This is a presentation from the 2013 American Academy of Pediatrics National Conference and Exhibition that discusses Maintenance of Certification, Quality Improvement and Electronic Health Records

1. Donna M. D’Alessandro, M.D.
Professor of Pediatrics
University of Iowa

2. Disclosures and Disclaimer
 “I have no relevant financial relationships with the
manufacturer(s) of any commercial product(s) and/or
provider(s) of commercial services discussed in this
CME activity.”
 AAP’s Pedialink - editorial board member
 I know a little bit about each– so before you do
something, please recheck with the appropriate group
to make sure doing the activity will get you what you
want/need

3. Overview
 MOC
 QI
 EHR
 Putting it all together

4. Objectives
 Learn about MOC and EHRs and how they can be used to
develop quality improvement programs
 I hope to show you that
 MOC – is a continuous process to maintain your professional
competency
 QI – is a continuous process to improve the care you provide
 EHRs – are continually advancing tools for us to use in our
practice
 Together they form a stalwart trio to help us provide the
best care possible and continue to improve our mastery of
pediatrics.

5. Alphabet Soup
 ABP – American Board of Pediatrics, “The Board”
 AAP – American Academy of Pediatrics, “The





Academy”
CME – Continuing Medical Education
MOC – Maintenance of Certification
QI – Quality Improvement
EHR – Electronic Health Records
MU – Meaningful Use

6. Maintenance of Certification (MOC)

7. Professional Development:
Recent History
 Late 1980s – change from time unlimited ABP eligibility
to time-limited ABP eligibility (or periodic
recertification)
 Initially activities included CME, and take-home
knowledge and decision-making computer programs
 Proctored test

8. Professional Development:
Recent History
 1990s and early 2000s
 Inconsistencies among practitioners
 Competency movement
 Patient safety movement
 American Board of Medical Specialties - governing board
of all medical specialties developed the idea of MOC
 Goals
 Improved professionalism
 Improve patient care including more consistency of practice among
providers
 Improved accountability to the public

9. What is MOC?
 Program of activities to “maintain” professional
competency
 There is no expiration date as long as the physician is
enrolled in the program

10. MOC Key Facts
 ABP is requiring MOC to maintain board certification
 State Boards are moving toward requirements to:
 Require MOC
 Require board certification
MOC

11. Basic Plan of MOC
 4 parts like Puzzle Pieces, not chronologically
ordered
 Part 1 Professional Standing and Licensure:
unrestricted license to practice
 Part 2 Life-long Learning Self Assessment:
participating in knowledge self assessment tools
 Part 3 Cognitive Expertise: passing a secure
examination
 Part 4 Performance in Practice: participating in quality
improvement projects

12. Basic Plan of MOC
 5-year cycle with 100 points for activities
 40 points each Part 2 and Part 4
 20 points either Part 2 or Part 4
 Part 3 – one test every 10 years (every 2 cycles)

13. Basic Plan of MOC
 Pediatricians with unlimited time eligibility
 May choose not to enroll
 May choose to enroll
 May need to enroll
 If enroll, pay fee, enter the MOC 5-year cycle

14. Basic Plan of MOC
 Pediatricians coming out of residency
 Will pay fee and enter right into the MOC 5-year cycle

15. Basic Plan of MOC
 Everyone else (time-limited eligibility) is in the
transition zone
 Have different requirements depending on the date of
last certification
 On next date of next certification, will pay fee and enter
the MOC 5-year cycle

16. Actually Doing MOC
 Check the ABP website to see your personal requirements –
www.abp.org
 If you don’t understand contact the ABP
 Pay fee ($1185 in 2013, $1230 in 2014) and enter the MOC 5-year
cycle
 Website has lists of activities that qualify for each part
 All activities




Have a “sell by” date
Have a different MOC point value
May be free or have an additional cost in addition the MOC fee
May or may not award CME

17. Part 1 – Profession Standing and
Licensure
 Submit a copy of your current state license every 5 years

18. Part 2 – Lifelong Learning
Self-Assessment
 ABP – has a variety of knowledge tests
 FREE, most with CME

General knowledge test, decision skills or subspecialty tests
 FREE, CME, 10-20 points/year/test
 AAP
 PREP questions – $213-226 in 2013, gives CME, 20 points
 NeoReviews - $110/year, gives CME, 20 points
 Pedialink Learning Plan – cost = FREE, but for MOC
must have PREP subscription, can link to CME almost
seamlessly, 20 points

