IRIS: “big data” comes to ophthalmology

How will the first registry for eye diseases impact patient care and your practice?

By Joseph F. Jalkiewicz with additional reporting by Christine Bahls

The AAO went live with its version of a patient data registry and reporting system in March. Called IRIS, this national database quickly received federal recognition for its reporting function: academy members, for free, can submit Medicare and Medicaid-related patient information to meet their physician quality reporting system requirements.

But it’s the promise of improving patient care and tracking efficiencies through big data that has ophthalmologists like Michael F. Chiang, MD, who chairs the academy’s medical information technology committee, most excited.

IRIS™ REGISTRY
Intelligent Research In Sight

In only six months since the outcomes registry opened, more than 5,000 physicians have signed up. That means nearly 1 in 3 of all practicing U.S. ophthalmologists (there are 16,500, according to the American Board of Ophthalmology) have signed up. Ten million patient visits were logged as of September, according to AAO records, with 3.85 million patients in the system since IRIS’s official launch in March.

“That’s a staggering number in such a short amount of time,” says Dr. Chiang. “It is great that there is so much enthusiasm for sending data into this registry. The more data that does come in…. the more improvement there can be, and the ophthalmology community can benefit from the collective knowledge that the registry holds. That is what makes this pretty remarkable. It opens up what we can do with this data in the future.”

“I can’t think of any downsides at this point,” says Larry E. Patterson, MD, chief medical editor for Ophthalmology Management. “I’ve been on it for a few months and the folks involved are stunningly competent. We aren’t at the place where it’s of value to doctors for clinical decision-making just yet, so that’s down the road. When that comes, I think it’ll be more in the form of an assist, rather than the physician just doing what the computer commands.”

Judging from interviews with other medical specialists who use registries, ophthalmologists can expect IRIS to help improve their practice workflows, reduce costs of care, and improve patient outcomes — with some saved time and effort.

“Registries are the most efficient way to do quality improvement,” says David May, MD, PhD, immediate past president of the Texas chapter of the American College of Cardiology (ACC). “Using a registry enables you to take a deep dive into what you are doing well and what you are doing poorly in your own practice. You begin to embrace the idea that collecting this data is important, not just for the health of your patients, but for the health and well-being of your own practice.”

Dr. Chiang says registered physicians are finding that IRIS, which in long-hand means Intelligent Research in Sight, is saving them time with their reporting requirements and that IRIS reduces manual entry and submissions.

While the focus is on quality improvement, the registrant’s identity is protected, Dr. Chiang says.

“An individual doctor owns his or her own data, and you can’t identify the data except for [it being] pooled data,” he explains.

The system is secure, the AAO says; no glitches have occurred. One challenge has been interoperability between electronic health records and IRIS. “Our doctors are using different EHRs, and using EHRs differently,” says Dr. Chiang.

The AAO, Dr. Chiang says, has been interested in how big data could help with improving patient care and tracking efficiencies for decades. It’s only recently, he continues, that technology has advanced enough to make clinical registry data easier to upload directly from EHRs, and also easier to access and analyze for quality improvement.

Prior to IRIS, amassing the necessary data would have been time-consuming because someone would have had to enter the data into a registry by hand. Besides, there was no interface.

But the advent of electronic health records provided some warp speed and interconnectivity. Compatible EHR systems are linked directly to the registry, and data syncs automatically. “It is really the technology catching up with the vision.”

In the future, IRIS could be used as a “remarkable” infrastructure for clinical research, Dr. Chiang says. Because ophthalmologists will have the data in IRIS, they can look at it quickly and assess its use, whether it be used in a public health study or even for clinical trials.

At least one other registry is involved in a clinical trial: the American Urogynecologic Society’s Pelvic Floor Disorders Outcome Registry.¹

And Dr. May says authors of an observational study are using the ACC’s registry to identify gaps and find solutions to help patients with atrial fibrillation who are not on anticoagulant drugs.

