ABMS/ABIM and ABIM Maintenance of Certification

(MOC) for Cardiologists

John Gordon Harold, MD, FACCChair-Elect, ACC Board of Governors

Member, Board of DirectorsAmerican Board of Internal Medicine

January 2009

Chronology of American Board of InternalMedicine Recertification, 1936–2004

• 1936 ABIM begins certification• 1970 ABIM endorses the concept of recertification • 1974 First voluntary recertification program offered• 1986 ABIM concludes voluntary recertification is a

failure; adopts prospective time-limited certification• 1987–1988 Critical care and geriatric medicine

certificates time-limited to 10 years• 1990 All ABIM certificates time-limited to 10 years• 1995 First comprehensive recertification program

offered• 2000 Recertification evolves to a program of

Continuous Professional Development (CPD)• 2004 CPD fully implemented

The Professional Landscape• Medical Societies (ACP, ACC, ACCP, etc…)

– National membership organizations– Promote education and provide CME– Develop clinical guidelines and publish medical journals

• Licensing Boards – State governed, non-profit– Issue and regulate medical licenses—required for

practice– Members of the Federation of State Medical Boards

• Certifying Boards (ABIM, ABFM, etc.)– National non-profit– Evaluate and certify the knowledge, skills and attitudes

of physicians—NOT required for practice– Members of the American Board of Medical Specialties

(ABMS)

The Need for Physician Assessment and Evaluation

• Clinical Judgment & Diagnostic Errors• Clinical judgment and the ability to deal with

uncertainty are especially critical with respect to misuse and overuse of processes of care.

• Misuse and overuse of processes of care (e.g., overprescribing antibiotics and unnecessary imaging and procedures) put patients at greater risk for unnecessary complications.

• Physician knowledge and clinical judgment are central to making correct diagnoses.

• Diagnostic errors are prevalent and consequential among physicians and may not simply resolve with more practice experience.

The Need for Physician Assessment and Evaluation

• Physician Skills Deteriorate Over Time• On average, clinical skills tend to decline

over time.• Amount of clinical experience does not

necessarily lead to better outcomes or improvement of skills.

• Fewer than 30% of physicians examine their own performance data.

• A physician’s ability to independently and accurately self-assess and self-evaluate is poor.

The Role of Certification and Maintenance of Certification

• Secure examinations of medical knowledge and clinical judgment can provide an effective means to assess whether physicians have incorporated new knowledge and have synthesized the knowledge over time.

• The ABIM Certification and Maintenance of Certification examinations in internal medicine and its subspecialties are designed to evaluate the extent of the candidate’s knowledge and clinical judgment in the areas in which an internist or subspecialist should demonstrate a high level of competence.

The Role of Certification and Maintenance of Certification

• These exams assess expertise in the broad domain of internal medicine or in the particular subspecialty and the diagnosis and treatment of both common and rare conditions that have important consequences for patients.

• The majority of questions on the ABIM exams require integration of information, prioritization of alternatives, and/or utilization of clinical judgment in reaching a correct conclusion.

The Role of Certification and Maintenance of Certification

• ABIM exam questions test “efficiency” or conservative management in health care.

• High performance on the ABIM Certification examination predicted decreased risk for future disciplinary action for American or Canadian medical school graduates.

Certification is Associated with Better Patient Care

• Mortality was lower for patients with acute myocardial infarction cared for by certified physicians.

• Certified cardiologists saved more lives than certified primary care doctors than doctors who are not board certified.

• Certification in surgery was a significant predictor of lower mortality and complication rates for colorectal surgery.

• Higher scores on the ABIM internal medicine Maintenance of Certification examination are associated with better performance on Medicare quality indicators for diabetes and mammography screening.

Patients and Physicians Believe In the Importance of Ongoing Assessment

• The Public Expects It• The public expects, in return for the

privilege of self-regulation, that physicians undergo a rigorous, periodic examination of knowledge.

• A recent ABMS consumer survey found 91 percent of respondents said that board certification is “very important” or “important” in choosing a doctor.

Patients and Physicians Believe In the Importance of Ongoing Assessment

• Physicians Value It

• In general, physicians seem to value the Maintenance of Certification process for its effort to improve quality of care and patient safety.

