Letter from the Chair
AJRR Board of Directors Chair
Daniel J. Berry, MD
As we move into the third quarter of the year, I would like to take this opportunity to do two things - to thank you for your support and commitment to a National Registry of hip and knee arthroplasty, and to ask for your support and to some degree continued patience as we move into our next phase of development. We set out to have 90% of all total hip arthroplasty (THA) and total knee arthroplasty (TKA) procedures in the AJRR - a lofty goal at that, but one to which we are committed and working hard to achieve. When I started as Chair in 2015, my goal was to continue our path towards a National longitudinal Registry with 1,000 hospitals contributing their data. To have a statistically sound, long-term, national-scale longitudinal Registry, there has to be care and diligence in everything we do. The good news is that our meticulousness to the details in security, data elements, and business agreements mean that our community is getting a high-quality Registry that will be able to endure, adapt, and grow with the needs of our stakeholders. In a few short years we have amassed close to 400,000 procedures in the Registry from over 700 hospitals. That's high by anyone's standards and we're on track to having close to one million procedures by the end of this year.
However, we still have a long way to go. Because the external landscape is evolving rapidly and the Centers for Medicare & Medicaid Services (CMS) and payers are putting a higher emphasis on orthopaedics (because of the increased use by the American public), concern over cost, usage, and quality all have had an impact on our goals and needed capabilities. We have had to pause and ensure that our data elements would be useful and relevant to the hospitals we serve. I commend the AJRR staff for their ability to take the quality initiatives that CMS and other organizations created and help provide solutions for you - all while focusing on our goal of ensuring the best possible longitudinal National Registry possible.
We've accomplished many things in the past several years. We became a qualified clinical data registry (QCDR) for the third straight year, able to provide Physician Quality Reporting System (PQRS) and Meaningful Use (MU) data submission on behalf of our surgeons; converted over our entire Registry to ICD-10 and instructed our participants on how to provide the new format to us (no easy feat and required hundreds of man hours to complete); we launched the ability to collect and report patient-reported outcomes that will help with the CJR pilot program (that was introduced this year by CMS); we published our second Annual Report and are in the process of our third; and, we created a User Group Network of AJRR participants where we learn from each other and gain recommendations and suggestions for future enhancements.
Our roadmap for growth will always be to ensure we are relevant to the needs of the orthopaedic community. One of our current problems is to get our Level II data element collection implemented so that collection of comorbidities and surgical complications will allow us to risk adjust our data. We planned for this to be activated by now; however, we wanted to make sure the data measures we selected are in alignment with what the hospitals and CMS have mandated. Our pilot program for submission of Level II data yielded results that we didn't anticipate, so we tweaked our platform to provide a more meaningful and relevant solution. Another priority to our future growth is to be able to have a platform ready for all our participants' and surgeons' quality initiatives - from CMS' Medicare Access and CHIP Reauthorization Act (MACRA) and Merit-Based Incentive Payment System (MIPS), as well as the American Board of Orthopaedic Surgery (ABOS)' Maintenance of Certification (MOC) program.
We will continue to create a longitudinal Registry so we can follow short and long-term implant performance and provide incomparable data to benchmark and improve arthroplasty outcomes. However, we are also evolving into a quality registry. With these adjustments, we see opportunities to be even more valuable to you. We hope that we've earned your trust and you will take this journey with us.
Registry development, creation, implementation, and ongoing maintenance are expensive and yet the cost back to participating institutions to be able to view their data against the nation is relatively inexpensive. There is great value to participants in being able to compare confidential individual institutional performance against national benchmarks. As a non-profit organization, we are passing only our costs to you and nothing more.
Our goal of 'Improving Orthopaedic Care Through Data' only can be achieved with your help, support, and commitment. Therefore, I'd like to ask for your assistance wherever you can provide it. If you're a hospital or surgery center and aren't submitting your data to us - will you please take the necessary steps to do so? If you're already submitting data to us, will you join our User Group Network so we can hear from you in our future enhancements and developments? If you're not signed up with us yet, will you do so to help us achieve the 90% goal?
Again, thank you for all of your support, contributions, patience, and assistance.


