Interested sites must fill out the online MPOG Application. Of note, MPOG participation requires current use of an Anesthesia Electronic Health Record. If your site does not currently use an electronic health record for anesthesia documentation, please contact us (mpog-admin@med.umich.edu) before filling out an application.
To ensure a smooth onboarding process, all questions in this application must be addressed. You may need to contact other teams at your site (billing, quality, IT) to obtain all required information – complete list of requests is available below.
This form can take about 20 minutes to complete. Once we receive your application, you will receive an email outlining the next steps.
View PDF Version of MPOG Application
Information needed to complete the MPOG Application
Contact information for key personnel. Required contact information includes: Name, Credentials, and current Email address.
- Anesthesia Department Chair/Head of Practice
- Site-Designated Quality Champion – This person is a practicing anesthesiologist who will participate in the MPOG Quality Committee on behalf of the site. They are responsible for reviewing site performance on MPOG QI measures and disseminating best practices locally.
- Site-Designated MPOG Principal Investigator (PI) – This person is an anesthesiologist who will lead research efforts for the site and participate in the MPOG Perioperative Clinical Research Committee (PCRC).
- Anesthesiology IT Champion – This person is an anesthesiologist that will work with the local technical and clinical teams to assist with implementing the IT infrastructure necessary to support MPOG participation. This role requires an understanding of concept mapping and local EHR documentation.
The Quality Champion, PI, and IT Champion roles can be fulfilled by one individual or multiple. We defer to the institution to determine who will be best suited for each role. All roles must be identified before the application can be submitted.
*Please note, although MPOG staff can provide technical consultation for implementing MPOG they cannot be the primary developers for technical implementation at your site.
Health System/Hospital Information
- Health System Name (If your site is not part of a Health System, then list Facility Name)
- Street Address, City, State, Zip Code, Country
- Approximately how many total cases are performed annually
- Number of facilities (Hospitals and Ambulatory Surgery Centers) that are interested in joining
- For each facility:
- Name
- Type of Location (i.e. Hospital, ASC, Cancer Center, Children’s Hospital, etc.)
- Facility NPI (If known)
- Electronic Health Record used for Anesthesia Documentation (i.e. Epic, Cerner, MetaVision, etc.)
- Is the same EHR used throughout the hospital?
- If no, which EHR is used on inpatient units?
- Are all interested facilities on the same electronic health record instance (i.e. same ‘version’ of Epic, Cerner, etc.)?
Billing
- Are the Anesthesia Professional Fees stored in the EHR to support billing for Anesthesiologists, CRNAs, and/or AAs?
- Are the Anesthesia Professional Fee Billing services supported by an external practice or billing vendor?
- If yes, provide name of vendor/practice
- List the roles this group supports for billing services (anesthesiologists, CRNAs, AAs, etc.)
- Does the facility contract Anesthesia Services from a private practice or external entity?
- If yes, provide name of Anesthesiology Practice Group or External Entity
- List the provider types this practice employs (anesthesiologists, CRNAs, AAs, etc.)
- Is this information the same for all interested facilities? If no, provide all practice and billing information.
Michigan Sites Only
- Contact information for your site’s Pay-For-Performance (P4P) Administrator
- Name, Credentials, Preferred Pronouns, Email address
Can occur while obtaining Legal Documents (Step 3)
File Checker
After completing the online MPOG Application (Step 1), prospective sites receive a link to download MPOG’s File Checker. File Checker is a standalone application that can run on any Windows workstation and does not require the MPOG framework be installed. This allows sites to get quick and accurate feedback on their extract development without the expense of server hardware or SQL Server licensing.
File Checker will scan extract files built for the MPOG framework to validate they pass the minimum spec (as outlined in the MPOG Import Manager File Specification Guide). If there are spec violations, it will report the file name, row number, and description of the failure. File Checker test results can be exported for further review by MPOG or internal extract development staff. For a complete step by step process, please review our File Checker User Guide.
Please note: File Checker is not capable of detecting any/all potential extract problems, nor can it determine the completeness of the data provided. Successful testing simply indicates a file can be imported into the MPOG framework. Additional validation of this data from within the MPOG Application Suite may reveal problems with extract design and/or completeness.
