The American Board of Otolaryngology is preparing to launch the final component of its maintenance of certification (MOC) program this year. In addition to the goals of lifelong learning and quality improvement, the last of this four-part program should help otolaryngologists comply with performance incentives from the Centers for Medicare and Medicaid Services (CMS).
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January 2012The program is intended to enhance the quality of care in otolaryngology, said Robert Miller, MD, MBA, executive director of the American Board of Otolaryngology (ABOto) and physician editor of ENT Today. The idea of Part IV is to tailor the education of the doctor as finely as possible, with feedback from patients and data comparisons between individual doctors and national numbers, he said.
“The two purposes of MOC are lifelong learning and quality improvement. Certainly people can read, go to lectures and other traditional CME activities that may or may not address areas that need updating,” Dr. Miller said. “But with MOC, it is really focused learning.”
Jack Gluckman, MD, chair of the ABOto’s MOC committee and professor emeritus of otolaryngology at the University of Cincinnati, said this phase of MOC is especially important. “This—of all facets of MOC—might prove to be the most helpful to the practitioner because it focuses so specifically on patient care,” he said.
Otolaryngologists certified before 2002 are not required to meet MOC requirements, but the Board encourages everyone to participate. Those participating in MOC are identified on both the American Board of Medical Specialties and ABOto websites.
The first three parts of MOC, professional standing, continuing education and self-assessment, and a cognitive exam, are in place and designed to help keep doctors on top of their game, both for their benefit and the benefit of patients. But Part IV digs deeper.
Part IV, called Performance in Practice, is based on the quality cycle: Measure data, analyze what you’ve measured, identify areas of strengths and areas needing improvement, develop an improvement plan, implement the plan and then re-measure to see how well you did.
Feedback Is Key
There are three components to Part IV: a patient survey, a peer survey and a patient registry involving data entry into an improvement module for easy comparison with national figures.
Patients will either complete the survey online or use a telephone response system. The Board will accept patient surveys completed through other acceptable organizations, such as Press Ganey, the healthcare performance improvement company.
The concept is for diplomates’ offices to give a card to a certain number of consecutive patients, who will then have the information needed to complete the survey.
The peer survey is still under development. It’s not been decided who exactly would be considered a peer.
“There are strengths and weaknesses in asking non-otolaryngologists to respond and using that as a measure,” Dr. Miller said. He said some boards use a “360 type of survey” with input from people like a hospital’s chief of staff, the head nurse of the operating room or referring doctors.
“We’re in the process of still deciding who will be surveyed,” he said. “We want to make sure that it’s meaningful.”
Patient Registry
The most complex piece of Part IV would be the third component, which will involve entering patient information into a registry. This phase would be designed to help physicians meet the requirements of CMS Patient Quality Reporting System (PQRS), in which doctors can have a percentage added to their Medicare reimbursements if they report their data. Eventually, there will be a penalty for not reporting the data.
The Affordable Care Act includes a provision that provides a 0.5 percent bonus, above the PQRS bonus, if a doctor participates in “enhanced Part IV.” How “enhanced Part IV” is defined is still up in the air, but Part IV of MOC is being designed to help meet those requirements, he said. “We’re going to set them up… as much as we can such that whatever they enter will also meet PQRS requirements, so they wouldn’t have to enter the de-identified data twice,” Dr. Miller said.
The registry interface will include modules based on specialty areas, with three or four conditions for each specialty area.
“The diplomate will enter data on a series of patients with a particular condition,” Dr. Miller said. “They will select a condition that they see with some frequency. There will be an online form [on which] they will enter five to ten elected data points about those patients. The diplomate’s data will be compared to national standards and results of others filling out the same forms.”
Then areas of improvement would be identified, leading back to the beginning of the cycle. This is proving to be the most challenging component to design, Dr. Miller said.
“What are the conditions that we should measure in each specialty area and within each condition?” he said. “What are the specific fields that we should collect data on?” ABOto is working with the specialty societies to answer these questions.
Dr. Miller said he hopes ultimately to take advantage of technology to make entering the data as simple as possible for the doctors. “With time, it could be just simply push a button and the information would be transmitted from the electronic medical record,” he said. “We’re not there yet, but I don’t see that being too far off into the future.”
The ABOto expects to have portions of the platform up and running in 2012. The board will use a template tailored for ABOto by publisher Wiley-Blackwell and the CME platform CE City. (Disclaimer: Wiley-Blackwell publishes ENT Today.)
“That keeps the cost down for the diplomates,” Dr. Miller said.
The fact that the patient registry data would be self-reporting is not a major concern, although the Board would retain the right to audit. “The vast majority of doctors want to practice great medicine, they really do,” Dr. Miller said. “And this would hopefully be a tool that will help them.”
He also emphasized that “this is not in any way, shape or form meant to be punitive. It’s all about quality improvement.”
Dr. Gluckman also said he is not concerned about that aspect of the process.
“Self-reporting is always a perilous route to go that can easily be gamed,” he said. “I would like to believe that the vast majority of our diplomates or practitioners genuinely want to improve their practices in order that they may improve the care of their patients. And while there are going to be a few aberrant souls, you can’t let the few dictate what is certainly a laudable task.”
Dr. Miller said MOC is not being done because of a concern about the quality of care.
“Because it’s such a competitive specialty and we get the cream of the crop of medical students going into the specialty, I think most otolaryngologists practice really good medicine. But we can all improve. And that’s what this is all about,” he said.
Dr. Gluckman said acceptance of the MOC program is growing.
“We’re moving slowly and I think are gaining traction and certainly increasing acceptance among the diplomates. At this stage it’s very much in its developmental phase and we obviously are going to work slowly forward. But, in fact, Part IV is now being accepted as being an essential part of MOC…. I think we’ve made huge strides in acceptance by the medical profession.”
He said there is good reason for that.
“Participation in MOC may have fiscal advantages, and it may be closely linked to maintenance of your state medical license,” he said. “So those are two giant carrots, together with what I think is the most important carrot, which is to improve patient care. That, I think, ultimately will win the day.”
Dr. Miller said it is a great opportunity to get the best kind of education: feedback related specifically to your own work.
“In other words, this is what a diplomate does,” he said. “So then he/she can focus particularly on those areas that could be improved in things that you actually do and see the results of it.”
Maintenance of Certification: FOUR PARTS
Part I: Professional Standing
- Must have certificate from the American Board of Otolaryngology
- Must have an unrestricted medical license
- Must maintain privileges at hospital/ambulatory surgery center
Part II: Continuing Education and Self-Assessment
- Part of a lifelong learning program
- 25 CME units per year
- Completion of self-assessment program that is clinically oriented, is specialty specific and is aided by online modules
- Non-punitive assessment
Part III: Cognitive Examination
- Secure, closed-book exam administered at testing centers around the country
- Totally clinical, no basic science
- 80 questions: 12 on fundamentals, and the other 68 on a selected practice area
- Focuses on specific practice, with clinical fundamentals and one specialty module
- Cannot be used to imply subcertification, except for neurotology and sleep medicine
Part IV: Performance in Practice
- Based on a quality improvement approach
- Will look at doctor-patient interaction and outcomes
- Will meet Physician Quality Reporting System requirement