When you hear hoofbeats, think of horses not zebras.
-Dr. Theodore Woodward, University of Maryland (1940s)

[“MOC” refers to Maintenance of Certification. If you are among those readers not familiar with the term, I suggest that you skip to the Background section before reading further.]

The Issues

While most physicians would agree that each specialist should possess and maintain a core of knowledge, opinions differ as to how to assess the ability of a physician to apply her/his knowledge, skills, and ability in practice. Among the key issues raised by physicians critical of the MOC process are the perception that MOC is not evidence-based and grades physicians on esoteric and irrelevant facts – zebras instead of horses. Further, some claim MOC is burdensome, costly, and often additive to other quality improvement and regulatory requirements. In response to these concerns, the American Board of Internal Medicine (ABIM) recently announced that it is working with three professional societies to introduce changes including the possibility of adding an “open book” test option. Whether these changes assuage physicians’ concerns is still a question.

A Potential Way Forward

What if while caring for people, physicians could demonstrate key MOC core competencies? With every patient encounter physicians and their practice teams generate data to support new measures for MOC aligned with the ABMS & ACGME Core Competencies. Some measures from the current set of available electronic clinical quality measures (eCQMs) could be used for this purpose but, in general, these measures reflect what can be measured not necessarily what should be measured.

Not everything that counts can be counted, and not everything that can be counted counts.
-William Bruce Cameron (not Albert Einstein as many often cite)

New measures, for quality improvement and MOC, should leverage the data and metadata from electronic health records. The measure set could be designed to cover not just a physician’s individual performance on the population she/he cares for, but how well that physician’s team and practice operate. As a result, the set could fulfill at least three of the six core competencies of MOC and address most of the key issues identified by physicians with the existing MOC process. If designed and implemented correctly, the data necessary to populate these measures could be generated without extra work by physicians and their teams other than the efforts necessary to improve care based on the results. Further, since these measures would be used for quality improvement, they would not need to meet all the stringent criteria necessary for measures used in public reporting. Data intermediaries (e.g., health information exchanges, qualified clinical data registries, analytics companies, EHR vendors) could build MOC-reporting functions based on the specialty-specific measure set and report on behalf of physicians to reduce the work for the clinical teams.

Below is a high-level outline of potential measures aligned with the ABMS Core Competencies. Readers familiar with the criteria used to guide patient-centered medical home (PCMH) development will note that some of the examples align with that concept. This is not a coincidence. The PCMH model is a systems-based approach to patient-centered care. ABIM, the American Board of Family Medicine and the American Board of Pediatrics currently offer MOC credit for becoming a PCMH because of this alignment.

• Practice-based Learning & Improvement
  • Identify 10 clinical measures aligned with the most frequently encountered conditions in the practice.
    • Determine the baseline performance.
    • Compare performance to national benchmarks.
    • Implement a quality improvement plan if performance is below a threshold (i.e., 75^th percentile).
    • Submit follow-up eCQM data at 6 months and 12 months to demonstrate improvement.
  • Use clinical decision support system (CDSS) to improve care (prerequisite includes the availability of context-sensitive CDSS).
    • Develop measures that reflect a physician’s interaction with CDSS.
      • Did the physician act on the CDSS recommendation?
      • If not, was a different action taken and the rationale provided to support the action(s)?
• Patient Care and Procedural Skills
  • Measures of treatment intensification/de-intensification (which could be linked to interaction with CDSS).
  • Measures of appropriate test/imaging in response to clinical situations where such guidance exists.
  • Measures related to preventive health activities (e.g., screening tests, anticipatory guidance, vaccinations).
  • Development of care plans for complex patients (based on ICD-10 diagnoses and other readily available information in the clinical record).
    • Companion measure reflecting review/update of care plan on regular basis.
• Systems-based Practice
  • The practice provides easy access to for patients (and appropriate family members/caregivers).
    • Use time/date stamp data to demonstrate adequate access to chart.
  • Demonstrate appointment/encounter management.
    • Time from patient request to scheduling of the encounter.
  • Team-based practice:
    • Examine metadata from EHRs to demonstrate that clinical team members:
      • Review charts of scheduled patients prior to the encounter.
      • Practice to the level of license:
        • Conduct triage of patient inquiries and concerns on a timely basis (using time/date stamp/signature information).
        • Engage patients/families in screening (e.g., screening for depression, substance abuse disorders, domestic violence), and education (e.g., anticipatory guidance, adolescent transition to adult care).
        • Conduct post-discharge and transition outbound calls to patients/families/caregivers.
        • Review and update care plans developed by physician and patient.
  • Laboratory/Imaging Results Review: Use date/time metadata to examine the lag between receipt and sign-off by the physician.
  • Measures of comprehensiveness of care: While currently challenging, use of EHR/practice management system data could provide reports about a physician’s scope of practice through the use of patient demographics, diagnostic codes (ICD-10), procedure codes (CPT) and laboratory/imaging test orders. This could also support the assessment of Medical Knowledge.