19. Pedialink Learning Plan (for MOC2)

20. iPOC ( for CME)

21. Part 3 – Cognitive Expertise
 Secure examination


Take once every 10 years (i.e. 1 time during 2 cycles of MOC)
Fee for one test included in price of MOC

22. Part 4 - Performance in Practice
 ABP

Practice Improvement Modules – FREE, get CME, 20 points
 AAP



EQiPP – $199/individual, has group discounts, get CME, 20
points
Pedialink- MyQiPP – approved, but details are being worked
out
Other programs
 CAQI – Chapter Alliance for Quality Improvement
 QuINN – Quality Improvement Innovation Network

23. Today We Still Need CME
 CME at Point of Care
 Cincinnati - Internet Point of Care Credit– FREE, 0.5
CME/?, receive one CME certificate, No MOC
 Pedialink iPOC – FREE, 0.5 CME/?, can collate
questions to receive one CME certificate, questions link
to the Learning Plan for Part 2 MOC

24. http://www.cincinnatichildrens.org/ed
/cme/cme/ipcc.htm
www.pedialink.org

25. Questions about MOC?

26. Quality Improvement (QI)

27. What is Quality?
 Meeting the needs and exceeding the expectations of the
patients and families that healthcare providers serve
 Delivering all and only the care that the patient and family needs
It is NOT…
 Telling at people to work harder, faster, or safer
 Creating protocols and order sets and then failing to monitor
their use or effect
 Quality Assurance - The planned and systematic activities implemented
in a quality system so that quality requirements for a product or service will
be fulfilled (ie. the standards are met each time)
 Research (but they can co-exist nicely)
- Modified from Institute for Healthcare
Improvement

28. Improving Quality
 Requires change - every system is designed perfectly to
achieve exactly the results it gets
 Needs to be kept simple
 if you don’t you destroy productivity, and unintended
consequences results in too big a disruption

29. Delivering Care and Making Changes
Structure
Inputs
•Patients
•Equipment
•Supplies
•Environment
•Training
Processes
and People*
Steps
•Physician orders
•Nursing care
•Ancillary staff
•Coordination
•Business practice
Outcomes of Care
Outputs
•Physiologic
parameters
•Functional status
•Satisfaction
•Cost
*Has the greatest chance to improve care, also
the closest to the care
- Modified from Institute for Healthcare Improvement

30. The Personnel Team
 One person (rarely) can make the changes necessary. It
is a system of processes and personnel that is
delivering care
 Team – can be small or large, with everyone involved
in some way.
 It is the actual people doing the work, not a
representative for others

31. Planning Steps for the Change
What do we want to achieve?
What changes will drive our progress?
How will we measure our progress?
How should we modify our latest changes?
modified from: The Foundation of Improvement by Thomas W. Nolan et. al

32. What do we want to achieve?
 Set a SMART goal


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Specific
Measure
Achievable
Relevant and reliable
Time limited
 “Increase the screening rates for dental caries in 5-
year olds within 6 months”
 May have more than 1 goal, so discuss options and
chose one goal to work on with the team
modified from: The Foundation of Improvement by Thomas W. Nolan et. al

33. What changes will drive our progress ?



Select changes that are the most likely to improve
outcomes
Recognize that not all changes improve outcomes
– “Just because you can, doesn’t mean you should”
and conversely, “Just because you think you can’t,
doesn’t mean you shouldn’t try.”
“Changing the EHR to include discrete structured
data to improve reporting”
modified from: The Foundation of Improvement by Thomas W. Nolan et. al

34. How will we measure our progress?

How will you know how far you have come to realizing
your goal?
Need more than 1 measure
It doesn’t have to be perfect
You be able to answer the journalistic 5Ws and H?
Who, What, Where, When, Why & How
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Pilot test
Collect data
Evaluate the data and compare it– overtime, to
benchmarks, to end aim
Evaluate regularly not just at the end
modified from: The Foundation of Improvement by Thomas W. Nolan et. al

35. PDSA Cycles - How should we modify our
latest changes?

Run PDSA cycles to implement your changes
and see your results

Can you answer the 5Ws and H?