• Physicians find the ABIM Maintenance of Certification program personally (61%) and professionally (71%) valuable.

Patients and Physicians Believe In the Importance of Ongoing Assessment

• 78% of physicians who completed an ABIM self-assessment of knowledge module agree that it helped them identify further areas of study, and 70% agree that it raised their awareness of how to improve patient care.

• 82% of physicians would recommend the ABIM practice improvement modules to a colleague. 73% indicated that they changed their practice as a result of the module.

Testing Theory

• Psychometric Evaluation:

• Key Components

• Relevance

• Difficulty

• Discrimination

Testing Logistics

• Subspecialty Test Administration• Fee: The one-time Maintenance of

Certification enrollment fee is $1,495. An additional fee of $700 is charged for each additional exam you take after the first exam. The fee, which is valid for 10 years, covers the required 100 self-evaluation points and one secure examination.

• Pearson VUE Computer-based (200 centers)• Individual workstations• Enhanced graphics, multimedia capability

American Board of Internal Medicine (ABIM) Recertification

• After 1990, ABIM grants only 10-year “time-limited” certificates. First wave of Interventional Cardiologists are now recertifying.

• Recertification requires physicians to pass a secure exam and earn 100 ABIM points every 10 years

ABIM points can be earned for knowledge modules (60 multiple-choice questions) and/or ACC SAP

Effective January 1, 2006 – 20 points must be earned for practice improvement modules (PIM); current ABIM PIM modules exist such as preventive cardiology and requires 25 patient surveys & 25 chart reviews. Participation in D2B counts towards Part IV credit.

ACC and ABIM Collaboration

– Award 20 ABIM points for practice improvement (PIM) for physicians who participate in D2B – quality improvement in ‘real world’ practices

– Every cardiologist who participates in ACC D2B can earn and claim 20 ABIM PIM points on the www.abim.org website

– ABIM PIM points are valid for 10 years and applicable for recertification in Internal Medicine, Cardiovascular Diseases, and Interventional Cardiology

– This is a ‘pilot program’ approved by ACC and ABIM to award PIM points

Recertification in Cardiovascular Disease Subspecialties

• In general, you do not need to maintain Certification in internal medicine to recertify in a subspecialty; however, a few exceptions apply:

• To be eligible for renewal of a certificate in clinical cardiac electrophysiology or interventional cardiology, you must maintain a valid underlying certificate in cardiovascular disease.

ABMS and the ABIM

• In 2006, the American Board of Internal Medicine (ABIM) transitioned to a continuous Maintenance of Certification (MOC) program for Board certified specialty physicians along with 23 other medical specialty boards of the American Board of Medical Specialties (ABMS). This change—which has been in development since 1998—reflects the shared belief that medical education is most effective as a continuum rather than an isolated learning event. While the program is guided by ABMS, the ABIM sets the specific criteria for curriculum and training for Internal Medicine and Cardiovascular diseases related certificates.

American Board of Internal Medicine (ABIM) Mission Statement

“To enhance the quality of health care available to the American public by continuously improving the process and maintaining high standards for certifying individual internists and subspecialists who possess the knowledge, skills and attitudes essential for the provision of excellent medical care.”

“Of the Profession…for the patient…”

ABIM- What We Do: Certification• Initial Certification

– Of internists (residents completing training)

– Of subspecialists (fellows completing training)

• Process– Program Director evaluates clinical

competence in patient care

– Meet licensure and training requirements

– Pass secure exam

– Subspecialty: certified in Internal Medicine, required training, pass subspecialty exam (e.g., Cardiovascular Disease, Infectious Disease)

Value of Certification

• Although voluntary, more than 87% of U.S. doctors are certified

• Recent Gallup survey demonstrates that patients value certification

• Other entities –health plans, hospitals, medical groups, licensing boards, other countries – are using certification and/or components

• Provides key vehicle to reduce measurement redundancy and motivate physicians to “get in the game”

Why MOC MattersWhy MOC Matters

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All Some Peak None Better

• 52% of studies showed decline in all areas– Knowledge

– Dx & screening

– Therapy

– Outcome

• Choudhry, Ann Intern Med 2005

% studies showing a decline in performance with age

ABIM Maintenance of Certification

• Required of diplomates certified after 1989; encouraged of all diplomates

• Every 10 years• Process

– Valid medical license– Examination of knowledge and judgment– Self-Evaluation

• Evidence of lifelong learning and periodic self-assessment—knowledge assessment

• Evidence of practice performance assessment and improvement—practice assessment

American Board of Medical Specialties (ABMS)

• ABMS is comprised of 24 medical specialty Member Boards, ABMS sets the standards for the certification process to enable the delivery of safe, quality patient care.