What about the remaining core competencies of Medical Knowledge, Interpersonal and Communication Skills and Professionalism? For Medical Knowledge, there would still be a role for Continuing Medical Education (CME) and self-assessment programs such as the American College of Physician’s Medical Knowledge Self-Assessment Program. Perhaps use of patient-generated health data and incorporation of person-driven outcomes could supplement the current patient experience surveys to support evidence of Interpersonal and Communication Skills. However, many physicians currently do not incorporate these efforts into their practice workflow. I don’t think the process I’ve described could address measures of Professionalism, though I welcome your ideas.

Next Steps

There are many challenges – but the result could be a more meaningful assessment of physician competence for all involved, especially patients. This concept aligns with the goals of the National Quality Strategy, the Medicare Access and CHIP Reauthorization Act (MACRA) Quality Payment Program, and the Patient-Centered Medical Home and Patient-Centered Specialty Practice concepts. It would take a concerted effort to define a set of metrics in collaboration with the ABMS Boards, have performance measure developers build the electronic specifications, data intermediaries and/or EHR vendors to build the MOC reporting function, and then a series of pilots with different specialties to refine the process and reporting format. There are no significant technical barriers to this idea. Just cultural and financial. I hope some of the current efforts, energy, and money being spent could be redirected towards what I believe might be a more productive strategy to drive patient-centered improvements in healthcare.

What do you think? Possible?

Background about Maintenance of Certification

The stated purpose of Maintenance of Certification (MOC) is to help ensure that physicians retain adequate knowledge of their specialty and changes in the practice of medicine. Competence is an important part of the Physician Charter. The Charter, written in 2002 and endorsed by more than 130 organizations includes among the Core Principles the commitment to professional competence:

Physicians must be committed to lifelong learning and be responsible for maintaining the medical knowledge and clinical and team skills necessary for the provision of quality care. More broadly, the profession as a whole must strive to see that all of its members are competent and must ensure that appropriate mechanisms are available to accomplish this goal.

For MOC, physicians must currently complete a series of activities that traditionally culminates with a secure examination. Here is the definition from the American Board of Medical Specialties (ABMS). I am an internist and my certifying board is the American Board of Internal Medicine (ABIM). Internists who took the exam from 1990 forward need to keep up their certification by completing certain activities culminating with an exam every 10 years. I passed the exam in 1989 and technically do not have to recertify though I have elected to participate in MOC.

ABIM describes the MOC process as:

…a structured framework created by their peers for keeping up with and assessing knowledge of the latest scientific developments and changes in practice and in specialty areas.

Among physicians, this is a hot topic. Some would tell you it’s a very controversial topic. Board Certification and Maintenance of Certification address the following six Core Competencies:

1. Practice-based Learning & Improvement
2. Patient Care and Procedural Skills
3. Systems-based Practice
4. Medical Knowledge
5. Interpersonal and Communication Skills
6. Professionalism

Historically MOC has had four components:

Part I: Professionalism and Professional Standing
Part II:  Lifelong Learning and Self-Assessment
Part III: Assessment of Knowledge, Judgment, and Skills
Part IV: Improvement of Medical Practice