Intake Form
In order for the Coordinating Center to better understand how your site is organized, sites must complete an intake form. This form is required for all sites applying for MPOG membership.
Security Documentation
MPOG will complete any associated project/security documentation after a site has completed File Checker testing, the Intake Form, and the Business Associate Agreement (BAA). Prospective sites must have all required extract files and validate they meet MPOG’s minimum spec (using File Checker) and complete the Intake Form before moving to Step 4.
Please submit both the completed File Checker results and the Intake Form to support@zendesk.com.
BAA required before Step 5; DUA, IRB, Bylaws, and MPOG Service Agreement required before Step 7
Complete a Business Associate Agreement (BAA)
A BAA is required for all institutions and should be vetted by your legal or contract office. The BAA must be in place before a site can start the technical implementation (Step 5). The MPOG technical team will NOT be able to assist a site beyond Step 4 until the BAA is complete.
A BAA is required because the HIPAA Privacy Rule requires that a covered entity obtain satisfactory assurances from its business associate that the business associate will appropriately safeguard the protected health information it receives or creates on behalf of the covered entity. Our legal department requests that sites us the University of Michigan BAA template.
Complete a Data Use Agreement (DUA)
The DUA is a contractual document used for the transfer of data that has been developed by nonprofit, government or private industry, where the data is nonpublic or is otherwise subject to some restrictions on its use. The DUA will need to be vetted by your legal or contract office and must be in place before you transfer data to MPOG (Step 7). MPOG has a DUA Template for institutions located in the state of Michigan, outside the state of Michigan, and Europe
Obtain IRB Approval from Local IRB
There are two IRBs required for MPOG participation:
- A centralized ‘umbrella’ IRB has been completed by the University of Michigan as the coordinating center. This IRB enables the collection of a limited clinical dataset (date of service is included) from the multiple institutions. This IRB does NOT need to be reproduced or established at each contributing center. As additional centers or data types are added to the MPOG effort, this centralized “umbrella” IRB will be updated with incremental addenda.
- The second is an institutional IRB that must be completed by all sites interested in joining MPOG. Each institution (including the coordinating center) are required to receive a performance site IRB approval from their own IRB to send their institution’s limited clinical dataset to MPOG. The University of Michigan Performance Site Application Example as well as the IRB MPOG Protocol can be used as a model for your institution-specific IRB.
If your site does not have a local IRB, then MPOG can oversee the IRB for your institution. If you have any questions about the IRB process or need IRB oversight, please contact mpog-admin@med.umich.edu for more information.
Review, Sign and Submit MPOG Bylaws
All sites must review the MPOG Bylaws, which are the membership terms for participation, and sign via SignNow. They must be signed by the department chair / head of practice and the anesthesiology PI or quality champion from your site. Once completed through SignNow, they will be returned to MPOG.
MPOG Service Agreement
MPOG requires a yearly fee for sites outside the state of Michigan to offset the administration fees at the Coordinating Center. In order for MPOG to invoice a site, we must put the MPOG Service Agreement in place at each new site. The service agreement will need to be vetted by your legal or contract office. It must be in place before you upload to MPOG to become an active site. .
For any questions regarding the regulatory / legal process, please contact Tory Lacca.
Can be done concurrently with Step 2 & 3
The first step in MPOG implementation is to obtain local servers that will house your local MPOG data. These must be separate servers and can be stand alone or virtual servers. See the Server Requirements document and contact support@mpog.zendesk.com with any questions.
*Please note, a site may purchase servers before the BAA is completed. The MPOG technical team may assist with setting up the servers but cannot move forward with any of the technical build (Step 5) until all files have met File Checker requirements and the BAA (Steps 2 & 3) is complete.
Dependent on Steps 1-4
After you have extracted files, checked them using the File Checker Software, finalized the BAA, and obtained the servers, your site can start the data configuration. Depending on your Anesthesia Information Management System (AIMS), your institution may need to develop and/or configure the data interfaces necessary to transfer your institution’s data to the central MPOG registry.
