Please stand by. You may begin. Great. Thank you very much. Welcome, everybody. My name is Jack Knightley. I am the chair of the NeuroPoint Alliance, and I'm on the ASR Executive Committee. And the goal of this webinar this afternoon is to, from a neurosurgical and NeuroPoint and WNS perspective, give a brief introduction to the American Spine Registry. My disclosures are that I am on the Executive Committee for this. So I think as a profession and as a society, we all understand the need for data in what we do in the region of spine surgical intervention. Spine and certainly degenerative spine disease is one of the most prevalent and costliest disease states worldwide. As we all know, back pain is one of the most common work-related disabilities in the U.S., and the prevalence is extremely high. The total cost for this exceeds $100 billion annually. The utilization of common spine procedures has grown geometrically over the last decade, and some of this is very fortunate because we have the ability to do different procedures now that we didn't have 20 years ago. But the cost of some of these procedures gets very high, as well as the indication. So these can range from $60,000 to $110,000 per procedure. And coupled with the large number, this leads to a very high societal cost, certainly just in the United States alone. Also of concern from a payer and from a public health standpoint is the question of whether there's unnecessary spine care, both from a diagnostic and therapeutic. Is this unnecessary and effective? Working within this narrative can be quite difficult, and if you don't have the data to prove it, then it's going to be hard to argue against it. Historically, MPA designed the QOD spine registry several years ago, probably 10 years ago now. When we finished with QOD spine, as it was most recently called, we had 125 contracted sites. And at the time, it was the largest surgical spine registry, literally, in the world. We had 38 states representative with greater than 300 hospitals, 1,300 surgeons, including both neurosurgeons and orthopedists. And more importantly, I think there was a good balance between academic and private practice. We contributed in both the cervical and lumbar spine modules to well over 100,000 patients into this registry. What did we learn from that? Well, first of all, the main goal was to design opportunities and really go into a deep dive on what we were doing with our patients. How were they doing? What were the real outcomes besides what we thought? Establish that, measure it effectively, and this came up with the registry project. And we built this platform across all of neurosurgery with input from orthopedists. We were able to standardize the collection of patient-reported outcomes, and we were doing this in a proactive fashion where doctors pretty much kind of drove how this kind of data was being collected as opposed to these large administrative databases, which payers and industry were relying on. This was more from the provider forward. We could really prove what we were doing with our patients. We also were able to improve the diagnostic delineation since we were stating this is exactly the procedure we were going to be doing, as opposed to, again, looking at data from the hospitals and administrative database where they were bundling together a simple discectomy with a large scoliosis correction. As we all know, those are very vastly different procedures, but in certain analyses, they were all bundled in the same thing and under the same way. With QoD Spine, we were starting to get really into what like procedures and comparing apples and apples and oranges to oranges. We also facilitated through the QoD Spine one of the first nationally specialty-driven quality improvement programs in the country in doing that. Along the way, even though this was a quality improvement project, we were able to support novel scientific research. And when issues such as the JAMA article regarding spondylolisthesis came up, we were able to get real-world data to write articles back to change that narrative and show that actually those procedures actually can work when done for the right time. We were kind of stuck with the point that we had a limited scalability. These programs were heavily dependent upon the data extraction folks putting this in, and we had a very difficult time of getting this data to go from an EMR system and from the hospital systems directly into the registry. And, again, it was very much people-heavy, which makes it more expensive because you needed those FTEs to actually get that data in correctly and efficiently. And the space was starting to fill up. And this is NeuroPoint. We had the QoD Spine. Historically, it was called NTQoD. All those changes were naming, and obviously that comes under the AANS. There were other registries out there such as NAS, et cetera, but the American Association of Orthopedic Surgeons did not have a spine registry, so to speak. And so, fortuitously, like minds came together and decided instead of having competitive registries, we should have complementary registries, and thus the development of the ASR. As noted in the bottom right, this is where the QoD sites were, but the AAS registry, specifically the American Joint Replacement, AJR, had over 1,500 persisting sites with 11,000 surgeons and well over 2 million procedures since they started that platform many years ago. And it was largely based on scalability, where the data could be given directly from the operative sites directly into the registry. So they had this fairly unique platform that we did not have. What we had was 10 years' worth of patients and clinical knowledge in how to actually deliver these kind of projects. So we decided to build this together. And the components