Utilizing AQUA Registry Measures Within Your Practice

Policy

Measure Benchmarks for Users - Deciles

Under the Quality reporting program, participants are scored on how complete and successful their reporting is compared to other participants through a series of benchmarks established by CMS. A benchmark is generated by reviewing historical performance data from two years prior (e.g., 2020 benchmarks are based on 2018 data). Additionally, a measure must meet the following criteria to establish a benchmark:

• A minimum of 20 eligible clinicians (ECs), or groups, must report on the measure.
• The reporting ECs, or groups, must meet data completeness and case minimum requirements.

CMS has created a matrix of deciles where measure benchmarks are separated into performance groupings that correspond with the number of points a clinician will receive. An EC’s performance will be compared to the benchmark, and points will be assigned based on a sliding scale. The below table displays the 2020 urology-specific, or Non-QPP, AQUA Registry measures that have received benchmarks, along with their respective deciles:

To better understand decile scoring, let’s suppose Dr. Smith submits data yielding a performance rate of 80% on AQUA18 (Non-Muscle Invasive Bladder Cancer: Early Surveillance Cystoscopy, Within 4 Months of Initial Diagnosis). The fourth decile ranges from 78.04% – 81.54%, so Dr. Smith will receive 4 points because 80% falls in the fourth decile.

It’s important to note that measures with benchmarks are worth a maximum of 10 points, whereas measures without a benchmark receive a 3 point floor. In general, if a clinician submits data for a measure, they will receive a minimum of 3 points—which is why the first and second deciles are not shown in the table above. If you have any questions about the above measures of decile scoring, please contact the AQUA Registry Team at AQUA@auanet.org.

What Should You Do If You Notice an Inaccurate Measure?

We strive to provide AQUA Registry participants with the most accurate data possible. However, sometimes the data do not appear as expected on the dashboard. Provided below are the steps you should take when you encounter this situation.

• Contact your CAMS representative or submit a service desk ticket. Details on reporting a service ticket can be found in the Pegasus Help Center, which is accessed through a link on the upper right-hand corner of your dashboard. Enter the “Get Started Here” section to view the information in the “About Service Desk” area. There is also an accompanying video to walk you through the process.
• The service desk request should highlight any issues you encounter, including specific information such as which measure is causing concern, the discrepancy area (in the denominator or numerator) and the list of patients. (Note: To enter PHI details in the ticket, check the “Select to Add PHI” checkbox).
• Enter one service request ticket per measure.
• A representative from FIGmd or the AQUA Registry Team will contact you within 3 business days to schedule a review call with your practice.

We are here to help you and your practice meet your quality improvement needs. If there are any topics on which you would like to see covered in this newsletter, please reach out to the AQUA Registry Team.

How Practices Have Utilized AQUA Registry Data for Quality Improvement

The interactive AQUA Registry dashboard identifies low-performing clinical areas in need of significant quality improvement. By examining contributing factors to these areas, practices can create an action plan for correction that can be implemented and evaluated throughout the year.

Through regular dashboard visits, AQUA Registry participants are able to:

• Track metrics on urology-specific measures
• Identify areas for improvement
• Monitor impact of improvement efforts
• Compare performance to peers on a national level

Innovative ways participants use the AQUA Registry for Quality Improvement:

• “…AQUA data registry is an additional opportunity for continuous improvement. The looming pay-for-performance coming down the pike means we need to get comfortable with benchmarks and comparisons to our peers. I, for one, do not want to be the guy sitting at 47% while the rest of the herd is at 75% on any metric. I see so much potential with this registry from patient safety to payer contracting in the future.”—Community practice, 1 provider
• “We expected poor results because we knew we were not doing well on the medication reconciliation measure. So, we implemented re-education efforts to providers and the data does show substantial improvement for the most recent two quarters. We will be able to monitor the impact of our quality improvement efforts.”—Community practice, 7 providers
• “Being able to track measures that are specific to urology is one of the most valuable benefits of the AQUA Registry; it is encouraging to be able to monitor measures that represent and impact our specialty directly.”—Academic practice, 10 providers

The leading driver for joining the registry is to assist with quality improvement initiatives. The AQUA Registry offers an unparalleled opportunity for urologists, and other urologic care providers, to improve the quality of care and treatment outcomes for your patients. If your practice has instituted new programs or initiatives based on the AQUA Registry data, we would love to hear from you and share your ideas with other practices within the registry. Email your thoughts to AQUA@AUAnet.org.