Daniel J. Berry, MD
AJRR Chair
CJR Data Submission Starts July 1
The Centers for Medicare & Medicaid Services (CMS) Comprehensive Care for Joint Replacement (CJR) Model requires the submission of data from July 1 to August 31, 2016, so it's time for the hospitals in the 67 Metropolitan Statistical Areas (MSAs) affected to be conscious of the steps that they will take to qualify. With the CJR, CMS gives hospitals a composite quality score based on the performance and improvement of two required quality measures. These quality measures are incredibly significant to hospitals, as their composite score determines if CMS offers extra money or asks for repayment at the end of the year. A lesser-known method for adding points onto your CJR composite score is to submit voluntary patient-reported outcomes (PROs), and that is an area where we can provide assistance.
The CJR is a five year model with the goal of improving quality of care and cost efficiency in hip and knee procedures. It will be changing its data submission periods and requirements annually. We collect all of CMS' voluntary PRO measures; hospitals have the choice between submitting either the VR-12 or PROMIS 10-Global and either the HOOS and KOOS, JR., or the HOOS and KOOS subscales.
Currently, CMS is testing out this preliminary PRO Performance Measures (PRO-PM) submission, and is offering two bonus points to hospitals that meet the requirements. Since it's the first year of the model, CJR is showing more leniency. To qualify in 2016, hospitals have to submit data on at least 50% or 50 hip and knee procedures, whichever comes first. This procedure volume is much easier as opposed to the subsequent years of CJR. Only pre-operative and risk variable data between July 1 and August 31 is required in the first year, with a submission deadline of October 31, 2016. Submitting PRO data now is a great way to boost your composite score, as the rules only ask for a portion of what will later be expected; CMS plans to make it mandatory before or during the CJR's third year.
Although AJRR's Level II patient risk, comorbidity, and complications data capability will be released at a later date, the AJRR Level III PRO platform already satisfies the CJR PRO submission category. Hospitals may find that PRO-PM came in handy this year if their other quality measure scores are not high enough to receive reconciliation payment.
For more information about the CJR, click here. CMS supplied frequently asked questions can be found here
AJRR at the 5th International Congress of Arthroplasty Registries
AJRR Board of Directors Chair Daniel J. Berry, MD, Director of Analytics Caryn D. Etkin, PhD, MPH, and Board Member Blair Fraser, at the Congress dinner at the Museum of Science and Industry in Manchester

The 5th International Congress of Arthroplasty Registries was held over Memorial Day weekend from May 28 -30 in Wrightington and Manchester, UK. Several AJRR Board Members and staff were present, along with our Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI) colleagues. Representatives from other registries and organizations from around the world also attended the meeting.
The meeting began on May 28 at Wrightington Hospital, the surgery center in which Sir John Charnley, the inventor of hip replacement, practiced. Several speakers gave speeches on topics such as the history of Wrightington, the current state of the International Society of Arthroplasty Registries (ISAR), statistics and methodologies, and registry value. Among the notable speakers was ISAR President Richard de Steiger.
From left to right: Ove Furnes, MD, PhD, from the Norwegian Arthroplasty Register, and AJRR Medical Director David G. Lewallen, MD, chatting over coffee
On Saturday, May 29, the meeting resumed at the Lowry Hotel Manchester, where it stayed for its remaining duration. Many other speakers presented over these two days, including AJRR Board of Directors Chair Daniel J. Berry, MD, AJRR Medical Director David G. Lewallen, MD, and AJRR Director of Analytics Caryn D. Etkin, PhD, MPH. During breaks between the sessions, meeting attendees observed posters in the back of the conference room that were created by the organizations in attendance. AJRR, CJRR, and AAHKS had multiple posters on display. The meeting closed on Monday with an awards ceremony and meeting summary.

To view the AJRR, CJRR, and AAHKS posters that were featured at the 5th International Congress of Arthroplasty Registries, click here.

Group photograph of all of the meeting attendees in front of Wrightington Hospital
From left to right: Paul Voorhorst, MS, MBA, from DePuy Synthes, and AJRR Board Member Gregory B. Krivchenia II, MD, standing in front of an AJRR poster
Be a Part of Arthroplasty Today, the Official Journal of AJRR
The American Association of Hip and Knee Surgeons (AAHKS) is looking for reviewers for their open-access journal Arthroplasty Today. This opportunity can expand your expertise and help get your foot in the door of the evidence based medicine movement. Applicants can choose their areas of interest and availability. For consideration, submit your curriculum vitae (CV) to Denise Rodd, AAHKS Publications Committee liaison at drodd@aahks.org.