of these were to have a larger quality vision for both orthopedics and the AANS NPA. We want to be able to provide real data to both our parent societies, but more importantly, provide feedback to the providers so they can go back to their individual practices to show how they're doing well and deliver the best outcomes to their patients. We can also use this data to help better define, both on a national level, value-based programs that these kind of procedures work well. And it's important data when the Washington Committee, et cetera, are working with payers and CMS on a national level to use this data to change a narrative or make it more informed. We also want to make sure that we can reduce the burden of the data going into the system, that it was not completely physician-driven or it's not an FTE required. We want to provide more information in the least possible energy state in the easiest fashion, which would be electronically, and also to show increased gaps in knowledges. So, again, that was the goal. The goal was to actually get this gap analysis, show what real-world practices are doing, provide a tool that individual physicians or sites can use for performance measurement, quality improvement, programs both at the regional level, at the local level, and then at the national level. And then, in the same fashion, be able to support the novel research, which we had seen with QODs, fine, could be done with this collaborative effort. The ASR was launched in January of last year, almost a year ago now, with over 150 sites, which we'll go over a little bit later. And somewhat unique, it's a unique entity between the AANS and the AALS. So the leadership of this is completely balanced between neurosurgery and orthopedics. Here is the inaugural executive committee, which is chaired by Tony Asher, and includes myself, Kevin Foley, and Chris Shaffery, with Steve Glassman co-chairing from the orthopedic side, currently Todd Albert, Daryl Baraki, and Dave Polley are the main members of the executive committee. But this project is far more than just with the executive committee. This is a very large undertaking, and there's several different subcommittees to represent the wide swath of performing surgeons, both orthopedics and neurosurgery, within the United States, both private practice and academics. And you can see here the operations committee, which is co-chaired from the neurosurgical standpoint by Moe Biden, and Clint Devon from orthopedics, as well as a data use committee, co-chaired by Praveen Mumineti and Doug Burton. Some of those names on the last slide, if you're following any of the research and to advocacy, et cetera, in the registry space, are well known. We also wanted to expand to make sure that it was not the same people doing the same type of projects. So we developed a key opinion leader task force to help us make sure that we're staying on mark and really did represent a wide variety of surgeons. And you can, again, see the list on the left. WNS President John Wilson and Mike Stimons recently participated as these key opinion leaders with a combined panel with the Joint Commission for Expert Panel. So being able to bring these kind of individuals into the fold has been very helpful as we make this process go forward. And, again, trying to represent many different organizations and suborganizations within neurosurgery. This is the current governance structure. And, again, it's equally split between the WNS and the AALS. And as I showed here, the Data Operations Committee and Data Use Committee. And currently we have our main module, which is to be the lumbar degenerative module and the cervical module, again, spinning off what we had done with QOD spine. These are our main projects because they represent well over 80% to 90% of the spine procedures done in the United States. The other modules will also be more in the deformity base, as well as tumor are being developed currently. This is a very busy slide and it's supposed to be because these are the data specifications that were in QOD spine before. So the Data Operations Committee took all the data that was being historically corrected and to see what was really relevant and what was not relevant, and we're trying to predict what in the future was going to be most important. The other harder part of this registry, which we found in QOD, which was the development of PROMs on a real-world basis, both in private practice and in academics, and what was going to be the PROMs in the past, what are going to be the PROMs in the future. So this committee spent a very large amount of time going through all these data elements to build the data library that would be most effective for us. In addition, thinking about how it could be as easily abstracted from the EHR as possible so as to limit the amount of people that are having to key data into this. There's a fair amount of change in methodology to actually perform this. This is currently the data elements that ASR is working on. You can see the basic demographics on the left, including, as of now, the COVID-19 status, especially given what's going on with the pandemic. But all the comorbidities are listed using ICD-10 codes, and the diagnosis codes help drive the comorbidity indexes and what the patients have. Then the very standard things, such as the name and address of the facility and the physician providing the services. But on the procedure type, instead of just putting spine surgery, the key words here are the CPT and ICD-10 code. We kind of deep into these administrative databases and things like Epic and Cerner from the hospital to find out what are the key codes actually to trigger entry into the registry and kind of limit the large number of CPT and spine codes down to make it, again, more