The analysis phase is imbedded in the
planning
modified from: The Foundation of Improvement by Thomas W. Nolan et. al

36. Questions about Quality
Improvement?

37. Electronic Health Records (EHRs)
 Computers that store health information that then health
care personnel (and patient/family) can access and utilize
to provide care, and hopefully improve health
 Healthcare provider controlled EHR
 Computerized patient record
 Electronic medical record
 Electronic health record
 Patient controlled EHR
 Patient health record
 Personal health record

38. EHRs are Not New
 Depending on how you want to define an EHR, first
ones go back to late 60s
 Probably even earlier to help with accounting/billing
that then could be used for epidemiological work
 Holy grail – integration – getting computers to talk to
each other

39. Fast Forward to Today
 Have computers that reasonably (sort of, maybe) talk
to each other
 Have Internet where information is easily/constantly
available
 Shouldn’t everyone have an EHR and use it to provide
quality care to patients and families?

40. History of EHRs and Meaningful
Use (MU)
 American Recovery and Reinvestment Act of 2009
(Recovery Act) signed into law
 Within the Recovery Act lies the Health Information
Technology for Economic and Clinical Health Act, or
the "HITECH Act”
 HITECH caused CMS to set criteria for :
 “Certified” EHRs
 For “meaningful use” of the EHRs
 Reporting quality measures
 Create an incentive system for providers to acquire, use
and report using EHRs

41. Meaningful Use (MU)
 Goal: to promote the spread of electronic health
records to improve health care in the United States.
 Improve quality, safety, efficiency, and reduce health
disparities
 Engage patients and families
 Improve care coordination, and population and public
health
 Maintain privacy and security of patient health
information

42. MU
 Criteria that defines
 Eligible professionals
 Eligible hospitals and critical access hospitals
 Implementation that is rolling out….

43. 3 Stages of MU
Stage 1
Data Capturing and Sharing
•Began 2011, use for 2 years
•Use an EHR
•Set of Criteria
•Core Objectives
•Menu Objectives
•Reports
Obtain an EHR and start to
use it
-Modified from Meaningful Use Overview, AAP

44. 3 Stages of MU
Stage 1
Data Capturing and Sharing
•Began 2011, use for 2 years
•Use an EHR
•Set of Criteria
•Core Objectives
•Menu Objectives
•Reports
Obtain an EHR and
start to use it
Stage 2
Advance Clinical Processes
•Begins 2014, use for 2 years
•Use a “Certified EHR”
•Set of Criteria
•Core Objectives (many were menu obj. in MU1)
•Menu Objectives
•Some new objectives
•All have higher standards or measures
•Reports Clinical Quality Measures
•Improved definitions/close loop holes
•Medicaid definitions
•Reporting periods
Increase standards and start to use for quality
improvement
-Modified from Meaningful Use Overview, AAP

45. 3 Stages of MU
Stage 1
Data Capturing and
Sharing
•Began 2011, use for 2
years
•Use an EHR
•Set of Criteria
•Core Objectives
•Menu Objectives
•Reports
Obtain an EHR and
start to use it
Stage 2
Advance Clinical Processes
Stage 3
Improve Health
Outcomes
•Began 2016, use for 2
years
•Being Developed
•Begins 2014, use for 2 years
•Use a “Certified EHR” by ONC
•Set of Criteria
•Core Objectives (many
were menu obj. in MU1)
•Menu Objectives
•Some new objectives
•All have higher standards
or measures
• Reports Clinical Quality
Measures
•Improved definitions
Increase standards and
Use the EHR for real QI
start to use for quality
-Modified from Meaningful Use Overview, AAP
improvement

46. Other Key Changes in MU2
 Patients have to actually sign-up and use the Certified EHR
 > 5% must send secure messages, >5% must access their
information
 Changes the definition of what constitutes a Medicaid
encounter
 Extends eligibility to hospital based providers (NICU,
radiology groups who are independent of the hospital but
practice within a hospital)
 Increased information exchange
 New pediatric specific clinical quality measures

47. Core Objectives (must report all)
1. Use computerized provider order entry (CPOE) for medication,
laboratory and radiology orders
>60 percent of medication, 30% laboratory, and 30% radiology orders
are recorded using CPOE.
2.Generate and transmit permissible prescriptions electronically
(eRx)
>50 percent of prescriptions transmitted electronically
3.Record demographic information
>80 percent of all unique patients seen have demographics recorded
as structured data
4.Record and chart changes in vital signs
5.Record smoking status for patients 13 years old or older
6.Use clinical decision support to improve performance on highpriority health conditions

