Tradeshows
Michael Kaufman
We need to see the connection between the work that’s happened between the summits, so we’re going to shift right now into a trade show. There are four different presentations and you’ll get to go to three of the four.
Maintenance of Licensure initiative
Carol Clothier
Good morning! My name is Carol, and I am going talk about the Maintenance of Licensure (MOL) Initiative. I am going to focus on the past year, in terms of new information for the board.
A quick context setting is that we have been working since 2003. We are developing policy recommendations as we move forward and we are framing how to move forward.
Our first policy recommendation was in 2004, where we stated that the state medical boards have a responsibility to the public. We produced the final report in February of 2008, and sent that upstream to the board. We looked at the feedback from a variety of locations. Based on the feedback, we made the decision that a lot of information is still needed to be sifted through before the board can make policy.
In May of 2008, we proposed a set of guiding principles and a study of the impact that we would have on the state medical boards and your organizations, if we moved forward to the house.
MOL needs to be about improving practices. It needs to be the rising tide that floats all boats. MOL needs to be administratively feasible, but also have the authority to set requirements. MOL needs to not be unduly burdensome to the practicing community. Lastly, there needs to be a variety of options for compliance, and there needs to be a balance between transparency and privacy.
Over the last year, we have been carrying out what the board has asked us to do. The community recommended three things that boards should adopt. The three components include, program for development, a high stakes exam every three years, and a demonstration of performance in practice.
Physicians need to be held to these to maintain licensure and it should include all physicians.
In October we brought 14 state boards together to see how the states would be impacted by these requirements. The task force came to a series of conclusions.
First, the recommendations are the most reasonable and most feasible. It makes the most sense to move forward. Secondly, the states have the authority to make this implementation. Thirdly, they identified a number of elements that need to be in place to minimize the impacts on physicians. There needs to be a national set of requirements that state boards can use. Boards need to think of putting the requirements in place where physicians can submit elements of compliance, but not necessarily where they need to submit data. From a physician’s perspective, it ensures that MOL is all about ensuring improvement and not about weeding out bad practitioners.
A lot of physicians are already doing a lot of this, and they need to be allowed to submit what they are currently doing. The highest impact is on the physicians that aren’t currently doing this.
We need an infrastructure to support this, and we determined that what we have in place today is sufficient, though it needs to evolve a bit. Medical boards already have systems in place for CME requirements. They are already moving from traditional lecture styles, to other ways of improving. There are still questions that are out there that need to be answered. As we looked at the document, we paid a lot of attention to the questions:
What do you do with physicians that are not board certified? The boards cannot insist on compliance without providing the information to allow them to be certified.
What about workforce issues? If state boards do not do this all together, are you setting up a situation where physicians will migrate to states with lower standards?
We need to study this more fully, to get the information to make the best decisions going forward.
We will present a set of recommendations to our board in May to move this forward.
We have an analysis document on our website that is available to all of you.
Q: Did you get any patient input into this process? Not for the task force, though we had a public member of the medical board on the special committee. I am not sure if the report was set to any consumer groups for feedback.
A: We are balanced with respect of information transfer between transparency and patient confidentiality.
Q: There is a desire to provide a flexible multi approach, but we need to balance that with what the board can …. Can you require one category license to pass through, and yet another specialty go through another avenue, though they aren’t equivalent. You then run into an issue with the Fourteenth Amendment of equal licensure.
A:
There is a discussion around physicians demonstrating competence within their own practice. You need a minimum threshold across the board, but we need to look closer into this.
Updates by ABMS and AOA-BOS
John Becker
I am from the AOA-BOS and we also have here the senior vice president from the ABMS.
Click here to see the PowerPoint presentation
I want to give you an insight into the American Osteopathic world. The association is made up of the members, board of trustees, department of education, bureau and certification boards. In 2007 the schedule for continuous education was approved. All the plans have to be approved by 2012.
The continuous certification replaces the traditional recertification. We require practitioners to maintain valid, unrestricted and unqualified medical license. The learning assessment (COLA) have eight modules and are available online. All diplomats must take all eight COLA modules with a 10-year cycle. There are three opportunities to repeat the COLA online in order to obtain a passing grade.
There is a formal recertification exam that is required to maintain the certification. The exam consists of both an oral and a written part. There are 4 cases and one of the stations is an interpersonal test. Diplomats must demonstrate an active practice of emergency medicine at the time of their application.
In addition to this process, there is a clinical assessment program (CAP). This provides an evidence-based measurement set. This is included in some of the residency training programs.
Q: The modules you mentioned, do you have to take them online every year?
A: They are available online for three years. You have three years to complete any one of them.
Q: What is the thinking behind having to pass only 6 of the 8?
A: I’m not able to answer that. It’s a learning process. There are articles that you read and then you have to answer questions based on that.
Q: What if someone stops paying their AOA dues?
A: I will defer to John. I don’t know if the guillotine falls immediately, but if they’re not due-paying members, they’re not eligible to sign up. There is further discussion about this. If someone falls out
Q: How many osteopaths participate in this?
A: Probably 80% in emergency medicine, but overall maybe about 60%
Rich Hawkins
The basic outline of the ABMS. There is a trust initiative and it declares that the premise of the ABMS is for the public safety and involves commitment to further of the ABMS as a public trusted agent. We need to create a relationship group. There is a restructure that will allow for the emergence of standards to advance the field of responsible physicians.