• The 24 Member Boards that make up the ABMS Board Enterprise covers over 145 medical specialties and subspecialties.

• ABMS is the authoritative resource and voice for issues surrounding physician certification

• The public can visit www.abms.org to determine if their doctor is board certified by an ABMS Member Board

American Board of Medical Specialties (ABMS)• Allergy & Immunology• Anesthesiology• Colon/Rectal Surgery• Dermatology• Emergency Medicine• Family Practice• Internal Medicine• Medical Genetics• Neurological Surgery• Nuclear Medicine• OB/GYN• Ophthalmology• Orthopedic Surgery

• Otolaryngology• Pathology• Pediatrics• Physical Medicine

& Rehabilitation• Plastic Surgery• Preventive Medicine• Psychiatry &

Neurology• Radiology• Surgery• Thoracic Surgery• Urology

ABMS Associate Members

• Accreditation Council for Continuing Medical Education

• Accreditation Council for Graduate Medical Education

• American Hospital Association• American Medical Association• Association of American Medical Colleges• Council of Medical Specialty Societies• Educational Commission for Foreign Medical

Graduates• The Federation of State Medical Boards of the United

States• National Board of Medical Examiners

What is

ABMS MOC™

Insert Board Logo

ABMS Maintenance of Certification ®  (ABMS MOC®).

• In 2000, the 24 Member Boards of ABMS agreed to evolve their recertification programs to one of continuous professional development – ABMS Maintenance of Certification ®  (ABMS MOC®). ABMS MOC assures that the physician is committed to lifelong learning and competency in a specialty and/or subspecialty by requiring ongoing measurement of six core competencies adopted by ABMS and ACGME in 1999. Measurement of these competencies happens in a variety of ways, some of which vary according to the specialty. This is carried out by all Member Boards using a four-part process that is designed to keep certification continuous.

Six General Competencies

1. Medical knowledge

2. Patient care

3. Interpersonal and communication skills

4. Professionalism

5. Practice-based learning and improvement

6. Systems-based practice

Six Core Competencies adopted by the Accreditation Council for Graduate Medical Education (ACGME)

1. Patient Care -Provide care that is compassionate, appropriate and effective treatment for health problems and to promote health.

2. Medical Knowledge -Demonstrate knowledge about established and evolving biomedical, clinical and cognate sciences and their application in patient care.

3. Interpersonal and Communication Skills -Demonstrate skills that result in effective information exchange and teaming with patients, their families and professional associates (e.g. fostering a therapeutic relationship that is ethically sounds, uses effective listening skills with non-verbal and verbal communication; working as both a team member and at times as a leader).

Six Core Competencies adopted by the Accreditation Council for Graduate Medical Education (ACGME)

• 4. Professionalism -Demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles and sensitivity to diverse patient populations.

• 5. Systems-based Practice -Demonstrate awareness of and responsibility to larger context and systems of healthcare. Be able to call on system resources to provide optimal care (e.g. coordinating care across sites or serving as the primary case manager when care involves multiple specialties, professions or sites).

• 6. Practice-based Learning and Improvement -Able to investigate and evaluate their patient care practices, appraise and assimilate scientific c evidence and improve their practice of medicine

A Four-part Process for Continuous Learning

• While ABMS guides the MOC process, ABMS' 24 Member Boards set the criteria and curriculum for each specialty. The four-part MOC process includes:

• Part I- PROFESSIONAL STANDING• Medical specialists must hold a valid,

unrestricted medical license in at least one state or jurisdiction in the United States, its territories or Canada.

• Part II- LIFELONG LEARNING AND SELF-ASSESSMENT Physicians participate in educational and self-assessment programs that meet specialty-specific standards that are set by their member board.