48. Core Objectives
7.Provide patients the ability to view online, download and
transmit their health information
8.Provide clinical summaries for patients for each office visit
9.Protect electronic health information created or
maintained by the Certified EHR Technology
10. Incorporate clinical lab-test results into Certified EHR
Technology
11. Generate lists of patients by specific conditions to use for
quality improvement, reduction of disparities, research, or
outreach
12. Use clinically relevant information to identify patients
who should receive reminders for preventive/follow-up
care

49. Core Objectives
13. Use certified EHR technology to identify patientspecific education resources
14. Perform medication reconciliation
15. Provide summary of care record for each transition of
care or referral
16. Submit electronic data to immunization registries
17. Use secure electronic messaging to communicate
with patients on relevant health information

50. Menu Objectives
(must report 3 out of 6)
1. Submit electronic syndromic surveillance data to
public health agencies
2.Record electronic notes in patient records
3.Imaging results accessible
4.Record patient family health history
5.Identify and report cancer cases to a State cancer
registry
6.Identify and report specific cases to a specialized
registry (other than a cancer registry)

51. Pediatric Clinical Quality Measures
(must report 9 of 64)
 Immunization status – rates for certain vaccines by age 2
 URI treatment – rates for URI not given an antibiotic at visit or within 3







days afterwards
ADHD – rates of initial follow-up visit within 30 days of med initiation,
rates of 2 additional visits within 9 months after initial follow-up visit
Depression – rates for screening for > 13 year olds, and follow-up if
positive
Dental caries - % of children with caries/decay
Asthma – rates of persistent asthmatics on chronic medication
Chlamydia screening – rates of >16 year old sex-active teens screened
Weight, activity and nutrition counseling – rates of Ht, Wt, BMI
documents, documented counseling for nutrition and activity
Pharyngitis – rates of appropriate testing and treatment for Group A
streptococcus

52. Questions about EHR and MU?

53. Three Examples
 Dental caries
 Persistent asthma
 Chlamydia screening

54. Basic Process –
Your Very Own PDSA Cycle








1. Background information search – CME, MOC2
2. Look for MOC 4 QI availability - MOC 4
3. Plan QI and Use EHR - EHR/MU
What do we want to achieve?
What changes will drive the process?
How will progress be measured?
How should we modify our latest changes?
Run reports for QI and MU
4. Use Questions that arise in #3 to do other searches

55. Dental Caries
1. Background Information Search – Get CME, MOC2
 What are the overall rates in my state/location?
 What are some of the local problems with dental caries
prevention?
 What do caries look like?
2. Look for MOC 4 QI availability
 My search of the ABP for MOC2 and MOC4 yielded no
specific programs

56. Dental Caries
3. Plan QI and Use EHR
 In Iowa, all 5 year olds must have a dental screening for
school entry and if have caries should be referred
 Problem: EHR doesn’t have to say whether caries are
present or not (and we often don’t do this)
 Problem: Screening for dental home is good, but referral
to dentist doesn’t say whether for dental home or for
caries
 Problem: No discrete data elements in EHR

57. Dental Caries
 What do we want to achieve?
 Screening all 5 year olds for dental caries
 Improved screening for dental home
 Improved documentation of dental caries present or not
 Improved rates of going to dental home

58. Dental Caries
 What will drive the process?
 Screening documents will ask about dental caries, presence of
dental home and last visit to dental home
 MA will review/ask these questions of parents
 Physician will document presence of caries and dental home,
last visit to dental home, and reason for referral if made
 At check out, front desk will ask parent if they would like
them to make appointment with dental home, give
instructions on hours/how to get there, insurance for the
referral
 Use a structured data element in EHR to help make reporting
easier?

59. Dental Caries
 How will progress be measured?
 Rates of screening for dental caries
 Rates of documentation of caries present or not
 Rates of screening for a dental home
 Number of families assisted in making
appointments, brochures distributed
 Rates of dental home visit within past year?
 Use EHR to run reports for this, or at least to identify all 5
year olds that should have been screened, or should be
screened coming up in the schedule
 Use EHR to report MU

60. Dental Caries
 How should we modify what we are doing?
 Move to screening all kids with teeth
 Improved rate of dental caries identification
 Close the loop – within the next year, do the families go
to dental home
 What new questions have arisen that should be
researched? Remember its your own PDSA – go back
to the start and get CME, MOC2

61. Asthma
 1. Background Information Search - Get CME, MOC2
 What are the categories of asthma?
 How do you define persistent asthma?
 What CPT codes can be used for persistent asthma?
 What medications are appropriate to treat persistent asthma?
 Should influenza vaccine be considered a chronic medication
also even though it is a biologic medication?
 2. Look for MOC 4 QI availability
 My search of the ABP for MOC2 yielded 1-10 potential
programs and MOC4 yielded 36 specific programs