MPOG has already developed configurable data interfaces for several AIMS systems including:
- Centricity
- Cerner
- Epic
Your institution will need to configure the data interface to manage its institution-specific AIMS content. If your institution uses an AIMS that has data interface capabilities already developed by MPOG (see list above), the technical effort required to contribute data to MPOG is markedly reduced. If your institution uses an AIMS that does not have an existing MPOG data interface, your institution will have to develop the data interface and content mapping routines, which will require significantly more work.
For Hospitals using Epic, the MPOG users guide is located in the Epic UserWeb on Galaxy, see your Epic TS for details. The MPOG Import Manager Playbook can help guide prospective institutions through the setup of MPOG should your institution not use Epic, Cerner or Centricity.
Import Manager File Pipeline
Additionally, there are data elements that are located outside the AIMS system, such as laboratory values, demographics information, preoperative/postoperative data, mortality, and billing data (professional fee and hospital discharge). See minimum data requirements page for a list of data elements required.
Dependent on Steps 1 – 5
Once your site’s technical team have extracted and imported one month* of data into your MPOG local database, contact the coordinating center to schedule a meeting with an MPOG QI Coordinator
*Please Note: Importing more than one month of data initially will cause additional and duplicative work at a later date.
The Clinical Onboarding process is separated into the following steps:
- Variable Mapping: Maps AIMS variables to standardize MPOG concepts.
- Data Diagnostics: Review diagnostics to ensure MPOG data is representative of your EHR documentation; diagnostics assist in identifying mapping or extract issues before uploading to MPOG.
- Case Validation: Answers a series of questions in the case validation tool to validate data is pulled into your local database accurately.
- If errors are found in steps 2 and/or 3 additional mapping updates and technical troubleshooting is likely to occur.
- Once the site QI Champion and MPOG Coordinator have established that one month of data has been cleaned, two additional months of data should be extracted/imported into your MPOG local database.
- Repeat Steps 1 – 3 on the additional two months worth of data
- Continue importing data into your local database until there are at least six months of data present. Once this data has been cleaned and validated, you are ready to submit to the MPOG Central Test Database.
Dependent on Steps 1 – 6
Once the data from your institution’s AIMS, institutional data sources, and surgical outcome registries are imported and validated in your local MPOG database, they are ready for submission to the MPOG Central – Test database. Once submitted to “Test”, the MPOG research and quality directors will review the data. If any data quality issues are found upon review, a site will need to repeat portions of the clinical onboarding process to improve the data prior to uploading to the MPOG Central Database. MPOG provides utilities to help automate the two steps involved in submitting data to MPOG:
- PHI Scrubbing: Your institution local servers include PHI elements that are NOT sent to the central MPOG repository. Prior to their removal, they are converted into hashed identifiers in accordance with the National Security Agency’s Secure Hashing Algorithm-256 (SHA-256). This hashing process eliminates the ability to re-identify the patient once the data is sent to MPOG. The MPOG Application Suite will also remove all protected health information (PHI) other than date of service / surgery prior to data transfer. The MPOG Application Suite will also remove all protected health information (PHI) other than date of service / surgery prior to data transfer. This includes name, date of birth, address, social security number, etc. For a complete list, please refer to HIPAA’s official PHI elements list. In addition, the suite will remove all public provider identifiers such as doctor name, doctor number (i.e. NPI), pager number, etc. However, all AIMS-generated system identifiers that are not publicly visible can and should be transmitted.
- Data Transfer: Your site will transfer a limited dataset to the MPOG Central – Test database using the provided transfer utility.
After approval of your site’s data in the MPOG Central-Test database, your site will be contacted by an MPOG QI Coordinator to provide next steps. In some circumstances, the data is approved immediately and you are ready to submit to the MPOG Central Production Database. In other circumstances, there may be minor changes required to the mapping or extract to meet the minimum requirements for submission to the MPOG Production environment. Either way, the QI Coordinator will provide direction and ultimately approve the site for upload to MPOG Central Production. To upload to Production, repeat PHI scrubbing and when uploading data choose “production” in the transfer utility.
All data at the MPOG Central repository is kept within a high-security data center owned by the University of Michigan. For more information on data security, see our Security Guidelines page.
Congratulations! Your institution is now an active member of MPOG. There are two options for participation. For more information, visit the Service Tiers webpage.