1. Maintenance of Certification (MOC) for Cardiologists Update for the Board of Governors John Gordon Harold, MD, FACC Chair, ACC Board of Governors Member, Board of Directors American Board of Internal Medicine September 13, 2009 Heart House

2. Proliferation of Board Exams Survey on Fellows in Training regarding multimodality imaging certification. Heterogeneous patchwork of specialties. No universal standard for training and privileging. ACC’s role: Fellows want ACC to recommend/suggest a process, and perhaps a timescale for taking or necessity of particular exams.

3. Proliferation of Board Exams Taking 4 Board exams immediately post graduation can cost up to $17,000 cost (exam fees, Board review exams, travel expenses) Idea of multimodality imaging exam. Modules in CT, Echo, Nuclear etc… Liaison to ABIM Issues of recertification.

4. 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…”

5. American Board of Internal Medicine Historical milestones 1936 - American Medical Association and American College of Physicians form the American Board of Internal Medicine (ABIM) 1941 - American Heart Association and ABIM develop certification in cardiovascular disease: 223 individuals certify. 2009 - 25,817 certified 1987–1988 Critical care and Geriatric Medicine certificates time-limited to 10 years 1990 - All ABIM certificates time-limited to 10 years (Grandfathers – pre-1990 certification) 2000-2009 -Recertification evolves to Maintenance of Certification (MOC) 2010 Move towards continuous MOC

6. Patients and Physicians Believe In the Importance of Ongoing Assessment 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. I believe I will serve my patients better.” –Brennan, TA, Recertification for Internists – One “Grandfather’s” Experience, N Engl J Med. 353:1989-1991. “Gaining a sense of success that is congruent with my core medical goals requires a different set of measures altogether.” –Baron, RJ, Personal Metrics for Practice – How’m I Doing?, N Engl J Med 353:1991-1993. “The recognition of quality outcomes has kept me in medicine. You need some sense that this is worth it. I’m getting the positive feedback. That’s where it’s at.” –Dr. James Wilson, Putting Quality Into Practice (www.abimfoundation.org)

7. 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.

8. 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

9. ABIM Certificates Related to Cardiology Internal Medicine Cardiovascular Disease Interventional Cardiology Clinical Cardiac Electrophysiology Heart Failure and Transplant Cardiology (available soon) Proposed: Multimodality Cardiac Imaging Proposed: Adult Congenital Heart Disease

10. ABIM Maintenance of Certification –The American Board of Medical Specialties (ABMS) guides the MOC process; ABMS' 24 Member Boards set the criteria and curriculum for each specialty. The four-part MOC process includes: –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 Evaluation of practice improvement.

11. 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 (Part IV) –60 points from either Self-Evaluation of Medical Knowledge, Self-Evaluation of Practice Performance, or a combination of both

12. Self-Evaluation of Medical Knowledge Part II ACCF’s ACCSAP6 ACCF’s CathSAP3 ACC.10 & i2 Summit 2010 ABIM Interventional Cardiology Simulations (SimSuite Bus, Regional SimSuite Centers, Convention based learning ACC Chapter Based MOC

13. Self-Evaluation of Practice Performance Part IV ACC’s D2B Initiative NCDR Practice Improvement Module ABIM’s Practice Improvement Modules Communication – Subspecialists Communication with Referring Physicians Hospital-based Patient Care (Heart Failure, Myocardial Infarction) Hypertension Preventive Cardiology

14. ABIM 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 (Part III) 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

15. 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. 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.

16. Value of ABIM 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. You are eligible to claim AMA PRA Category 1 Credit™ for completion of ABIM self-evaluation modules. Provides key vehicle to reduce measurement redundancy: convergence of maintenance of licensure and maintenance of certification.

17. Value of ABIM Certification Pay-for-performance and recognition programs now reward and recognize diplomates who are enrolled in Maintenance of Certification and who regularly complete program activities such as ABIM Practice Improvement Modules (PIMs) Aetna Blue Cross and/or Blue Shield Plans CIGNA HealthCare Health Alliance Plan Humana United Health Care Bridges to Excellence PQRI credit for MOC participation as part of proposed Senate Healthcare reform legislation

18. Interventional Cardiology Maintenance of Certification Did you sit for the Interventional Cardiology certification exam in 1999? It’s time to renew your certificate in Interventional Cardiology! Your current certificate is only valid through December 2009.

