is one of the biggest ambulatory registries in the US in part because ophthalmologists have joined in large numbers, and because ophthalmology is a high volume specialty. With such an enormous amount of data, roughly 88 million patient visits in a little over two years, it is a potentially powerful tool and resource for clinical research and for quality improvement on a national level. Questions such as: do certain drugs work, do certain things cause side effects, what’s the natural history of disease, what are the medical or surgical outcomes of disease, and many more, could be answered by the analysis of data in IRIS.

“If you have a registry that doesn’t have that many people, it’s not that useful. You have to look at big data,” says Dr. Chiang. “Registries in general can be really powerful tools for recruiting or identifying patients for clinical trials. Right now, the way that we enroll subjects is very hit and miss in many ways. Registries are a potential mechanism for identifying subjects who may fit certain eligibility criteria. There’s enormous potential.”

“I’m heavily involved with clinical research, and there is tremendous potential value in analyzing outcomes of a large number of patients over time,” says Charles Wykoff, MD, Ph.D., codirector of research at Retina Consultants of Houston, Blanton Eye Institute and Clinical Assistant Professor of Ophthalmology at Weill Cornell Medical College at the Houston Methodist Hospital. “In Europe there are excellent models of databases and patient registries that are set up to collect patient treatments and outcomes. IRIS could definitely be used to do that.”

GAME CHANGER

According to Dr. Williams, the beauty of the IRIS registry is that it’s all computerized. Not only can its sophisticated algorithm go into medical records and search out specific information, but it can also function with up to 40 electronic medical record systems. In addition, the Academy is working on integrating IRIS with EPIC-based systems at several academic medical centers.

“Currently, IRIS looks at more than 350 measures of data points using electronic medical records, pulling out things such as vision, patient demographics, procedures, and doing this on a real-time basis,” says Dr. Williams. “Over the course of a year, we can determine how often a patient with a particular disease is treated with a particular treatment. It’s very seamless for the ophthalmologist. This is a game-changer beyond anything we’ve seen in ophthalmology.”

CONCLUSION

There is no doubt that the IRIS registry is here to stay and likely to grow. It is now recognized in Washington DC and health policy circles as the largest registry in the world.

“By 2018, we’ll have projected data in 40 million patients and more than 130 million individual patient encounters,” Dr. Williams says. “That kind of data is beyond anything we’ve frankly imagined. We’re very excited about the potential for this to make us better doctors, both at an individual and at a professional level.” RP

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