62. Asthma
 Problem – inconsistent use of various terms for asthma
 Problem – don’t know if patients are receiving
appropriate medication
 Problem – not clear who is primarily managing the
asthma

63. Asthma
 3. Plan QI and Use EHR - EHR/MU
 What do we want to achieve?
 Improved rates of accurately recorded asthma status
 Improved rates of persistent asthmatics on controller
medication
 Improved rates of persistent asthmatics receiving an
influenza vaccine
 Clarifying who is primarily managing the asthma

64. Asthma
 What changes will drive the process?
 EHR will run a report for certain CPT codes (asthma,
bronchiolitis, reactive airway disease) and charts flagged
 As patients come to office, MA will review all medications
asking specifically about asthma medication, Will review
immunizations including influenza
 Physician will review and refine the diagnoses, entering
accurate diagnosis into problem list
 Physician will review medications and appropriately renew or
prescribe controller medication
 Physician will review with family who is primarily responsible
for the asthma management and record this in the problem
list

65. Asthma
 How will progress be measured?
 Run reports with EHR for these CPT codes to identify
patients

Rates of generic asthma and asthma modifiers
 Cross reference those that are persistent asthmatics with
medications

Rates of 1,2,3, medications use
 Cross reference with those that received influenza vaccine
within past year
 Rates for all asthmatics, persistent asthmatics, entire practice
 Rates for recording in problem list who is managing the
asthma
 Run reports with the EHR and report MU

66. Asthma
 How should we modify our latest changes?
 How many persistent asthmatics have asthma action
plans
 How many actually know they have them, and can
identify what to do
 How could we work closer with the
allergist/pulmonologist to manage the persistent
asthmatics?
 What new questions have arisen that should be
researched? Your own PDSA cycle again - CME, MOC2

67. Chlamydia
 1. Background Information Search - Get CME, MOC2
 What are the guidelines for Chlamydia screening,
treatment and other STI screening/treatment?
 Who should be screened and when?
 2. Look for MOC 4 QI availability
 My search of the ABP for MOC2 yielded 1+ potential
programs and MOC4 yielded 3 specific programs

68. Chlamydia
 Problem – best to have this as a discrete data element
 Problem – problems with confidentiality, accurate
reporting by patients and recording by health care
providers
 Problem – appropriate providers being conveniently
available to adolescents

69. Chlamydia
 3. Plan QI and Use EHR - EHR/MU
 What do we want to achieve?
 Screen all sexually active teenagers (13+) for Chlamydia
 Screen all sexually active teenagers (13+) for other STIs

70. Chlamydia
 What changes will drive the process?
 Identify all sexually active teens using confidential
forms/computers, MA verbal screening and physician
screening.
 Physician will document presence of sexual activity and
previous screening, review appropriate results and treatment
 Physician will offer screening and will document results or if
teen declines screening
 Provide resources for other sexual health providers in area
 Front desk will ask teen if they want help making
appointment with another provider, give instructions on
hours/how to get there and insurance

71. Chlamydia
 How will progress be measured?
 Rates of screening for Chlamydia and other STI or declination
 Rates of documentation of sexual activity or not (probably
will need to do chart review because no discrete data element
in EHR currently)
 Rates of referral to other sexual health provider
 Rates of referral sexual health provider visits within past year
 Number of teens assisted in making appointments, brochures
distributed
 Run reports with the EHR and report MU

72. Chlamydia
 How should we modify our latest changes?
 Move to screening all teens (if did a subset before)
 Improved documentation rate for sexual activity
 Close the loop – within the next year, do the teens go to
the referral provider
 Distribute condoms in office?
 Work with schools and pharmacists to assist teens
locally?
 What new questions have arisen that should be
researched? Your own PDSA again - CME, MOC2

73. Summary
 The objective of this session was to learn about MOC and
EHRs and how they can be used to develop quality
improvement programs
 I hope your can see how
 MOC – is a continuous process to maintain your professional
competency
 QI – is a continuous process to improve the care you provide
 EHRs – are continually advancing tools for us to use in our
practice
 Together they form a stalwart trio to help us provide the
best care possible and continue to improve our mastery of
our pediatrics.

74. Donna M. D’Alessandro, M.D.
donna-dalessandro@uiowa.edu