ABMS/ABIM and ABIM Maintenance of Certification (MOC) for Cardiologists John Gordon Harold, MD, FACC Chair-Elect, ACC Board of Governors Member, Board of Directors American Board of Internal Medicine January 2009

Chronology of American Board of Internal Medicine 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…” (ITALICS ARE SUGGESTED POINTS OF EMPHASIS) The Board is committed to ensuring quality patient care and setting standards for internal medicine and the subspecialties. Private, non-profit certifying organizations with many stakeholders but no “members” No regulatory authority Standards set for the profession by the profession 87% of US physician voluntary certify Primary accountability to assure public of high quality care

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 Matters 52% of studies showed decline in all areas Knowledge % studies showing a decline in performance with age 52% of studies showed decline in all areas Knowledge Dx & screening Therapy Outcome Choudhry, Ann Intern Med 2005 The evidence presented in this slide illustrates that there is a quality issue that MOC can help to solve. This slide illustrates the need for demonstrated commitment to lifelong learning and improvement, which really stands at the center of why MOC matters. ABIM’s MOC responds to this growing need for physician improvement and maintenance of competence so that as we age the quality of patient care we provide does not decline.

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 Medical knowledge Patient care Interpersonal and communication skills Professionalism Practice-based learning and improvement Systems-based practice

Six Core Competencies adopted by the Accreditation Council for Graduate Medical Education (ACGME) Patient Care -Provide care that is compassionate, appropriate and effective treatment for health problems and to promote health. Medical Knowledge -Demonstrate knowledge about established and evolving biomedical, clinical and cognate sciences and their application in patient care. 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).

ABIM Practice Improvement Modules Chart review Patient survey Practice review Performance Report Improvement Many diplomates can choose to earn their 20 required Practice Performance Assessment points by using one of ABIM’s Practice Improvement Modules. It involves three steps: Data Collection, Plan for Improvement, and a Test of Change. The Data Collection step contains three segments, a chart review of patient records, an automatically administered patient survey of patients from the practice, and a simple practice survey of the systems in current use in the practice. The patient survey is automatically collected using a toll-free telephone number and an automated voice response system. The answers to the survey questions are electronically recorded in the ABIM data base for the individual physician. The chart review data and the practice survey data are uploaded from the candidate’s computer over the internet to the ABIM server where the data from the patient survey is aggregated and analyzed to produce the practice analysis. The practice analysis is automatically downloaded to the candidate’s computer. The practice analysis is interactive so that while reviewing the report, the candidate selects areas for improvement and automatically develops a practice improvement plan. The candidate then performs a rapid test of the impact of the plan on his or her practice by performing a PDSA (Plan, Do, Study, Act) cycle to test the impact of the change. When the test is completed, the candidate reports the results of the plan and the Test of Change as the Impact of the practice improvement module on the practice. plan act do Impact study

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 These are the options that will enable the diplomate to complete a medical knowledge module. A minimum of 20 points is required for self-evaluation of medical knowledge against the 100 required points in the overall Self-Assessment of Medical Knowledge and Practice Performance. For example, diplomates who use the ACP MKSAP-13 can earn up to 80 self-evaluation points toward MOC. In addition to ACP MKSAP-13, the ABIM has approved six new modules developed by specialty organizations, which will be come available in 2006. These modules can be applied toward the medical knowledge requirement.

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. Below are ABIM’s web resources to assist you in meeting the MOC requirements. Also, visit Cardiosource to access ACC products and resources for MOC credit.

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 Bashore et al. JACC Vol. 37, No. 8, 2001 ACC/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. Visit the ABIM website to enroll…go to the Physician Login and enter your ABIM candidate number or social security number and your password. If you have never logged on before, your default password is your six-digit date of birth. Everything you need is on the site, and the your password-protected Home Page, accessed using the “Physician Login”, is where you enroll and complete your practice characteristics profile and check your MOC status. You also order medical knowledge modules and PIMs, and register to take the exam in the from your Home Page. Use the ABIM website as your primary information source for current information, exam dates, requirements, etc. You can view this information without entering the physician login. For specific details for interventional cardiology, go to “get information by subspecialty” and select “interventional cardiology. Remember that your current certificate is valid for 10 years, so you can enroll in the next cycle as soon as your certificate expires and begin to meet the requirements. The exam can be taken and passed in years six through 10. You do not have to have all of your self-evaluation requirements met before you pass the exam, but they must be completed before your certificate expires.

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. Below are ABIM’s web resources to assist you in meeting the MOC requirements. Also, visit Cardiosource to access ACC products and resources for MOC credit.