A Four-part Process for Continuous Learning

• Part III-Cognitive Expertise They demonstrate, through formalized examination, that they have the fundamental, practice-related and practice environment-related knowledge to provide quality care in their specialty. THE SECURE EXAM!!!

• Part IV-PRACTICE PERFORMANCE ASSESSMENT: They are evaluated in their clinical practice according to specialty-specific standards for patient care. They are asked to demonstrate that they can assess the quality of care they provide compared to peers and national benchmarks and then apply the best evidence or consensus recommendations to improve that care using follow-up assessments. Part IV testing occurs through the use of :

• PRACTICE IMPROVEMENT MODULES (PIM’S).

Performance Report

Performance Report

Improvement

Chart review Patient survey

Impact

plan

do

study

act

Practice review

ABIM Practice Improvement Modules ABIM Practice Improvement Modules

Medical Knowledge Assessment

Knowledge Options Points

Any ABIM knowledge module 20 pts

ACP MKSAP-13 (up to 4 modules or total of 80 pts)

20 to 80 pts

Self-evaluations developed by others (e.g. ACC SAPs)

VARIES

ABIM Certificates Related to Cardiology

• Internal Medicine

• Cardiovascular Disease

• Interventional Cardiology

• Clinical Cardiac Electrophysiology

• Heart Failure and Transplant Cardiology (available soon)

Maintenance of Certification

• To maintain your certificate, you need to earn a total of 100 self-evaluation points.

• If you are renewing one certificate:• Complete self-evaluation modules to earn 100

points: – 20 points in Self-Evaluation of Medical Knowledge – 20 points in Self-Evaluation of Practice

Performance – 60 points from either Self-Evaluation of Medical

Knowledge, Self-Evaluation of Practice Performance, or a combination of both

Multiple ABIM Certificates• If you are renewing more than one certificate (e.g.,

Cardiovascular Disease and Interventional Cardiology:• You can apply the 100 points you have earned to both

certificates you are renewing, provided that the 100 points are still valid at the time your second certificate expires. (Once your points are completed, they are valid for 10 years.)

• You will need to take and pass the exams for each certificate. It is easy to participate if you are renewing more than one certificate, e.g., internal medicine and a subspecialty. You earn your 100 points of self-evaluation only once and apply the points to each certificate you renew. (The points you earn must be valid at the time each certificate expires. Each self-evaluation module is valid for 10 years.)

Certification in Interventional Cardiology• To become certified in the subspecialty of

interventional cardiology, physicians must have:• Been previously certified in Internal Medicine by

ABIM.• Maintained a current underlying certificate in

Cardiovascular Disease by ABIM.• Satisfactorily completed the requisite graduate

medical education fellowship training.• Demonstrated clinical competence in the care of

patients.• Met the licensure and procedural requirements• Passed the Certification Exam in Interventional

Cardiology (Secure Exam, Part III).

Cardiovascular Disease Exam• Michael R. Zile, MD, Chair, Charleston, SC • Gerard P. Aurigemma, MD, Worcester, MA • Anne B. Curtis, MD, FACC, Tampa, FL • George William Dec, Jr., MD, Boston, MA • Carl V. Leier, MD, Columbus, OH • William C. Little, MD, Winston-Salem, NC • Emile R. Mohler III, MD, Philadelphia, PA • Frank E. Silvestry, MD, Radnor, PA • James D. Thomas, MD, Cleveland, OH • Paul D. Thompson, MD, Hartford, CT • George W. Vetrovec, MD, Richmond, VA • Joseph A. Vita, MD, Boston, MA • Kim Allan Williams, MD, FASNC, FACC, Chicago, IL

Interventional Cardiology Exam• Alan C. Yeung, MD, Chair, Stanford, CA • Theodore A. Bass, MD, Jacksonville, FL • Eric B. Bates MD, Ann Arbor, MI • Peter B. Berger MD, Danville, PA • Stephen G. Ellis, MD, Cleveland, OH • Ted E. Feldman, MD, Evanston, IL • Daniel M. Kolansky, MD, Philadelphia, PA • Albert E. Raizner, MD, Houston, TX • Christopher J. White, MD, New Orleans, LA

Clinical Cardiac Electrophysiology Exam

• John M. Miller, MD, Chair, Indianapolis, IN • Alfred E. Buxton, MD, Providence, RI • Hugh G. Calkins, MD, Baltimore, MD • Peng-Sheng Chen, MD, Indianapolis, IN • Edward P. Gerstenfeld, MS, MD, Philadelphia, PA • Bruce B. Lerman, MD, New York, NY • Bruce D. Lindsay, MD, Cleveland, OH • Paul J. Wang, MD, Stanford, CA • Mark Allen Wood, MD, Richmond, VA

ABIM Maintenance of Certification (MOC)

– MOC Part I: Professional Standing – Current, unrestricted medical license.

