Join us as we examine the evolution of the American Society of Anesthesiologists National Anesthesia Clinical Outcomes Registry (NACOR). The initial NACOR concept, first discussed in 2008 when it collected quality data from a handful of anesthesia groups, is now a robust QCDR that currently supports PQRS reporting for over 400 anesthesiology groups. We will discuss the key organizational and technological challenges encountered, and how these challenges were addressed to ensure that NACOR is accessible to anesthesiology groups of all sizes, including small groups with limited IT support and groups that practice in multiple hospitals with multiple EMR vendors. Addressing these challenges has required taking innovative approaches to health data integration and a relentless focus on attaining scalability in business and technical operations. Today, NACOR provides a robust clinical data set that is being used to improve outcomes in anesthesiology.