19. ACC Collaboration with ABIM ACC is collaborating with ABIM on new MOC requirements emerging from ABMS. ACCF PIMs built in collaboration with ABIM to meet critical member needs. ABIM MOC Sessions at ACC.09 and ACC.10 SimSuite Simulation Bus for Interventional Cardiology modules The ACCF Life-Long Learning Portfolio

20. Questions on MOC? Go to www.abim.org “Maintain and Renew Your Certification” for general information. Go to “Get Information by Subspecialty. Go to the Physician Login to enroll, check your status, order modules and register to take the exam. Visit the ACC MOC Toolkit on Cardiosource, review the frequently asked questions and link to ABIM resources: www.cardiosource.com/MOC

22. Process for Approving New Cardiology Subspecialties Request submitted to ABIM from specialty society or other external group ABIM CV Board ABIM BOD ABMS Committee on Certification, Subcertification, and Maintenance of Certification (COCERT) ABMS BOD ABMS Assembly Note: Input from external stakeholders (e.g., relevant societies, other ABMS Boards) is sought throughout the proposal development and review process. Revisions to the application may be required in order to be forwarded to the next stage of approval.

23. Criteria for Subspecialty Certification Criteria for MOC Focused Practice Basis for Certification or MOC Focused Practice Practice is distinct from the parent discipline Practice is a component of the parent discipline Unique body of knowledge that cannot be completely incorporated into the parent discipline Large numbers of diplomates focus practice in the area while others may not focus at all Practice Adds Value The practice meets an important social need and improves care The focused practice meets an important social need and improves care How Competence is Acquired Requires supervision and direct observation of competence Requires demonstration of self- directed, continuous learning and self-evaluation of practice over time Formal training for at least 12 months No formal training beyond initial certification requirements Technology or Site of Care Involves learning use of complex technology or practice in specific sites of care Involves same technology and sites of care used by the broad discipline Impact on Parent Discipline The positive benefits outweigh the negative impact on the parent discipline

24. Process for Exploring New Disciplines within Cardiology Review by the ABIM Subspecialty Board on Cardiovascular Disease. If the CV Board approves the proposal, it is then forwarded to the ABIM Board of Directors. ABIM would seek support from the CV and Internal Medicine communities at large. With community support and approval by the ABIM Board of Directors, the new discipline would then need to be approved by the American Board of Medical Specialties (ABMS). Minimum 1 year

25. Criteria for Recognition as Subspecialty Certification Requires a unique body of knowledge that cannot be fully incorporated into the “parent” discipline Has clinical applicability to be practiced in a form distinct from the “parent” discipline Contributes to the scholarly generation of new information, and advances research in the field There is an important social need for the discipline and evidence that its practice improves patient care

26. Criteria for Recognition as Subspecialty Certification Achieving competence requires supervision and direct observation provided in formal training settings Requires a minimum training period of 12 months The positive value of certification in the new discipline must outweigh any negative impact on the practice of, or education in, general internal medicine or an existing subspecialty

27. Criteria for Recognition as MOC Focused Practice Body of knowledge is a component of the “parent” discipline (cardiology) Large numbers of cardiologists focus their practice in the discipline, while others may not practice the discipline at all There is an important social need for the discipline and evidence that its practice improves patient care

28. Criteria for Recognition as MOC Focused Practice Proficiency or can be gained through self-directed, continuous learning and self-evaluation of practice over time, and does not require direct observation of technical procedures or skills that can only be achieved through formal training To become proficient in the discipline requires a volume of experience (focus) that defines the discipline The positive value of certification in the new discipline must outweigh any negative impact on the practice of, or education in, internal medicine or an existing subspecialty

29. Certification Models for CV Disciplines 3 years Cardiovascular Disease (CV) training CV certification At least 1 year sub- subspecialty training Certification in CV subsub- specialty 3 years Cardiovascular Disease (CV) training “Third-Tier” Subspecialty Training Model: Focused Practice Model: CV certification At least 3 years post-fellowship practice experience in focused practice area MOC in CV with focused practice in ________

30. Cardiac Imaging Request from American Board of Radiology (ABR) to explore joint ABR/ABIM certification in cardiac imaging Possibly as focused practice in MOC instead of initial subspecialty certification –Currently, the only MOC focused practice discipline in development is Hospital Medicine – which is pending approval at ABMS

31. Questions