relevant to degenerative conditions. Again, things such as data surgery and the approach, et cetera. What you see here in bold is the implants and grafts. This is one of the, again, leveraging on the experience of AJR and what we could not readily do in QAD in the past is the ability to have all the individual implant unique identification numbers put into the registry. And this is going to be very important with our industry partners going forward so we know what implants are being put in and specifically if there is any failure with the device over time. And then standard postoperative complications based on ICD-10 coding and at different type areas. Again, all these should be relatively easily abstractable from an EMR going forward. That's the big build. The hardest part, again, is using patient-reported outcomes because many folks don't use that much on a day-to-day basis. And getting patient-reported outcomes, especially on long-term follow-up patients, can be difficult, especially if they're not coming into the clinic. For example, it can be very difficult to get the outcomes of a patient with a standard discectomy or laminectomy when you're out. If they're doing well, you're not going to have them necessarily come back into your office to see them. But we still need to have this type of data. And as I alluded to earlier, what was historical, such as ODI and NDI, for example, and numeric pain scores, what is going to be more relevant in the future? And there's a multitude of patient-reported outcomes that are out there. And after a lot of work, again, by the Data Operations Committee, we've kind of narrowed this down to the recommended, which you see there is a PROMIS-10 and a VR-12. But depending upon the sophistication and how aggressive you want to be in checking your patients, you can go up to use PROMIS-CAT, PROMIS-29, and EQ5D, which is a legacy measure from the QOD work. All these can be captured in ASR. For sites that want to do this on a much more aggressive level, we've also developed what's called ASR operative forms. Again, this is a very busy slide and took a fair amount of work by the Data Operations Committee. And it looks difficult at how you're going to fill this out. The whole idea here is to have all these different elements that are within this form will be built into the various different EMR forms. So there will be discrete data elements. As the forms get built out, if you click on this, it will actually then populate your operative note. And then with a fixed field, that can actually be downloaded into the registry. But it's also being designed such a fact that when you're doing this, and whether you do it or the nurse in the operating room does it, or et cetera, it can populate your op notes. So it actually should help with the physician as they put their brief op notes in. By just doing a series of click data forms, it will populate your op note with very discrete, very searchable terms that will go into the registry and will also help locally with your coders for both either in your own individual practice or with the hospital so they know exactly what was done and there's no confusion about a spinal prosthesis or did you do a decompression here or a fusion there. It's by level, et cetera. So, again, a lot of effort went into designing these data elements. And the key here as we go forward is to build these into EMR systems so that the doctor or instructor does not have to put this information in necessarily into the registry. It will automatically populate from the EMR. That is one of the bigger builds. And, again, how do you put patient-reported outcome measures into these systems? ASR is designed that it can be put in. It's not a one-size-fits-all. Depending upon how you collect PROMs, and we have sites that have never used PROMs before, and we have other sites that are using PROMs on 80% to 90% of their patients for many years. So there are obviously very different processes for those different sites. So PROMs can be paper or electronic. We'll talk about that in a second. We want as a baseline, baseline preoperative PROMs, as I noted in Slide 2 before, and at a minimum the follow-up will be 90 days. But depending upon the level of participation a site may want to participate in, we can have the ability to have one-year follow-up. And the system is flexible enough that you can even put even longer-term data in if you want, if you're going to follow those patients for a long period of time. And, again, different sites may have different needs for both local follow-up as well as participation in value-based programs or participation with payers at their level may have different follow-ups. But the patient-reported outcomes should be able to be tracked over that time. The PROM management, as I said before, if you're not doing PROMs, then the AAOS platform has a PROM solution, which is seen here, which you can use for free. It comes with the system. So that if your site doesn't have it, then you can register, and this will send baseline PROMs that are needed for ASR to your individual patient. But if that does not work for your site, then you can do either a third-party or you can just do paper and manually upload it. Or if you're using it in day-to-day operations in your EMR system, then the EMR can actually push that directly into the registry. So there's a multitude of ways that this data, which is the hardest data to get into the system in a meaningful fashion without relying completely on data abstractors to both get the data and then input it into the registry. The AAOS, again, through their AGR program and their suite of portfolios, is an authorized vendor with a multitude of technology vendors, including Epic and Cerner, which are the leading ones in the market, helping design