In the last 6-9 months a committee has been working to define the standards. We are getting comments and criticisms so we can bring it to the board of directors for approval in March. Some of the topics is the gathering of information about patient care, threshold for CME and legitimate self-assessment, active performance review by physicians. Some of these may be a burden for physicians but we need to show why this is important. We need to build a rationale document that can support these claims. Doctors often perform with less than desirable ways in their interpersonal skills and we want to see that these improve. We need to identify efficiencies they can make in these communication skills. If we show them this evidence it will help them along in the process.
Q: How do you address the inter-rater reliability with patient satisfaction?
A: You can’t train the raters, but they are being provided only the scores of improvement. We only use evidence from patients that are credible. There is a core survey that’s available and there are practitioners who would like different information.
Q: Is there parallel discussion with the licensure community?
A: There have been preliminary discussions but there needs to be more. We wouldn’t want to head down the path of having different standards.
Q: What is the surveyor?
A: It is which tool you use to take the patient survey. There are commonly accepted standard tools and we’re trying to get people to use the same tools, in order to provide consistent data as long as we have some flexibility.
AMA Physician Consortium for Performance Improvement – PCPI
Click here to see the PowerPoint presentation
Ardis Hoven
I want to walk you through some of the basic elements of PCPI. We want to focus on excellence in health care delivery and fairness in provider accountability. This project started several years ago. Other countries achieve better healthcare results with lower funding, and different regions in the US make very different healthcare investments without a huge difference in outcomes. We need a comprehensive, robust performance measurement system that is transparent and fair.
I am a practitioner of medicine. I do not develop guidelines and regulation rules for a living. So who does what in this world of medicine? The development of measurement tools
The mission of PCPI is to improve patient health and safety by developing measures of healthcare performance.
PCPI membership is open to a number of organizations and to individuals passionate about healthcare performance. Our current membership includes more than 100 medical specialty and society representatives.
How do we develop measures? We look for opportunities for improvement. We look for representatives from all populations involved in the process. We link measures to an evidence base. The consortium does not develop clinical guidelines – it relies on available guidelines. The measures leave room for valid medical and patient decisions to deviate from the guidelines.
We have development measure for more than 40 areas of clinical care. We focus on quality. Our measures are derived from the best medical evidence. The process is driven by physicians. There is a harmonization with many other groups. We are currently reviewing all PCPI measurement sets, and we are looking at new measures for intermediate and long-term outcomes and care coordination. We are developing measures on appropriateness and patient safety.
Who is using our measures? Physicians. Medical Boards. Electronic health care vendors. Public and private health plans. Employers. Local and national quality improvement initiatives. These measures have been imbedded into a number of quality improvement initiatives.
One of the big sticking points has been the feasibility and validity testing. Are we really measuring what we think we’re measuring? We need to understand feasibility, reliability and unintended consequences. We are continually looking for new opportunities and partners to test our measures. We have a number of tests ongoing.
In the future, we are going to identify coordination care measures – we will move beyond a focus on the individual physicians to team-based measures. We will focus on quality improvement collaborations. We want to foster quality measurement registries that are disease-based – many of these registries exist, but we want to offer our resources to support these and connect them. The registries will help us identify the best practices in the near future – the registries offer a potential source of innovation.
Many of these initiatives require the data access that would only be provided by Electronic Health Records.
PCPI has been working for two or three year with the EHR vendors to make sure their products will easily call on these kinds of data sources.
Changes in CME
Norm Kahn
I am going to talk about the inclusion of performance improvement into Contining Medical Education. The current model of CME started in the 1940s. The message was “Trust us. We’re keeping up.” CME was delivered through lectures, journals, and enduring materials. All of these vehicles can be delivered on the web. The biggest criticism of CME is that it didn’t change practice behavior.
The AMA launched two initiatives. The second one resulted in a change in practice behavior. The new message is that physicians continually measure themselves against national standards and their peers. This system of Performance Improvement CME is making an impact. A number of certifying boards already accept PI CME credits. We hope to impact Maintenance of Licensure in the future.
Ten specialty societies are active in this arena right now. This is a big jump from the four societies that were using this in October 2008. We are still very early in the adoption of this tool, but remember that traditional CME lasted for 60 years! We are moving out of the early adoption stage into the mainstream adoption phase.
Improving Performance in Practice is a real-world example. This was launched by the ABIM Foundation. We have selected several practices around the country to measure data on diabetes and other diseases. The data is collected at two collaborating hospitals, and those hospitals will provide coaching back to the practice in a second intervention. During this second intervention, the practices are educated about performance improvement systems in general.
You cannot ask a practice to measure 25 different things. We ask them to select four diabetes measures and three asthma measures. For example, the wrong thing to measure is how many patients are below the guideline of an A1C below 7 – this will cause practices to exclude patients. The better measure is what percentage of your patients have an A1C above 9. The biggest improvement for patients is seen if they drop from 10-8, not from 8 to 7.
It is hard to make changes in practices. Different practices will have very different outcomes. One of the biggest obstacles is the implementation of Electronic Health Records, and even once they’ve been implemented, they will consume a practice for over a year.
The Performance Improvement CME is being adopted more and more broadly. This system is also beginning to demonstrate cost savings. A number of states are already rewarding practices financially for participating in this system. The Medical Home is one business model. We have moved from two states to seven states, and several more are asking to participate. The states or groups of insurers are paying for this – there is no out-of-pocket expense for practices.
There is still a lot of traditional CME out there, and PI CME is just in its fourth year. It has a long way to go! We would go a long way if Oregon were to be an innovator and adopt this. We have a potential funder to expand this project to new states. The practice needs to have a registry, but they do not have to have an EHR.