If you have a unique technique or tip that is helpful in the operating room or office, please let Arthroplasty Today know. Our official journal publishes a feature that describes a novel concept that helps with efficiency or improvement in the care of the arthroplasty patient. If interested, submit your manuscript here.
Upcoming June Unet Call
On June 16, 2016, our User Group Network (Unet) will be holding a conference call at 12 p.m. CDT. The call agenda is being finalized by the Unet Advisory Board on June 10, and suggestions for discussion topics are encouraged. If there is a specific topic you would like to hear discussed, please contact our Director of Marketing and Communications Lori Boukas at boukas@ajrr.net. Unet is made up of those who are involved in the implementation and management of any aspect of the Registry in their institution - from those who are running the process to the IT staff submitting the data. This conference call will be of interest if you would like to communicate with other Registry users for useful information and help shape the orthopaedic Registry community through your insights and contributions.
To register for the upcoming Unet conference call, click here. If you register for the call, you'll automatically be put on our email distribution list.
From the Hill
by Marisol Goss

Visit the Advocacy & Public Affairs Section of our website to learn more
Over the last few months, our efforts have been focused on significant regulatory advocacy activities. On April 27, 2016, the Centers for Medicare & Medicaid Services (CMS) published the Medicare Access to CHIP Reauthorization Act - Merit-Based Incentive Payment System (MACRA - MIPS) proposed rule which contains many provisions related to Qualified Clinical Data Registries (QCDRs). One of the promises fulfilled by the MACRA proposed rule is to provide Medicare bonus payments to providers if they submit quality data through a QCDR. The proposed rule positions QCDRs on par with Electronic Health Records (EHR) in the spectrum of Health Care Information Technology (HIT), and allows QCDRs to host additional innovative measures for performance improvement.  
Reporting to a QCDR is one of the limited methods available to providers for reporting all three areas of MIPS: quality, clinical performance improvement activities, and advancing care information. The QCDR Physician Quality Reporting System (PQRS) reporting is inclusive of all patients, not just Medicare. This puts QCDRs at a strategic advantage to encourage use as the centerpiece of the new all-payer quality initiative. CMS is encouraging the use of QCDRs to promote quality and accurate data, and our participants will benefit from the quality incentives. We will be submitting comments to CMS on the MACRA proposed rule by the deadline of June 27, 2016. 
For ongoing information and copies of our comment letters, click here.
Health Datapalooza and the Safe Sharing of Data 

From May 8-11, over 1,400 individuals from the health information technology world gathered in Washington, D.C. for the Seventh Health Datapalooza conference. Dr. Caryn Etkin attended the meeting, which addressed data harmonization and encouraged safe and secure ways to share health data on broad scales. Some of the conference's key speakers included Vice President of the United States Joe Biden; Secretary of Health and Human Services Sylvia Mathews Burwell; two senators; international ministers of health from both Israel and the UK; and leaders from top IT corporations.

Vice President Biden spoke about the National Cancer Moonshot Initiative, and also encouraged those in the health IT community to facilitate more rapid sharing of data across communities. Specifically, organizations should make it easier for patients to access their medical records and provide options to patients should they wish to share their data for research purposes. Secretary Burwell announced the "A Bill You Can Understand" design and innovation challenge. The challenge seeks to promote new approaches to understanding medical billing systems.
Authorized Vendor Profile 

Last month we introduced a new section called "Authorized Vendor Profile.Each volume of The Register now features a summary of a different technology vendor that is capable of submitting data to the AJRR.
General Description: CODE TECHNOLOGY is a full service solution for collecting orthopedic outcome data for hospitals, group practices, and providers. They make collecting patient-reported outcome (PRO) data simple. CODE connects with patients on your behalf, out of the doctor's office, and at a time that is best for the patients. This is the reason they are able to maintain a high capture rate across all collection intervals. For the patient, CODE feels like an extension of your practice. For the organization, your outcomes program can be up and running in 30 days. Once in place, you'll feel no disruption to your workflow - CODE takes care of everything quietly in the background.
Features Offered:
Here's how CODE TECHNOLOGY makes collecting PRO data effortless:
  • No manual data entry required from staff 
  • Data collection takes place completely outside hospital setting
  • Complication/readmission tracking
  • Access to comprehensive analytics and benchmarks
  • No IT support needed
  • No additional staffing requirements
  • Seamless data submission to AJRR for inclusion in the Registry
Integration with AJRR: As an AJRR Authorized Vendor, CODE can submit all Level III PRO data directly on your behalf. This means no extra work or staff for your organization. If you're looking for more information, download the CODE PROs to AJRR guide here.
Fun Fact: Out of the 10,000+ total joint patients in CODE's database, 94% have an email address. The average patient age is 66.