these systems where this information can flow relatively easily into the registry. This is a hard project, and anybody who says it's a piece of cake is not wrong. To quote Tony Asher, there's not a bunch of leprechauns in these systems that are automatically going to get the right information into the registry. So it's important both on a national and a local level to design these systems. So it's worth an effort in the front because then once the data is flowing in, it will be a lot more efficient for you as a site to have this data put in. Again, ASR through AAOS has these partnerships already on a multitude, whether you're doing it at one big site. If your office is in the hospital and you have Epic for everything, then that will be easier than if you're in a private practice like I am where I have to work on three or four different EMR systems and have to build different interfaces for that. But, again, this will allow in the future for all this information to go through. Another thing that the AAOS platform brings is the ability to get Medicare data. Medicare does not give their data out for free, and it's very expensive in the degree of sophistication of being able to get Medicare claims data and the privacy that goes onto it is a very high hurdle, and very few professional societies can do that. But because AAOS is so big with their joint registries, et cetera, they have claims for all the Medicare data, which they can bring to the table. So once you have a patient into the ASR, the system will then get it dumped from Medicare. So any patient that's a Medicare patient, they will go back and be able to track that patient's data for up to five years, and that data will also include cost data, admissions, transfers, et cetera, a very rich data set that is, again, very difficult to get to. But this will allow for full longitudinal tracking of these patients, both in the past as well as going forward. There's also relationships with NIS and other of these large administrative databases so that we can link this data to get a much richer data set to see how the patients are doing, what the cost is for the patient, et cetera. Similar negotiations are also going on with a lot of the third parties, a lot of the individual commercial payers at a large-scale basis, such as a Blues, et cetera. So that's all good. You're getting all this information. But how does that get back to the individual doctor? Again, at its core, this is a quality improvement. So this is a copy of the dashboards, which are being rolled out now, that each site will be getting and each doctor will be getting. It will show you what type of procedures you're putting into the system, whether decompressions or effusions, et cetera. It will also give the comorbidities associated with that, anesthesia levels, what your complication rate is, what kind of antidepressants you're getting, what kind of anesthesia, et cetera. These are just some of the basic templates that are coming out. If your site wants more data, again, you can get a download of all your individual data in essentially a glorified Excel spreadsheet. So you can manipulate that data as you see fit because the data is your data. It's going into a national data by, but any data that going out, any data going out besides that, outside of that would be all de-identified except the data that's going back to your individual site. Again, there will be benchmarking to this. So you will be benchmarking if I were to get my own individual report card. Granted my site can compare me to the other doctors that are in my practice, but I will not be able to be compared to the folks within the state or in the region. You will only be benchmarked to the national average, which is identical to what we did in QOD. You were just, your benchmark performance was to all the patients that are in the QOD. But again, here we're going to have a much, because of all the comorbidities and the ICDN codes we're checking, we'll be able to put much more likes and likes together. There's a much larger volume of patients in this particular system. So how are we doing so far? We started back in January. Our goal was to get to 120 sites. We have 151. We have 67 that are actively submitting their data on a day-to-day basis. And there's 149 that are in, we call leads, but are in progress of getting contracting, et cetera. So again, we consider this a very strong performance in one year. This slide shows the number of cases that are in ASR. And you can see that patients and procedures in red, that's ASR, and blue is QOD. Again, this is the 10-year history we have with QOD of patients going in there. And once a site, if you're an existing QOD site, once you get into the system, your data will be there. So you'll be able to benchmark your data compared to historical norms and be able to continue to track your patients if you need to. Again, what are the research options for this? And I always go back to this. ASR is a quality improvement effort at the ground level. Sites can have access and support their own data to do individual projects that they want to. And ASR can serve as a backbone for that advanced research efforts because it'll have such a rich data set. We will have some degree of partners for analysis, but it'll be collective data, which is all de-identified. Access to this data is gonna be tiered. And this is why, in the old days, we used to call in QOD vanguard sites, which means that you had to have at least an 80% long-term follow-up, which is mostly the patient report outcomes at one year, which can be a hard row to hoe, so to speak. So, and we're not gonna be using the term vanguard, and we're in the final stages of what that actually means, but it'll be a tiered system, with the lowest tier being that you're putting