– MOC Part II: Lifelong Learning and Periodic Self-Assessment – Options include the ABIM’s 60-multiple choice question self-assessment Knowledge Modules or the ACCF self assessment program, ACCSAP 6.

– MOC Part III: Cognitive Expertise – recertification examination every 10 years.

– MOC Part IV: Practice Performance Assessment (a new requirement effective January 1, 2006) – Evaluation of practice improvement.

Collaboration with the ABIM• Collaborating with ABIM on new MOC

requirements emerging from ABMS. • ACCF PIMs built in collaboration with ABIM to

meet critical member needs. • The ACCF Life-Long Learning Portfolio:

– Linked to ACCF learning, quality improvement and performance data sources.

– Catalog and identify gaps in individual knowledge, competence, and performance.

– Document learning activities and improvement.– Support members in meeting requirements of

accrediting, certifying, licensing, and payer agencies.

• Simulation.• Grandfathers.

Interventional Cardiology• Procedural Requirements • Interventional cardiologists must submit a Form Attesting

Interventional Cardiology Practice, verifying their performance as primary operator, co-operator or supervisor of 150 percutaneous coronary interventional (PCI) cases in the two years prior to expiration of their certificate.

• If interventional cardiologists are unable to meet this requirement, they may provide a procedural log of 25 consecutive cases, including outcomes, in which they have served as primary operator.

• The documentation period for certificates expiring December 31, 2009 may start no earlier than July 1, 2007 and end no later than October 1, 2009.

• The form also requires verification of participation in a PCI quality improvement project.

Bashore et al. JACC Vol. 37, No. 8, 2001ACC/SCA&I Expert Consensus Document on Cath Lab Standards June 15, 2001:2170–214

• Board certification: Requirement for added qualification in interventional cardiology: 12 months in ACGME-accredited program and pass grade on ABIM examination (“Board”) for interventional cardiology.

• As of 2003, only candidates who have successfully completed the 12-month fellowship will be allowed to sit for the examination. Before 2003, “practice pathway” possible (150 cases over 2 years or 500 since training).

• Procedural: Recommended average procedural volume: 75 cases per year (150 in 2 years) – these were ACC published recommendations at that time. Now being revisited by ACC and ABIM.

• Recommended Cardiovascular PIMs • Communication – Subspecialists • Communication with Referring Physicians • Hospital-based Patient Care (Heart Failure, Myocardial

Infarction) • Hypertension • Preventive Cardiology • Self-Directed (using data from approved sources including the

ACC’s National Cardiovascular Data Registry, or to report on group practice QI projects)Instructions for using NCDR Data to complete Self-Directed PIM

• ABIM Approved Continuous Quality Improvement (CQI) Programs - ACC D2B: Door-to-Balloon Time Initiative and ACP Closing the Gap - Cardiovascular Risk

• Medical Knowledge Modules • Interventional Cardiology Simulations

Enrolling in Maintenance of Certification

• Visit Physician Login at www.abim.org• Enroll online.• Complete Practice Characteristics Profile and update

your contact information.• Certificate cycle is 10 years; new cycle begins when

certificate expires.• Begin to complete modules at your pace, as soon as

you enroll.• Pass exam in years six through 10.

Questions?

• Go to www.abim.org “Maintain and Renew Your Certification” for general information.

• Go to “Get Information by Subspecialty” and select Interventional Cardiology.

• Go to the Physician Login to enroll, check your status, order modules and register to take the exam.

• Call ABIM’s Contact Center, 1-800-441-ABIM or…

• Visit the ACC MOC Toolkit on Cardiosource, review the frequently asked questions and link to ABIM resources.