Welcome to ACQUIRE, the OGS Quality Registry. ACQUIRE is a MIPS qualified registry, and the goal of ACQUIRE is to allow for providers in female pelvic medicine and reconstructive surgery to participate in quality reporting and avoid the penalties associated with non-participation in quality reporting for CMS. This is developed to report meaningful quality measures that be easy to use for providers. This video serves as a brief introduction to the registry and how to use it for quality reporting. The database is straightforward to use. Once data agreements have been completed, providers will be given their own login credentials that they can use to log in. In addition, any site with multiple providers, one provider will have administrative privileges to allow for review of all providers within that group. It's important to note that this is the first iteration of the registry, and as with all programs, this registry will undergo evolution and improvements. So once you enter, you'll hit the landing page where you'll see two areas, including performance and patient information. And we're going to ignore those for right now and focus our efforts on add new patient. This is the process for adding patient information. So clicking on this will result in a demographics page appearing. This requires minimal demographics and includes four areas that are required. The first is the medical record number, and we recommend that you use the same type of medical record number for all your patients. So either use your office medical record numbers or your hospital medical record numbers, but try to maintain a consistency there. A date of birth is self-explanatory, and we recommend entering it manually as it takes a long time to go all the way back into the months. First name is required, as is a last name. Insurance type can be selected if you're interested, but it's not required. Data service, you'll have the opportunity to enter that in. It's generally the default date is the same day data entry. We recommend doing this the same day that you operate, as that's when the information is most fresh in your mind. You'll notice that I cannot pick a date in the future because it will not allow for future data entry, so all data entry will have to be after the procedure. Picking your date will then populate the patient age, and then the data entry area will appear, and you'll see there are five domains, diagnosis, procedure, history, intraoperative, and postoperative. And you'll notice that some of these areas have no questions populating them, and the reason for that is until we have some of the baseline information about the diagnosis and procedure, we can't do that. And the reason for that is until we have some of the baseline information about the diagnosis and procedure, we don't know what quality measures will be relevant. As information is entered, relevant quality questions will emerge in these different areas to allow for quality measures to be captured. We try to minimize the number of questions answered and keep it only to those that are relevant to the patient at hand. So if the patient had a surgery of pelvic organ prolapse or urinary incontinence, these questions are answered. Patients with stress incontinence can participate in this database, and they'll have the opportunity to have the information entered in the procedure. It's simply not relevant to any of the quality measures, whether she had stress incontinence. You'll see there are other questions here, including a procedure for a diagnosis of gynecologic or pelvic malignancy performed at the same time, or a procedure for a separate benign gynecologic diagnosis. And this makes sense, that you would not want to penalize somebody for not offering a pessary for somebody who's having surgery for a uterine malignancy at the time of a prolapse repair. So identifying a yes to these questions will result in this case being removed from the relevant quality measures. Next, we come to procedures, and was a procedure performed for pelvic organ prolapse? If so, you'll have the opportunity to address which areas were repaired. And was a hysterectomy performed? And if so, was it done vaginally? And was it done for pelvic organ prolapse? And then were any of the following procedures performed, a continence procedure, urgent continence procedure, or fecal incontinence procedure? And the date of surgery is entered manually to confirm that we have the right date. You can see now that several questions are now populated in the history, and these are quality measures related to events performed preoperatively. So was a risk assessment with a risk calculator performed, yes or no? Was preoperative sexual function assessed? If yes, we click yes. If no, then we have the opportunity to explain, was the patient unwilling or unable to participate in the assessment of her sexual function? Many of our patients are elderly, demented patients who are unable to participate in that discussion, in which case that would be excluded. You would not be penalized for not assessing preoperative sexual function. Was a pessary offered? And was a pessary attempted? And was the patient screened for stress incontinence? And finally, was a preoperative objective measurement system used to characterize the degree of prolapse? So all patients undergoing prolapse, would it be expected a POPQ or a Baden-Walker system be performed preoperatively? Enter operative, many of these quality questions are familiar to us. Was VTE prophylaxis indicated? Yes, and if so, was it given? Did the patient require antibiotics? If so, were they given and when they stopped within 24 hours? Did the patient die during the procedure? If the answer is yes, there's no point in doing cystoscopy. If the answer is no, the cystoscopy question will stay there. Was the surgery performed emergently? If yes, then we don't really care about pessary fittings. If it was not performed