in basic information with basic pros, with somewhat limited three to nine month follow-up, as opposed to a higher tier, which has significant data input burden that you're doing all your patients, and you have, and the science of this is gonna change, how much, if you're the highest tier, does it have to be 80% or 70%? There's some statistics that are gonna change because QOD in the past was not every single patient. It was on a sampling methodology. So, and there's no other spine registries that are gonna have these numbers with these type of patient-related outcomes. So, this is, someone's gonna be a moving target, but obviously, the higher level tier is what you're gonna have access to the more of the aggregate data, are those sites that are putting in, you know, 80 to 90, you know, high level, shooting for approximately 80% of all patients having patient-reported outcomes, and if you've done that before, that can be a pretty high road. But if you're just trying to go with your basic patients, how are they basic patients doing at three, six months, then you can be participating relatively easy without having, you know, additional FTEs are gonna have to put that, those kind of data burdens in if you wanna be a higher tier site. So, why do sites participate? A, to benchmark yourself. B, I wanna see how I'm doing both internally as a practice, you know, what, how my patients are doing, what can I bring if my, if there's a problem with patients, well, what subset of the population of my patients are having issues or infection control or re-operations, et cetera. This is especially important is if you're having to interact with your hospital systems on a somewhat competitive basis, or certainly with the payers, you now have a well-adjudicated process of here are my patients, and I know my data because I helped put it in there, and you can actually have your data as opposed to relying on somebody else's data. Again, we're gonna be able to monitor long-term, longitudinally, our patient outcomes as opposed to the three months that the hospitals typically get. If you're participating in AB&S, if you're participating in ASR, this will help with your level four continuous certification. So if you participate here, this helps you with maintaining your certification. If you're an orthopedist, this would be help with your MOC. AB&S calls it continuous certification. Participating with the advanced payer programs, such as a Blue Distinction or the Aetna programs, participating in these registries will help you participate at those levels to be a center of excellence, if you will. And also with the National Distinction programs, the Joint Commission is having an advanced certification, and it's fine, which there's now, it's under review and for public comment, but the ASR is gonna be the default registry platform if you wanna participate in those programs. Similarly, again, leveraging on some of the larger programs that AOS has with their joint registry, participate in MIPS, QCDRs, and BPCI Advanced. These CMS-driven quality improvement programs, participating in ASR will help you fulfill some of the requirements to participate in those programs. Certainly for industry and for us, if we're putting in implants, we'll be able to sort of balance that. Again, part of the power is that all those widgets and all those indications, all those unique portions of screws and blockers and rods, et cetera, interbody implants, standalone cervical implants, et cetera, will be into the system. If all of a sudden, on a national level, we're starting to see that a certain implant is having problems, we'll be able to get that right back to the sites and to the physicians to know that there's a problem with these implants, not just, is I having my own problem with this in New Jersey or is this a national problem? Again, bringing this back very quickly. Again, the bottom line is the whole goal here is to improve the value of care delivered to our patients. If I think I'm doing a really good job and then I realize that from a benchmarking standpoint, I'm below the norm on whatever it may be, it's gonna drive me naturally to try and get the best care of my patients, see what I can change in my practice to be the best that I can be for my patients. Again, some of the unique capabilities, again, is the implant survivorship, giving actionable data back to the patients. Once you participate in the system, you log into my system, it'll then go back and look at that individual patient back as far as a patient may have in the system. For example, as long as they have ICD-10 going back to 2015, 2016, when that was implemented, if one of my patients is registered into ASR EPIC, which we have in our hospital, at least going back to when they implemented EPIC, we'll be able to download directly that patient's data all the way into the system without having to rely on FTEs or administrators to go back. If we really wanted to look at how a patient did two to three years ago, without having to key that individually, it'll automatically be abstracted. This will also help physicians who are not that adept at coding. That's one of the reasons we spent a fair amount of time with some of those forms, is that the coding is embedded behind the scenes in there. So as long as you're clicking that, that should help your coders do the most accurate coding, both for the hospital and for your individual coders, because it'll be right there. And again, for device surveillance. What are the future considerations? As I noted before, we're working on a deformity coverage. Right now ASR will cover basic deformity. I should know this. I think it's like three to four level fusions are covered. Something in those frames, again, it's kind of linked to the ICD-10 GOAT. I believe it's