The movement to measure and improve quality and performance is coming to emergency medicine via changes in board certification, and its arrival is placing pressure on individual physicians and specialty professional organizations alike.
Changes to Maintenance of Certification (MOC) will seem like nothing new. The American Board of Medical Specialties (ABMS) set new national goals for certification in 2000, converting it from a periodic milestone into a continuous process. In response, the 24 member boards, including the American Board of Emergency Medicine (ABEM), designed multi-part systems intended to ensure 6 core competencies: patient care, medical knowledge, practice-based learning and improvement, communication skills, professionalism and ethics, and systems-based practice.1
Across all the boards, that demand for core competencies produced similar certification systems comprising 3 main benchmarks: maintaining a valid license; annually reviewing and self-testing on a list of significant journal articles; and taking a decennial exam analogous to the recertification exam that formerly existed. In emergency medicine, the process—called EMCC, for Emergency Medicine Continuous Certification—has been in existence since 2004.2
The new 3-part process, rolled out at different rates across the sundry specialties, has not always been well received. By 2004, for instance, family physicians were concerned that their 2-year-old self-assessment module was overly difficult, and the American Academy of Family Physicians' Congress of Delegates was urging that the new program be suspended.3
The controversy may grow, particularly in emergency medicine with the 2011 implementation of the fourth step in the MOC process—called “Assessment of Practice Performance (APP)” within EMCC.
Raising Eyebrows, Doubts
Like its counterparts in other specialties, APP is the most quality-focused step in the revised certification process, and the most closely linked to national initiatives to measure and improve performance as part of health care reform. As such, it is raising eyebrows among emergency physicians and the emergency specialty organizations, who ask whether metrics meant for doctors who have ongoing care of a patient can be applied to physicians whose patient encounters may be single and brief.
“One of our concerns, which we have discussed with ABEM, is that there are different circumstances for our members than for physicians in a typical office-based practice,” said Dean Wilkerson, MBA, JD, the executive director of the American College of Emergency Physicians (ACEP). “Emergency physicians may never have seen a patient before, and after 20 minutes may never see him or her again. The challenge for (emergency medicine) is to develop a practice assessment and performance improvement tool that will meet what ABMS has in mind.”
As designed by ABEM, APP—also called simply “Part 4” because it represents the fourth section of the EMCC process—comprises 2 main activities, one performed once each 8 years and one performed twice within the same period, that must be verified by someone with direct knowledge of the physician's work.4 Clinically active emergency physicians (defined as treating 20 patients within a 4-year period) must perform what the board calls a “Communication/Professionalism Activity.” ABEM defines that as a survey, focus group or set of interviews that elicits the views of at least 10 patients on 3 categories of physician behavior: communicating and listening to staff and patients; providing information about clinical impressions, tests, procedures and options; and showing concern by demonstrating respect and asking about pain relief.
Twice within those same 8 years (once in each 4-year subset), clinically active emergency physicians must also perform what ABEM dubs a “Patient Care Practice Improvement Activity.” As defined, that includes reviewing clinical care data from 10 patients treated by the physician or that physician's group, including access measures, outcome and feedback; comparing the data to evidence-based guidelines or peer data; developing and implementing an individual or group plan for improving one aspect of care; and then surveying 10 additional patients to see whether performance has improved or at least been maintained.
Anne Harvey, PhD, ABEM's associate executive director for evaluation and research, acknowledged some diplomates may perceive the requirements as burdensome: “We do understand these are an imposition, but we believe they are necessary,” she said. But, she added, the board believes that up to 90% of diplomates practice in institutions where such data is already collected: for continuing medical education, Center for Medicare and Medicaid Services (CMS)' Physician Quality Reporting Initiative (PQRI) submissions or Joint Commission “core measures” review.
For most diplomates, that would make achieving Part 4 merely a matter of tapping that data, rather than designing a new system for collecting data afresh. Regarding the communication activity, Dr. Harvey said, “I guarantee that any hospital's patient feedback survey will contain these questions already.”
Some experts in the specialty contend that amassing such data is crucial whether or not physicians or groups have previously collected it.
“There are a lot of people in emergency medicine who wash their hands of evaluating the patient encounter because they believe we have such a small piece of the puzzle,” said Joseph T. “Jody” Crane, MD, MBA, business director of the Fredericksburg (MD) Emergency Medical Alliance and a faculty member in the emergency department operational and clinical improvement collaborative of the Institute for Healthcare Improvement.
“But the truth is, we have a lot to do with the whole functioning of the US health care system, and there are lots of opportunities for emergency physicians to improve the status of the health care environment,” Dr. Crane said, pointing to Joint Commission core measures such as administration of aspirin on arrival for acute myocardial infarction.5 The MOC process, particularly Part 4, demonstrates that emergency physicians are interested in quality of care and engaged in improvement, he added: “We should be the biggest patient advocates, because we're on the front lines with the patient. It's one of the things we signed up for.”
