Aligning Graduate Medical Education Improvement Projects With Merit Incentive-Based Payment System Requirements via Functional Outcome Measures

Abstract

The Merit-based Incentive Payment System (MIPS) is a requirement for all physicians for value-based reporting. Medicare has approved registries as a mechanism for MIPS reporting. Concurrently, residencies continue to abide by the Accreditation Council for Graduate Medical Education’s (ACGME’s) curriculum requirement of utilizing/practicing quality improvement (QI).The objectives of this study were as follows: (1) incorporate a meaningful functional outcome measure into an electronic health record (EHR) to track spine functional outcomes; (2) generate a report containing covariables extracted from the EHR system to provide trackable data for current and future resident QI projects/investigations; and (3) establish an infrastructure to align ACGME QI initiatives with the MIPS requirements. This pilot study and retrospective analysis successfully demonstrates how a meaningful functional outcome measure can be incorporated into the EHR system for QI. Moreover, it demonstrates successful establishment of infrastructure for alignment of QI projects for ACGME residency requirements with MIPS requirements.