Beyond CME and Examination for Recertification – Maintenance ...


Published on

  • Be the first to comment

  • Be the first to like this

No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide
  • In addition to the ongoing feedback ABIM receives from our PIM surveys, we also survey diplomates upon completion of Maintenance of Certification.
  • Beyond CME and Examination for Recertification – Maintenance ...

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