Some emergency physicians may have fears that, if outcomes and existing quality data are harnessed to certification, they will be judged on the performance of others, said Judd E. Hollander, MD, professor and clinical research director in the department of emergency medicine at the Hospital of the University of Pennsylvania: “I can image a physician in the ED thinking, ‘If someone botches a procedure in the cath lab, how is that related to what I did?'”
But Dr. Hollander's colleague Jill M. Baren, MD, MBE, an associate professor of emergency medicine and pediatrics at Penn and current president of the Society for Academic Emergency Medicine, said, “It may be more challenging for us to develop the right metric” to measure performance in emergency medicine, “but I don't think it absolves us from developing the metric. We shouldn't take ourselves out of the equation just because we haven't developed that metric yet.”
Measure for Measure
Some existing quality metrics do apply to emergency medicine—not only the Joint Commission core measures, but more than a dozen of the PQRI benchmarks that, if met, qualify physicians for a small incentive bonus over CMS reimbursement.
Emergency medicine's MOC Part 4 has yet to be implemented: Diplomates will have the option of reporting their performance assessments on the ABEM site from the beginning of 2010, and will be required to from late 2011, depending on when their certification comes due. Other specialties implemented their Part 4 requirements several years ago.
Internal medicine's “Self-Assessment of Practice Performance,” for instance, offers 3 different pathways through which internists may be evaluated. One, the “Practice Improvement Model” (PIM), asks them to complete Web-based modules that cover a range of subjects and include chart reviews, surveys of a minimum of 25 patients, and independent input via phone or Web from patients themselves.
The 16 PIM modules are aimed at physicians who have little access to institutionally collected quality data. So, following filing of chart review and survey data, the modules' Web tools ask participants to choose some outcome or process they want to improve, design a pilot project to improve it, perform a focused re-measurement across weeks to months in order to assess the pilot project's impact, and report back the improved results. The module and Part 4 certification are not considered complete until the improved results are tendered. (That process is several steps more complicated than the ABEM version, which in its verification component asks only for confirmation that a performance review was conducted; unlike ABIM, it does not ask for proof that performance improved.)
Two other pathways allow physicians to submit performance data they already receive from their practice group or health system, or from within an institution's existing quality improvement infrastructure, said Eric S. Holmboe, MD, senior vice president for quality research and academic affairs at the American Board of Internal Medicine (ABIM). 6
ACEP is considering asking ABEM to sponsor a task force exploring whether quality data submissions, such as to PQRI, could be dual-purposed to fulfill the MOC Part 4 as well, according to Wilkerson. “It would be ideal for our physicians not to have to do 3, 4 different things,” he said. “If we can get credit for them in several arenas at once, the membership may not feel this is so onerous.”
That idea received broad support in April at a national policy forum convened by ABMS, including an endorsement by Barry M. Straube, MD, CMS' director and chief medical officer, that explicitly linked MOC changes, PQRI reporting and health care reform.7
“Be Careful What You Wish for”
But Brent Asplin, MD, MPH, chair of emergency medicine at the Mayo Clinic, cautioned against going down that road without careful evaluation. Pointing to the different degrees of effort required by the ABIM and ABEM Part 4s, he warned that tying the emergency medicine MOC to CMS measures could result in its becoming more rigorous and complex.
“Everyone supports the notion of harmonizing the wide range of requirements that are coming down from regulators, but it could end up being a case of ‘Be careful what you wish for,'” he said. “All emergency physicians need to do is look at the range of requirements for satisfaction of Part 4 across the medical specialties to understand what might be required of them.”
Though emergency medicine's iteration of Part 4 has yet to be implemented, the process of altering MOC is likely to become yet more complex. In March, ABMS announced additional MOC standards, including increasing the communications assessments to every 5 years; adding patient safety self-assessments; and harmonizing the continuing medical education (CME) requirement for all specialties to 25 credits per year, with 8 of them involving self-assessment.8 At the same time, the Accreditation Council for Continuing Medical Education has also announced expanded requirements, tying CME more tightly to quality improvement efforts by requiring that CME courses and activities be preceded and followed by self-assessments to measure changes in physician performance.
Specialty organizations such as ACEP are concerned for their ability to provide the new measures, and concerned for the status of their members' licensure if they are audited, found not in compliance and suspended, said Tom Werlinich, associate executive director in charge of ACEP's educational products division.
“Philosophically, who would not be in favor of cost reduction and improved quality?” he asked. “Philosophically, we endorse and support what all these entities are trying to do. But the hoops that both the physicians and the organizations like ACEP are being put through are very substantial.”
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