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Beyond CME and Examination for Recertification –
Maintenance of Competency
Rebecca Lipner, PhD
VP, Psychometrics and Research Analysis
rlipner@abim.org
CNG Quarterly Meeting
March 17, 2010
Presentation Outline
Background on medical board certification History and philosophy of Maintenance of
Certification (MOC) Development of MOC program Planning and Implementation of MOC program Communication with stakeholders and reactions Challenges
Background:Physician Education, Licensure, and Certification
Medical Societies (Colleges, Academies & Societies)• National membership organizations (ACP, ACC)• Promote education and provide CME• Develop clinical guidelines & publish medical journals
Licensing Boards • State governed, non-profit, federated (USMLE/NBME)• Issue and regulate medical licenses— required for practice• Varying requirements for CME for maintenance of licensure
Certifying Boards (American Board of _____)• Non-profit “oversight” organizations• “Of the Profession, For the Public” • Certification and Maintenance of Certification define “the field”
(i.e., expectations of physician knowledge and responsibilities)
American Board of Medical Specialties (ABMS)
Founded in 1917 out of concern for quality care Largest self-regulatory group of physicians in US About 725,000 practicing certified physicians
24 ABMS member boards
• Allergy and Immunology• Anesthesiology• Colon & Rectal Surgery• Dermatology• Emergency Medicine• Family Medicine• Internal Medicine• Medical Genetics• Neurological Surgery• Nuclear Medicine• Obstetrics & Gynecology• Ophthalmology
• Orthopaedic Surgery• Otolaryngology• Pathology• Pediatrics• Physical Medicine and Rehabilitation• Plastic Surgery• Preventive Medicine• Psychiatry & Neurology• Radiology• Surgery• Thoracic Surgery• Urology
ABMS Member Boards
The American Board of:
American Board of Internal Medicine (ABIM)
ABIM founded in 1936; not for profit
Independent; certified physicians are Diplomates (not members)
~230,000 physicians certified in Internal Medicine
Increasingly involved in the national health policy dialogue
ABIM’s Mission
To enhance the quality of health care by certifying internists and subspecialists who demonstrate the knowledge, skills, and attitudes essential for excellent patient care.
“Of the profession… for the patient”
• Cardiovascular Disease• Endocrinology, Diabetes
and Metabolism• Gastroenterology• Hematology• Infectious Disease• Medical Oncology• Nephrology• Pulmonary Disease• Rheumatology
• Adolescent Medicine• Clinical Cardiac
Electrophysiology• Critical Care Medicine• Geriatric Medicine• Hospice & Palliative Care• Interventional Cardiology• Sleep Medicine• Sports Medicine• Transplant Hepatology
ABIM’s Subspecialty Disciplines
Stakeholders
Patients Physicians Others interested in physician performance
• Consumers, payers and insurers, pay for performance (P4P) organizations
• Quality organizations• AHRQ, AQA, NQF, NCQA, PCPI (AMA)
• Federal government • Centers for Medicare and Medicaid Services
(CMS)• Healthcare reform
History Leading to MOC - Milestones
1970 – First time-limited certificate issued (ABFM) 1973 – Boards adopt recertification principles 1982 – Many board administer recert exams 1999 – Six general competencies (with ACGME) 2000 – Boards commit to MOC and 4 components 2006 – Boards receive approval of MOC programs 2009 – New standards to synchronize 24 boards
(developed by Committee on Monitoring Maintenance of Certification (COMMOC))
Institute of Medicine Quality Reports
Patient welfare firstPatient welfare first
Patient autonomyPatient autonomy
Social justiceSocial justice
Need for Continuous Physician Assessment
On average, clinical skills tend to decline over time Amount of clinical experience does not necessarily lead
to better outcomes or improvement of skills• Choudhry, N.K., R.H. Fletcher, and S.B. Soumerai, Systematic Review: The Relationship
between Clinical Experience and Quality of Health Care. Annals of Internal Medicine, 2005. 142(4): p. 260-273.
Fewer than 30% of physicians examine their own performance data.
• Audet, A.-M.J., et al., Measure, Learn, And Improve: Physicians' Involvement In Quality Improvement. Health Affairs, 2005. 24(3): p. 843-853.
A physician’s ability to independently and accurately self-assess and self-evaluate is poor.