A full list of AJRR's Technology Partners can be found here.

Data Corner
Our 2014 Annual Report has a wealth of information on procedural and component data. Figure 4 (pictured above) and Figure 5 (pictured below) contain some interesting findings. Arthroplasty procedures in the Registry are disproportionately performed at large to medium-sized hospitals and teaching facilities when compared to smaller community based non-teaching facilities. Some small hospitals may not be performing elective hip and knee arthroplasty at all. Thus, the distribution of hospitals submitting data to AJRR, while spanning the full range of hospital sizes and types, is somewhat weighted toward larger sized academic and teaching facilities when compared to American Hospital Association (AHA) data on the profile of all hospitals nationally. These figures describe the characteristics of the hospitals submitting data to AJRR. Please note that some data were not available for submitting hospitals.
Slides with all the tables and figures from the 2014 Annual Report can be found on our website
Upcoming Webinars

Introductory Webinars
AJRR staff continues to host introductory webinars for those who are interested in joining the Registry and would like a basic overview of what we offer. If your institution resides in one of the CJR metropolitan statistical areas, this webinar should be of special interest to you! Introductory webinars will be held at the following times this year:
To register for one of these sessions, click here.
Previous Webinars

Patient-Reported Outcomes Informational Webinar
Our Analytics team hosted an informational webinar about the AJRR Level III/patient-reported outcomes (PRO) platform on both December 9, 2015 and January 6, 2016. Recommended PRO measures were discussed, as well as the reasons for why starting a PRO data collection program is beneficial. Our Director of IT demonstrated how to use the new dashboard system, and along with the Analytics team, fielded questions on how to get started reporting. To listen to a recording of the webinar, click here. To view the slides, click here.
Recordings and slides from all other previously held webinars can be found on our website
Our Newest Hospitals

We've welcomed these participants into the Registry since the last volume of
The Register:

#690 - Doctors Medical Center in Modesto, CA
#691 - Upstate University Hospital in Syracuse, NY
#692 - Arizona Spine & Joint Hospital, LLC in Mesa, AZ
#693 - Lafayette Surgical Specialty Hospital, LLC in Lafayette, LA
#694 - Mountain View Regional Hospital in Casper, WY
#695 - The Physicians Centre Hospital in Bryan, TX
#696 - Huntington Hospital in Pasadena, CA
#697 - Robert Wood Johnson University Hospital Somerset in Somerville, NJ
#698 - Robert Wood Johnson University Hospital in New Brunswick, NJ
#699 - Northwestern Medical Center, Inc. in Saint Albans, VT
#700 - National Park Medical Center in Hot Springs, AR
#701 - Carolina Pines Regional Medical Center in Hartsville, SC
#702 - Capital Medical Center in Olympia, WA
#703 - Southwestern Medical Center in Lawton, OK

AJRR currently has 703 participating hospitals in all 50 states! Click here for a full list of all participating sites.

AJRR in the News

AJRR's collaboration with AOA and AAHKS to align quality initiatives and reporting through the AJRR Orthopaedic Quality Resource Center received media coverage with the articles below:

Joe Kohli, MD, CEO and founder of AJRR technology vendor [m]pirik, gave his opinions on the Comprehensive Care for Joint Replacement (CJR) Model and mentioned his company's seamless integration with AJRR:

The recent naming of AJRR Medical Director David G. Lewallen, MD, as President of the Orthopaedic Research and Education Foundation (OREF) received coverage: 

To view our press releases, click here.

Special Thanks to All of Our Contributors!
The Register is the official newsletter of the American Joint Replacement Registry serving to connect the orthopaedic community. For questions, comments, or concerns, please contact Erik Michalesko, Marketing and Communications Specialist at michalesko@ajrr.net

The Register editor: Erik Michalesko
Contributing authors: Caryn Etkin, PhD, MPH, and Marisol Goss.

2016. All rights reserved.


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