Maintenance of Certification and the IRIS Registry

Integrated IRIS Registry users can complete an improvement project that counts toward requirements for Maintenance of Certification (MOC) and the Merit-Based Incentive Payment System. To complete an activity that helps satisfy both programs’ requirements, you should submit your project proposal to the American Board of Ophthalmology no later than Aug. 31.

• To get both MIPS and MOC program credit for the project, you must conduct the improvement activity over a minimum of 90 days.
• To earn MOC credit from the American Board of Ophthalmology, you must first submit a project proposal to the ABO. The ABO says to allow at least four weeks for approval of your project. 
• The last day to begin an improvement period that qualifies toward both programs is Oct. 1.

If you don’t get ABO approval of your project in time to complete 90 days of improvement during calendar year, you can still earn credit toward MOC, but you won’t earn 2019 MIPS credit for the project.

Who Can Complete This Type of Improvement Project

In order to complete a qualifying improvement project, you must access the IRIS Registry dashboard. To access the dashboard:

1. Your practice’s EHR system must be integrated with the IRIS Registry; and
2. You must have access to the dashboard that shows your individual performance on the electronic clinical quality measures and quality improvement measures.

For new practices, the deadline to sign up to integrate your EHR system with the IRIS Registry is June 1.  Practices already integrated with IRIS Registry can look at their previous years performance data to identify a measure for the improvement project.

Note: If you do not have an EHR system, you can still use the IRIS Registry to report on other types of MIPS improvement activities, but you can’t use the registry to complete a project that also qualifies toward MOC.

How to Complete a Registry-Based Improvement Project

To complete a project that satisfies both MOC and MIPS requirements, you need to complete three phases: proposal, improvement and post-project reporting. 

Phase 1: Propose project to the ABO

In order to propose a project, you need to first review your performance in the IRIS Registry.

1. Log in to the IRIS Registry dashboard at https://iris1.aao.org/DashBoard/login.aspx. IRIS Registry usernames usually follow the format: Firstname.Lastname
2. Choose Provider from the left-hand navigation menu, then your name from the list that appears. You will see all of your measure performance rates compared to the registry average for all users.
3. Decide on which measures you want to improve your performance. Choose one or two.
4. Go to the ABO website and log into their MOC portal.
5. Complete and submit the Registry-Based Improvement in Medical Practice Activity application using your ABO MOC status page. The application will ask you to develop a plan to improve on the measures you selected. The ABO website offers various examples and resources for developing improvement plans.

Phase 2: Project completion

To earn credit for both MOC and MIPS reporting, you must complete at least 90 consecutive days of improvement by Dec. 31. To do so, you must get ABO approval for your project and start your improvement period by Oct. 1.

• Once you submit your application, the ABO will respond to your proposal within four weeks.
• The ABO will notify you when it has approved your proposal and provide instructions on when to begin improvement activities.
• During the 90-day improvement period, you can check your IRIS Registry dashboard to review your progress. Dashboard data updates on a monthly or quarterly basis.

Phase 3: Post-project reporting

If you completed at least 90 consecutive days of the improvement period by Dec. 31., your project qualifies to earn credit toward MOC and MIPS reporting requirements. To receive credit for both, you must satisfy two separate reporting requirements.

• MOC credit: Once you complete at least 90 days of improvement, follow the ABO’s instructions to report on the outcome.
• MIPS credit: Follow the instructions to attest to improvement activities through the MIPS part of the IRIS Registry dashboard. Report the improvement activity PSPA_2: Participation in MOC Part IV.