Steps to Join

Is your department or hospital currently using an anesthesiology information system (AIMS) and interested in joining MPOG?  It requires both technical and clinical resources to join, but in return you are able to participate in impactful research projects and innovative quality improvement programs.

Sites must fill out the online MPOG Application and identify key personnel.  Once the online application is received by the coordinating center, you will receive a welcome email and the File Checker Software (Step 2). Key personnel include:

      • Anesthesia Department Chair
      • QI Champion, MD
      • PI Champion, MD
      • Local Technical Support* (Job Responsibilities)
      • Epic Technical Support (if using Epic as AIMS)

*Please note, although MPOG staff can provide technical consultation for implementing MPOG they cannot be the primary developers for technical implementation at your site.

(Can be done concurrently with Step 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.

Must occur prior to Step 8

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 8).  The MPOG technical team will NOT be able to assist a site beyond Step 7 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. 

The University of Michigan has a BAA template that is located in the Downloads section.

Can occur concurrently with steps 2 – 8, but must be completed prior to Step 9

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 9).  

The MPOG DUA Template is located in the Downloads section of the website.

Can occur concurrently with steps 2 – 8, but must be completed prior to Step 9

There are two IRBs required for MPOG participation:

  1. 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.
  2. 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 can be used as a model for your institution-specific IRB. The sample application and coordinating center approval letters are located in the Downloads section of the website.

If your site does not have an 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.

Can occur concurrently with steps 2 – 8, but must be completed prior to Step 9

All sites must review, sign and returned the MPOG Bylaws which are the membership terms for participation.  They must be signed by the department chair / head of practice and the anesthesiology PI or quality champion from your site.  Once they are signed, return them to Tory Lacca.

Can be done concurrently with Steps 2 – 6

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 in our Downloads section.

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 8) until the File Checker and BAA (Steps 2 & 3) are complete.

Dependent on Steps 1, 2, 3 and 7

After you have extracted files using the  File Checker Software, finalized the BAA and obtained the servers your site can start the data configuration. Depending on your institution’s AIMS, your institution or department 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:

  1. Centricity
  2. Cerner
  3. 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 significant more work.

For Hospitals using Epic, the MPOG users guide is located in the Epic UserWeb on Galaxy, see your Epic TS for details.  If your hospital uses any other AIMS, the MPOG Import Manager Playbook, Generic that guides prospective institutions through the setup of MPOG is located in the Downloads section of the website.

Additionally, there are data elements that are located outside the AIMS system, such as laboratory values, demographic, preoperative and postoperative, mortality or professional fee data. See the minimum data requirements page for the list of data elements required.

Please note, although MPOG staff can provide technical consultation for implementing MPOG they cannot be the primary developers for MPOG implementation.

Dependent on Steps 1 – 8

Once the data from your institution’s AIMS, institutional data sources, and surgical outcome registries are extracted into your local MPOG database, they are almost ready for submission to the central MPOG database.   MPOG provides utilities to help automate the following:

  1. 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.
  2. Data Transfer: Your site will transfer a limited dataset to the central MPOG database using the provided 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.

If you have any questions or need further assistance, we look forward to hearing from you!