emergently, then the pessary fitting becomes relevant. Was an intraoperative rectal exam performed at the time of prolapse repair? This relates to an apical suspension. For patients undergoing posterior repairs, was synthetic mesh used? And was an intraoperative cystoscopy performed? This is a quality measure for prolapse. Finally, we have three postoperative questions, including bladder, bowel, and ureteral injuries, and we can comment intraoperatively, was there an injury to any of these? But as you can note, these are reported within 30 days of surgery. We can't comment on 30 days of surgery until they have passed. So as we save this, we'll want to press save and not save and complete, because if we press save and complete, we can no longer update this information. I do want to point out that bladder injuries are relevant for those of us performing midgerithal slings. So if we have a midgerithal sling injury on the day of surgery, was the only bladder injury perforation a midgerithal sling trocar, in which case, yes, this will now become an exception to the bladder injury outcome measure. If it's no, then it's no, and you had a bladder injury, and that will be captured into the information. So we're going to save this. And this brings us back to our landing page, where we can see all of our patient information. So we can see I've got 17 patients in this database. They can be sorted by first name, last name, date of birth, or medical record number. I can also search for any of them. So some of the ones that have been entered here, I can go looking to find them to see if I would need to update anything or find anybody. So if either Vladimir Trump or Kellyanne Trump need an update, I can search for them. Now, you'll see up here is a bell with the number two next to it. These are two patients that have post-operative patient information waiting to be entered. And I click on that. We'll find that I've got these two patients, and I'm going to look for it. So here's Katherine Thompson. Her surgery was over 30 days ago. I'm going to come down here, and I'm going to confirm that she's in this database. She did find her in a post-op, so now I'm going to save and complete that. And with that, you'll notice that now goes to a one, and my patient information is updated. So this part of the registry includes performance outcome measures. We have a total of 19 different quality measures. Providers do not need to report all 19 measures. You only have to report six, and you have the opportunity to select whatever six you would like. So it obviously makes sense to select the six that you're the best at. For instance, here, number two, which is pelvic organ prolapse preoperative assessment for occult stress urinary incontinence, we have 100% compliance, 13 eligible, 13 met. I'm going to want to report that one. If we look further on, I've got a couple other where I've got high compliance. I've got 100% with compliance, and I'm going to report that one. I've got 100% with complete assessment and evaluation of pelvic organ prolapse prior to surgical repair, and several others where I've got 100% compliance. And so those will be the ones that I want to select. But also looking at this, I realize AUGS number one. I say cystoscopy at the time of hysterectomy for pelvic organ prolapse to detect lower urinary tract injury. I always do that. And I see I have 13 patients who are eligible. Ten of them have met, but three of them have not met. So I'm going to click on that and say, all right, which ones are a problem? And I see here, okay, this one's a problem, this one here. So let's go ahead and take a look at some of them and see what's going on. So I look at Teresa Zim here, and I call her up. We're going to update the visit and take a look and see what's happened. Now, this one has not been saved. And that's important to note here because I look and I say, okay, was an intraoperative cystoscopy. There's my problem. I didn't pick it. I forgot to answer it. So I'm going to say, of course I did. I press yes. Again, I'm going to press save. I don't want to press save and complete until I'm completely finished with all data entry, and I'm not sure that we're at 30 days there. So that's good. The visit was saved successfully. And I look and I say, look at that. It has been updated. So now I've only got two that have not met. Okay. So I click on that two, and let's see who else has not met. There we see Karen Acorn and Catherine Thompson. So let's take a look at Karen Acorn. So I'm going to sort this. And there's Karen Acorn. I'm going to go to update information. I'm going to go to update visit. And there's my information. And one thing I note, this has been grayed out. Uh-oh. I've got a problem. And sure enough, I forgot to answer that question. And so because it's grayed out, I can't save anything. It's already saved and complete. It's locked. And so I have a problem because there I have a question I didn't answer. And because I hit save and complete, I can no longer correct this. And that's an important thing to be aware of. And so we don't want to press save and complete until you're truly sure everything is finished. And as noted before, I've got two here awaiting patient information notification, two more waiting for data update. So I can go ahead and update those patients. And we see here there's Teresa Zim. Okay. And I have just corrected the intraoperative cystoscopy. And, by the way, I can say, yes, it's been more than 30 days. I'm going to click no, no, no. Now I press save and complete. And I'm back at my landing page. And my problem is I've got two that I've not met because I did not complete the data enter correctly. So this concludes our introduction of the registry. We thank you for your attention. And we're happy to take any questions that you may have. Thank you very much.

ACQUIRE

OGS Quality Registry

MIPS qualified registry

quality reporting

CMS penalties