Review of the AQUA Registry Dashboard Features

The AQUA Registry Dashboard is an innovative tool to help you review and track documentation processes and treatment outcomes of CMS and urology-developed measures at a practice and provider level.

To review the many dashboard features and provide you with the tools to assist you in navigating the dashboard, we encourage you to participate in the June 30th dashboard demonstration webinar. Contact AQUA@AUAnet.org to register.

One of the topics we will be highlighting during the webinar is how to identify the progress of your selected measures. Displayed on the dashboard under each measure is an indicator that helps track the status of the chosen priority measure. Once the measure is in the ‘Measure Verified’ stage, it is ready for your final review.

What are the different status indicators of a measure and its significance?

The significance of the measure status indicators is described below:

• Exploration in Progress: The FIGmd technical staff is conducting an initial exploration and mapping of the EHR or data files received from the practice.
• Verification in Progress: It indicates that data processing has been completed, and final measure performance verification is being done.
• Awaiting Practice Clarification: It signifies that clarification from the practice is needed on data for the selected measure(s).
• Measure Verified: It specifies that FIGmd has verified measure performance, and it needs to be reviewed by the practice.
• Measure Operational: It signifies that the practice has reviewed and signed off the on the measure performance.
• Measure Non–Operational: It indicates that FIGmd has not verified measure performance, or no data is present for this measure.

Please note: The AQUA Registry Team is committed to refreshing your 2020 AQUA Registry dashboard with your 12 selected priority measures by July 31, 2020. If your practice selected more than 12 priority measures, any additional measures would be refreshed 3-6 measures per month, until all your selected measures have been refreshed on your dashboard.

Professional Development

Collaboration with ABU

The AQUA Registry and the American Board of Urology (ABU) have solidified a partnership, where AQUA Participants, meeting certain eligibility criteria, can receive credit for completing the Practice Assessment Protocol (PAP) requirement. The PAP is a two-part assessment of one’s knowledge of the current clinical guidelines, and it is a requirement for the ABU’s Life Long Learning program.

The AQUA Registry Team distributes Certificates of Participation, quarterly, to any newly eligible providers. To receive a certificate, the participant must meet ALL of the following requirements:

1. Participant is a Urologist
2. Participant belongs to a Classic/Elite level practice
3. Participant’s practice is actively transmitting data to the AQUA Registry and utilizing the quality improvement tools
4. Participant’s practice has paid their annual subscription level fee

Participants meeting the above requirements will be issued a certificate. To redeem the certificate for PAP credit, the participant must submit it to the ABU via email ( L1coordinator@abu.org) or fax (434-979-0266).

Additionally, due to the COVID-19 pandemic, the ABU has extended the deadline for the PAP from April 1st to October 1st. Please contact the AQUA Registry Team at AQUA@auanet.org for any questions regarding the Certificate of AQUA Registry Participation.

Customer Service Survey

Watch your emails for the Summer AQUA Registry Customer Service Survey, which is coming out on June 22nd. Your participation helps us tailor the registry to meet your needs and gives us the opportunity to address any questions you may have. We want to hear from you! It only takes a few minutes to complete the survey.

Important Dates

Tips & Tricks

Verana Health Partnership:

On April 13, 2020, the AUA announced it has entered into a collaboration with Verana Health, a healthcare technology firm focused on curating and analyzing health care data to advance medical research and innovative medical care for patients. Learn More

COVID-19

Visit Coronavirus Disease 2019 AUA Information Center to stay current on AUA events and other information relevant to AUA’s members.

New for 2020

The new Improvement Activity: COVID-19 Clinical Trials (IA_ERP_3) is now supported by the AQUA Registry for the 2020 MIPS performance period. Learn More

For your convenience, we are providing a link to the letter CMS sent to clinicians.

Registry Dashboard Login

The process to log in to your AQUA Registry dashboard was recently streamlined. You are no longer required to click the “2019 Dashboard” link to access your current data. Pegasus is now the default view upon login.

AUA 2020 MIPS Reporting Webinar

On March 10, 2020, the AUA hosted a webinar where various aspects of the MIPS programs were explained. You can view that webinar and access the supporting presentation slides here.