three to four. We're actively working with national thought leaders, both in orthopedics and neurosurgery, on a spine tumor module, mostly for epidural disease, et cetera. The holy grail for a lot of the, for both industry and for everybody, is to be able to input radiographic imaging. We can technically do it, and the data now has become relatively free. The question is what to do with it. And if you were to put all your radiographic data in, that means someone's got to take that data out and put it in a plain film or CT or an MR, et cetera, and who's going to read it? So right now, that's a theoretical strategic, but once AI learning comes in, that may be a much more doable solution. This system is only for the United States currently, and part of that's to do with regulations in different countries, but we've already had conversations with a multitude of players internationally to link up some of these data fields to do this. The integration of EMR capabilities is one of the most difficult components, and that is, it's going to be an ongoing process until the government says that you have to have one common will. As anybody who's been in this space knows, I could have a complete, I could have a complete smart form built in my system or Darrell Brocky's at University of Utah or whomever, and I can say, here, I built this whole thing out, putting it on thumb drives, knock yourself out. You can have, all that IT is yours, but you're still going to have to get somebody at another EPIC site to rebuild that. And until we have one common library, it's going to be difficult for that. ALS, because we're, again, leveraging with AJR, is having EPIC build that, so, right now, and hopefully within the next quarter, by the end of this quarter, which is coming up rapidly, or next quarter, there'll be an algorithm that every site will have access to if you're on the EPIC and Cerner's close behind to have that algorithm written, so you can just go, it'll be much easier to program that into the system to push the data through smoothly again, so you're limiting the amount of time that people have to either just put into a spreadsheet or abstract it by hand. And again, we also want to support other programs, as I said before, the joint certification. The FDA and CMS, having been on a few conferences, these calls with those folks over the past, are now asking, ask how they can participate, as opposed to, you know, demanding that we participate, so it's really kind of turning them on their heels, and they have certainly seen the power of having all the people who do spine surgery, both neurosurgery and orthopedics, that do it, and they understand the power of the collaboration between both societies. That's a, again, this is an introduction, it's kind of an overview. I know we kind of went through this rapidly. I'm happy to share these slides. I think I saw some of these questions going through, and if you reach out to us, anybody who has interest in ASR, if they're not participating already, you can certainly reach out to MPA, or as you can see on the slide, the American Spine Registry, just Google that, and the staff from ASR, who's both orthopedic and neurosurgery, will certainly help you answer any of your questions. If there's any specific questions, this is one of our, will be the first of a couple of different calls. If folks really want to get into the weeds about, about the codes and how to build these, we're planning on having subsequent webinars going into that, but this, again, is more of a high level about what we're doing, why we did it, and where we've come so far, and hopefully where we're going to be going in the future. So, I'm just going quickly through the questions here. Dr. Strunk. Yeah, the implants are going to be followed with this, and then we're having ongoing conversations with industry. There's some regulatory issues that they need to follow their devices, and certainly if they bring new devices to market for post-market surveillance and how that's best going to be done. So, this is one of the best platforms to actually do this, and how to partner with them for financial support is an ongoing process. Medtronic and Nuvasiv, Irene can correct me, and Stephan can correct me if I'm wrong, have already partnered with us for 2020. They're going to be some of the first companies involved, and this is a partnership to a degree, so we can make sure that we're collecting the appropriate information that they're going to need in a long time to have that information. And that, again, currently in significant discussions with them. I'm sorry, I'm trying to read through all of these questions at the same time. Dr. Groff, how successful is a Bones module that Epic markets for data abstraction to ASR? Apparently, that works really well if you have the Bones module, which is if your Epic site has Bones, and that means that interface has been more accurately built. If you think about it, a lot of these registries, 80% of the data is concordant. You know, what's the diagnosis code, blah, blah, blah, blah. It's just that for hip and knees, there's nothing against my colleagues in orthopedics, and hip and knees are like four or five diagnosis codes. And if you're a spine surgeon, and you look at how many codes there are, there's, you know, substantially more. So it's a little bit more difficult to actually get that. So the Bones module, if you have it, but if you don't have that, being bluntly honest, we're working on getting the Epic to have the master library. So if you have discrete data fields at, I'll just use myself as an example, at Atlantic, I wrote a bunch of these already, but they can't, as I said earlier, they can't go to Mike in Boston. But Epic is supposed to be giving the, if it's on the core data library, then