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  • ABO Diplomates—How to Get Started on Your MIPS/MOC Improvement Project

    By Flora Lum, MD, Vice President, Academy Quality and Data Science Division, Chris McDonagh, Senior Editor, Eyenet Magazine, Molly Peltzman, Manager, IRIS Registry, and Jessica Peterson, MD, MPH, Manager, Quality and Health Information Technology Policy

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    Has your practice integrated its electronic health record (EHR) system with the IRIS Registry? And do you have access to the dash­board that shows your individual performance on quality measures? If so, you are now eligible to work with the American Board of Ophthalmology (ABO) in designing your own improvement in medical practice project. This can potentially earn you credit both for the Maintenance of Certification (MOC) process and for the Merit-Based Incentive Payment System (MIPS).

    Meet these deadlines. You will need to submit your project proposal to the ABO by Aug. 31, 2018; implement the project for at least 90 days by Dec. 31, 2018; and, using the IRIS Registry, attest to your MIPS improvement activities by Jan. 15, 2019.

    Why Do an IRIS Registry–Based Improvement Project?

    Under Part IV of MOC, you can earn credit for participating in a quality im­provement project. The ABO suggests that you can use your IRIS Registry data to plan and monitor such a project (, though there also are options that do not involve the IRIS Registry (

    Here’s why an IRIS Registry–based approach might work best for you.

    Automated data extraction. The IRIS Registry extracts the relevant data from your EHR system and shows how your performance compares against that of your colleagues. This enables you to make informed decisions about what you need to improve.

    Take advantage of this option’s flex­ibility. Pick from any of the measures that are available in the IRIS Registry dashboard. After identifying an area (or areas) that you would like to improve, design your own custom improvement plan. Use the IRIS Registry’s monthly reports to monitor your progress, and make adjustments as needed.

    Reduce your overall administrative burden. Provided that you meet the relevant deadlines, your project will qualify as an MOC Part IV improve­ment activity and as a MIPS improve­ment activity.

    Terminology: Improvement Activities

    MOC. The term improvement activities has sometimes been used to refer to projects on the MOC Part IV: Improvement in Medical Practice menu.

    MIPS. In the MIPS program, improvement activities can mean 2 things:

    1. The term can refer to the improvement activities performance catego­ry, which is 1 of 4 performance categories that can contribute to your MIPS final score, along with qualitypromoting interoperability (formerly known as advancing care information), and cost.
    2. The term can refer to the individual activities that you perform to earn points for the improvement activities performance category. (For example, IA_AHE_1 Engagement of new Medicaid patients and follow-up is a MIPS im­provement activity, and another is IA_PSPA_2 Participation in MOC Part IV.  View an at-a-glance list (PDF) of the 24 improvement activities most relevant to ophthalmology.)

    How to Do an IRIS Registry–Based Improvement Project

    There are 3 phases to your project. You will need to 1) develop your plan and submit it to the ABO for approval; 2) after obtaining the ABO’s approval, implement the plan; and 3) submit a report to the ABO and complete an ABO feedback survey.

    First identify areas that need improvement. Log in to your IRIS Registry dashboard (for log-in instructions, visit Identify 1 or 2 IRIS Registry measures where you would like to improve your performance. For example, measures that MOC Part IV participants have focused on have included:

    • Measure 14 (labeled QPP 14 in the IRIS Registry) Age-Related Macular Degeneration (AMD): Dilated Macular Examination
    • Measure 18 (IRIS eCQM2) Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy
    • Measure 19 (IRIS eCQM3) Diabetic Retinopathy: Communication With the Physician Managing Ongoing Diabetes Care
    • Measure 130 (IRIS eCQM17) Docu­mentation of Current Medications in the Medical Record
    • Measure 140 (QPP 140) Age-Related Macular Degeneration: Counseling on Antioxidant Supplement
    • Measure 191 (IRIS eCQM4) Cat­aracts: 20/40 or Better Visual Acuity Within 90 Days Following Cataract Surgery
    • Measure 374 (IRIS eCQM19) Closing the Referral Loop: Receipt of Specialist Report

    Design your project. Set improve­ment goals for your selected measure(s) and decide what steps you should take in order to succeed. Such steps would be changes to the care delivery process that could include, for example:

    • Tools, which are things (e.g., use of a checklist to make sure quality measure actions are performed and documented)
    • Strategies, which are changes in procedures or policies (e.g., adding a reminder to send out a template letter to the primary care physician after seeing a diabetic patient)
    • Systemic approaches to care delivery involving the comprehensive integration of tools and strategies (e.g., to help close the referral loop, office staff send out reminders to specialists who haven’t sent a report on a referred patient with­in 2 weeks)

    Use ABO’s template. Use the ABO’s project submission template, which includes the following:

    • Project title
    • Project description, including the measure(s) from your monthly IRIS Registry report that you will focus on
    • Background information, includ­ing which month you will be using to establish your baseline performance
    • Project setting, which describes your practice setting
    • Study population, which describes the type of patient that the project applies to (e.g., patients presenting for cataract surgery, diabetic patients, all patients)
    • Project team, which lists the individ­uals who will contribute to the project, along with their roles
    • Quality indicators/performance measures, which include the IRIS Registry measures that you will be monitoring
    • Improvement plan

    Submit your proposal to the ABO by Aug. 31, 2018. At the ABO’s website (, log in to your MOC portal. From your status page, you can submit the proposal for your improve­ment project. The ABO’s review and approval process will take at least 4 weeks.

    Implement your plan for 90-120 days. Use the IRIS Registry’s monthly reports to quantify your performance before (baseline), during, and at com­pletion of your improvement project.

    Practice improvement is an ongoing experiment: Make changes as needed. By using the IRIS Registry’s monthly reports to monitor your progress, you can see whether you are likely to meet your goals. If it seems that you are fall­ing short, you can reevaluate your plan and make further changes to your care delivery processes.

    Report your project’s outcomes to the ABO. Using an ABO template, write a short summary of what you learned from the project.

    Complete a feedback survey. After you submit your report, the ABO will ask you to complete a short survey.

    Finally, attest to completing a MIPS improvement activity. Provided you met the relevant deadlines, you can use your IRIS Registry dashboard to attest that you completed IA_PSPA_2.

    Learn More Online

    To learn more about MOC Part IV, visit You also can email

    To see examples of registry-based improvement projects, visit

    To learn more about MIPS, visit the Academy’s MIPS hub page and MIPS 2018: A Primer and Reference.

    IA_PSPA_2: Participation in MOC Part IV

    IA_PSPA_2 is a medium-weight MIPS improvement activity.

    Defining the activity. The CMS descriptor reads, Participation in MOC Part IV for improving professional practice including participation in a local, region­al, or national outcomes registry or quality assessment program. Performance of monthly activities across practice to regularly assess performance in prac­tice, by reviewing outcomes addressing identified areas for improvement, and evaluating the results. To learn more about this improvement activity, includ­ing suggested documentation, see

    Contribution to MIPS improvement activities score. As a medium-weight activity, IA_PSPA_2 earns you 20 points if you are part of a small practice and 10 points if part of a large practice. CMS determines practice size based on historical data (see Small or Large Practice?). You can score up to 40 points for your improvement activities performance category score, which is converted into a percentage—e.g., a 20-point total would be a score of 50%; 40-point total, 100%—before it is factored in to your MIPS final score.

    Contribution to MIPS final score. Every ophthalmology practice should be able to score 100% (i.e., 40 points) for the improvement activities performance category. If you do that, the category will contribute 15 points to your MIPS final score, which would be enough to avoid the MIPS payment penalty.