Already, the Academy is accumulating significant data on diseases and conditions. For example:

• Number of patients with AMD—

• All AMD: 217,941

• Exudative AMD: 57,579

• Number of patients with diabetic retinopathy: 110,620

• Number of patients with cataract surgery: 86,646

• Number of patients with open-angle glaucoma 200,340

Expect easy set-up and implementation

When IRIS was announced earlier this year, AAO officials said a component that attaches to each practice’s electronic health records system would require about three hours of set-up by a staff person familiar with IT. The component then extracts blinded data from the EHR at night and sends it to a cloud-based registry for sorting, analysis and reporting.

IRIS’s workings are based on those of PINNACLE, cardiology’s largest outpatient quality improvement registry. The registry is not difficult to set up, says Dr. Thomas Maddox, MD, chair of the PINNACLE Research and Publications Committee, noting that 81% of practices spend less than two hours each week on tasks and maintenance related to PINNACLE, which has an EMR built into the clinical workflow to improve efficiencies.

“We simply collect all the data on every patient we serve on a daily basis; every night, all the data gets uploaded into the registry system, which compiles, sorts, and analyzes the data and returns the results at regular periods,” Dr. May explains. “The wheels don’t slow down at all.

“We can get the data we need along every step of the patient encounter. The receptionist can ask, ‘Are you a smoker?’ The med tech can ask, ‘Do you have an advance directive?’ The questions are distributed across the staff, so that everyone who touches that patient — doctors, nurses, technical staff is acquiring data,” he adds.

Expect some pain — and then some gain

“When that first round of data comes back, you’re not really prepared to see that you’re not as good as you thought you were,” Dr. May says, noting that for many practices, the first data returns can serve as a potent, painful eye-opener that the ship is not sailing as tightly as they might have thought.

Dr. Frederick Grover, MD, a member of the Society of Thoracic Surgeons (STS) agreed. Leveraging the STS database has enabled his practice to identify and improve upon several areas of patient care, such as lengths of stay and using the internal mammary artery as a conduit in coronary artery bypass graft patients to compare favorably with national utilization standards.

“We also found that our use of preoperative beta blockers as recommended by national guidelines was not satisfactory, so we introduced checklists and other processes to ensure that this was close to 100%,” Dr. Grover says.

Expect to find opportunities

Dr. May says he places his practice’s PINNACLE reports, which break down performance metrics by individual staff members, on the conference room table when staff members come in each quarter for their review.

“I’m not so much interested in seeing the data and calling someone out on the carpet,” he explains. “I’m interested in ‘how do I teach someone to get better?’ As you start measuring, you start getting improvement, and your entire practice starts to make improvement really rapidly.”

“Assuming the data are meaningful and accurate, the data will inform providers how they’re doing, and [highlight] opportunities to provide even better care,” says Clifford Ko, director of the American College of Surgeons’ registry, the National Surgical Quality Improvement Program (NSQIP). “Of course, the devil is in the details regarding the success and sustainability of a registry, but overall, data are essential for quality evaluation and improvement.”

A recently published report on NSQIP, Dr. Ko says, indicated that “over 80% of users reported improvement using this registry.”

Expect to see financial improvement

Using a registry to identify and make workflow improvements is just one way to increase revenue. Using the STS database, for example, two surgical practices in Michigan have been able to save more than $1 million in costs due to post-op renal failure over the course of one year, says Richard L. Prager, MD, head of adult cardiac surgery at the University of Michigan Health System in Ann Arbor.

Data collected for a registry can also be used to preserve a practice’s bottom line in other ways by demonstrating compliance with regulatory measures such as meaningful use, PQRS and others. The AAO reports that many practitioners signing up for IRIS are doing so to help avoid PQRS penalties, which could be a painfully significant percentage of Medicare billings. For example, vital signs such as blood pressure, respiration, and other data can be measured, recorded, and uploaded daily to demonstrate compliance.

“Some view this as busy work and may ask, ‘Why am I doing this when it really has nothing to do with my care of the patient?’ But it’s important to demonstrate that you can collect and leverage this data for continued certification renewals,” Dr. May said.

Physicians who have questions about IRIS can call the Academy at (415) 561-8500. Ask to be directed to IRIS. OM

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