you don't have to worry about if it's at Brigham or Mayo or Atlantic or whatever, it's already there. And that makes it much, much easier to write the op notes and et cetera to drive that information to ASR. The registry data from Katie Arrico, thank you for this question. The data is owned by you, your site. So I own my data. The de-identified data is owned by ASR for those different projects. So, but none of your identified data is gonna be pushed out. Even if it's going for industry for device regulation and they wanna know how a certain implant did, whether it's Medtronic or Striker or Invasive, whomever, they'll be able to link that data, but they won't be able to see who did those procedures, et cetera. So you have your own data. And if I wanted to work with Mike Groff or a couple other sites, you can pool your data to do individual research studies. There'll be some that'll be done both on an individual work group and there'll be a lot that are also done on a national level. But this is one of the reasons we did that. Tiered aspect, there are other surgical registries where you could be not even putting in one or two, you know, one or two patients. You're not really putting anything in. You're not spending effort, but you have access to the entire database, which a lot of folks said to that, you know, is unequal, especially if you're doing all the work and somebody has equal access. There's a data use and there's a scientific committee that will vet any research projects that similarly what we did with QOD when we had the issues with spinal lysesis, we were able to pivot that and there's a work group off of that. But that's because those groups put their own data together. QOD did not give the identified data to a group, et cetera. Everything's gonna be de-identified. Hopefully I answered that question. Will you consider e-clinical work for an EHR? Absolutely, since we just migrated to that, I am actively working that and I will, whoever answered that question, as soon as I finalize that, you're more than welcome to our processes for that. We just migrated to that. I believe synovial cyst and is in the ICD selection for, in the pathology. Do they know that code for the, the CPT code for that? I don't know, 2265, whatever it is, is actually in the, is one of the trigger codes. Thank you, Katie, for the prior authorizations. We are working with industry that if you're participating in this and you, and your performance is such that you're having good outcomes, that's actually one of the preliminary conversations that if I'm a participating ASR, A, the payer will be able to get my data, but they'll also know that my patients do well. If you've done any discussions with some of these payers, they wanna know now what, it's not just what procedure did, but you know, what was their ODI, what was their Delta pre-op to baseline, et cetera. Those types of things, which would be very difficult to do just in your own EMR, but with the ASR, you'll be able to click that with a switch and say, okay, these patients, this disease process, here's my average pre-op, here's my post-op pain, performance, disability, et cetera. It'll be there with a click of a switch that you'll be able to get. And hopefully that will help if, you know, A, for pre-op authorizations, so you're not getting denied and peer-to-peer very, very frequently. Okay. Again, if you reach out to Irene or Stephan or myself, and you want this slide deck, I'd be happy to share it. Obviously, if you have any information, it's really easy to Google ASR, the American Spine Registry, and there's a lot of information there. And going forward, hospitals did absolutely nothing, I shouldn't say that. Did the hospital underwrite this? I think that's a more of a theoretical question. One of the problems, and this is my own personal opinion, the AOS, certainly AJR, was driven by hospitals' systems to get joints, because there's so many of those procedures being done. Whereas QOD started with more on an individual surgeon champion level in its infancy. As it got bigger, it got a little bit more systems-based. So are we getting direct, is the American Hospital Association or whatever doing that? No. Different hospitals, if they're participating in accreditation projects like Joint Commission, have already seen the power of that. So they may help authorize the costs that may be needed, especially if you don't have bones or whatever. If you don't have an off-the-shelf EMR extraction program, the hospitals could be helping that at a local level, but they're not doing it at a national level. Stephanie and Irene, did I miss anything? Good. I don't think so, Dr. McPherson. Sorry, go ahead, Stephen. Okay, with that, I appreciate everybody taking time out in their holiday week. Again, reach out to American Spine Registry or us at MPA. You can, there's a question mark on the MPA website. Irene and Stephan from AANS MPA staff will be more than happy to help. And if anybody has any individual questions, just let me know. We will broadcast out when we start doing any more, some more detailed. And certainly, as we, and if you're participating in ASR, once we find out that you're interested in this, if you're participating in ASR, once we find solutions for common EMR integration projects, we will be, you know, happily to share that. It's not competition, it's for our society to make this work. And most of the directors are very, more than happy to share whatever solutions are working for them with everybody. Okay. And with that, I will close it. And again, happy holidays to everybody. Be safe. Thank you for watching.

American Spine Registry

NeuroPoint Alliance

Jack Knightley

spine surgeries

data collection

patient-reported outcomes

electronic health record systems

benchmarking