• Davis, D.A., et al., Accuracy of Physician Self-assessment Compared With Observed Measures of Competence. JAMA: Journal of the American Medical Association, 2006. 296(9): p. 1094-1102.
Choudhry NK, Ann Intern Med, 2005;142:260-73
“Point in Time Mastery” is Not Enough
Lower Performance All Outcomes
MOC Guiding Principles
Its purpose will be to assure
high standards for patient care It will provide physicians with the means to
continually assess and improve their abilities It will assure stakeholders that physicians are
being assessed by reliable and valid measures It will be transparent to public and communicate
information about physicians’ competence
ABMS/ACGME Competencies
Practice-based
Learning & Improvement
1
Interpersonal &
Communication Skills
5
Professionalism
6
Medical Knowledge
4
Patient Care
2
Systems-based
Practice
3
Development of MOC Program- Four components
1. Professional standing (licensure) • Hold a valid, unrestricted medical license
2. Lifelong learning and self-assessment• Evidence of participation
3. Cognitive expertise (examination)• Covers the scope and range of the discipline• Is clinically relevant
4. Practice performance assessment• Proven scientific, educational and assessment methodology• Reflects patient care and should result in quality
improvement
ABIM Assessments (initial)
Lifelong learning• Medical Knowledge
• Medical society products accepted• Procedural Skills
Cognitive expertise• Discipline specific
Practice Performance• Practice improvement modules
• Practiced-based learning and improvement• Systems-based practice
• Interpersonal communication skills• Patient and peers
Which of the following is the most likely diagnosis?(A) Chronic bronchitis(B) Bronchiectasis(C) Asthma(D) Pulmonary fibrosis(E) Left ventricular failure
Question 20
Click icons on lung fieldsfor audio
Could this simulator be used for testing as well as training?
SimSuite® (Medical Simulation Corporation)
Practice Improvement Module (PIMSM)
Performance Report
Performance Report
Improvement
Chart review Patient survey
Impact
plan
do
study
act
Practice survey
Based on Picker patient and CAHPS
surveys
Based on Wagner’s Chronic Care Model & IHI’s Idealized
Office Design
Evidence-based guidelines
Physicians Achieving Significant Change
Target Measure Category
(Mean re-measurement N=31 patients) Number of physicians
Mean Δ
Blood Pressure or Lipid Control 52 + 28%
Medication Selection/Adherence 12 + 33%
Non-pharmacological Treatment/Self-care Support
69 + 50%
Patient Evaluation & Testing 35 + 37%
Review of Hypertension PIM re-measurement results for general internists (115) and subspecialists (53)
New 2009 MOC Standards
A more continuous & comprehensive process Integrate the patient’s voice Supports transparency to the public Address patient safety Address communication skills and
professionalism Include assessment of cognitive skills Incorporate quality improvement
New Standards - Public Benefits
Improve quality of care and patient safety Objective criteria for evaluating a
physician’s performance Improved ability of public to make well-
informed healthcare choices Give patients a voice
New Standards - Physician Benefits
Certification is a professional value Physician is helped in pursuit of lifelong learning Alignment with external environment
• Reduce redundancy - Streamline credentialing & privileging
• Reduce malpractice costs• Align with other strategies for physician accountability
(e.g., P4P)
Examine Current MOC Program
What is the value of certification? What do patients think of certification? What is the rate of participation? What do physicians think of MOC? What do physicians think of the products? What is the evidence?
Value of ABIM Certification
Although voluntary, more than 87% of U.S. doctors are certified
Almost 90% of time-limited doctors recertify
Gallup survey demonstrates that patients value certification
Other entities –health plans, hospitals, medical groups, licensing boards, other countries – are using certification and/or components
Physicians eligible to claim CME (AMA PRA Category 1 Credit™)
Public Expects Physician Evaluation
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Re-evaluatedevery so
many years
Periodicallypass a written
test ofknowledge
Have highsucces ratesfor diseasestreated most
often
Not ImportantLess ImportantNeutralImportantVery Important
How important is it that doctors have the following…
MOC Completion 1990-1998 Cohorts
Lipner et al, Ann Intern Med, 2006; 144(1):29-37.
Maintain/improve professional image
Update knowledge Maintain/improve patient
care or safety Personal preference or
interest Required for employment
Takes too much time Too expensive Not required for
employment Requirements
unreasonable No monetary benefit
Participate Not Participate
Attitudes about MOC -- Reasons to…
Physicians’ Attitudes Towards MOC
Part 2: Self-Evaluation Process was valuable learning experience• 77% Strongly agree or agree
Part 3: Satisfied with test experience • 83% Strongly agree or agree
Part 4: Performance Improvement Module
• 73% changed their practice as a result of completing the module
• 82% would recommend the PIM to a colleague
Physician Reactions After Completing Part 4 I didn’t know how I was doing. I am surprised by what I’m missing. We can do something about this! Small changes can make a big difference. Patient survey & chart audit were more valuable
than I thought – I learned a lot. An EMR with registry function can help with
repeated measurement.
Physician Reactions (continued)
“Ah-Ha” – I thought I was doing better• Powerful – believe data
Want to change, but don’t know how• What is “System-based practice”?• What is rapid-cycle test of change?
Emotion• Anger – “ABIM has no business being in my
business.”• Fear – “I’ll uncover performance data that will
hurt me.”• Gratitude – “Thanks for giving me a way to
know and improve practice.”
Studies Linking Certification/MOC and Quality
Better outcomes & more reliable care JAMA, 2004, Vol. 292, pp.1038-43
15% less mortality in myocardial infarction Acad. Med., 2000, Vol. 75, pp. 1193-98
Higher rates of preventive service (Mammography, hemoglobin A1c monitoring, influenza vaccination)
JAMA, 2005, Vol. 294, pp. 473-81
40% less mortality in colon resection Surgery, 2002, Vol. 132, pp. 663-70
Higher rates of prescription of aspirin and beta blocker after MI
JGIM, 2006, Vol. 21(3), pp. 238-244
Higher rates on diabetes care process measures for Medicare beneficiaries
Arch Intern Med, 2008, Vol. 168(13), pp. 1396-1403
Implementation - Planning:Committee Structure Oversight
Steering committee• Outside consultant• Project management
Board meetings/conference calls• Executive committee• Entire board
Internal Staff Committee Structure
Program Architecture• Conceptual design of CMOC• Product strategy to fulfill milestone contents
Finance• Fee structure• Incentives/behavior
Communications & Engagement• Stakeholder engagement• Web information
Early Initiatives & Evolutionary Principles• Automatic Enrollment• Multimedia to exams
Challenges for ABMS MOC
Communication about program changes Resistance to a more continuous process Many disciplines under internal medicine
• Specific tool development costly
Infrastructure changes – e.g., fees Rigorous, scientifically sound assessments
• Patient care, performance assessment
Research demonstrating validity (difficult, costly) Increasing transparency – appropriate level
Challenges (continued)
Degree of interaction with “other” stakeholders Public and government engagement Politics: Healthcare reform and meaningful use Complexity in quality arena …
Health Care Quality RelationshipsPurchasers (Government, Purchasers (Government,
Employers, Leapfrog)Employers, Leapfrog)Purchasers (Government, Purchasers (Government,
Employers, Leapfrog)Employers, Leapfrog)Insurers HC-Insurers HC-Plans CMSPlans CMSInsurers HC-Insurers HC-Plans CMSPlans CMS
Patients
QualityQuality
HospitalHospitalHospitalHospital JOINT JOINT COMMISSIONCOMMISSION
JOINT JOINT COMMISSIONCOMMISSION
NCQANCQANCQANCQA
ABMSABMSABMSABMS
FSMBFSMBFSMBFSMB
Consumer AdvocatesConsumer Advocates
Specialty Specialty SocietiesSocietiesSpecialty Specialty SocietiesSocieties
PharmaciesPharmacies LaboratoryLaboratoryLaboratoryLaboratory
AQA/NQF AQA/NQF MeasuresMeasuresAQA/NQF AQA/NQF MeasuresMeasures
Academic Academic EntitiesEntities
Academic Academic EntitiesEntities
ConsultantConsultantConsultantConsultant
Research (RWJ, Research (RWJ, RAND, AHRQ)RAND, AHRQ)
Research (RWJ, Research (RWJ, RAND, AHRQ)RAND, AHRQ)
ACGMEACGMEACGMEACGMECare Care ManagementManagement
Care Care ManagementManagement
ACCMEACCMEACCMEACCME
Physicians
QIOsQIOsQIOsQIOs
HIT VendorsHIT VendorsHIT VendorsHIT Vendors
Thank you!
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