In the not too distant past, physicians would complete residency training, and if they passed their specialty board-certification examination, they were board-certified for life. Most of us would agree that passing an exam 15, 20, or more years ago does not guarantee, or even imply, clinical competence in the present. Although Emergency Medicine has always had a time-limited certificate requiring a recertification examination, the same cannot be said for other specialties.
Today, we practice in the age of continuous certification for all specialties. The American Board of Medical Specialties (ABMS), the oversight organization for all 24 specialties, began the journey toward continuous certification in 2000 in response to feedback from the public, industry, and the federal government. As such, all medical boards, including the American Board of Emergency Medicine (ABEM), are now required to participate in continuous certification, a process called Maintenance of Certification (MOC). Our MOC program, originally entitled EMCC (Emergency Medicine Continuous Certification) but recently changed to ABEM MOC, was implemented in 2004. It continues to evolve and undergo periodic updates. The overall guiding principle behind our ABEM MOC is simple but very important—design a program that meaningfully helps emergency physicians stay current and develop professionally, while minimizing the time burden and costs. The goal of this article is to demystify the newest component of MOC, Assessment of Practice Performance (APP).
Licensure, Learning, and Assessment
The first three components of ABEM MOC are well known and relatively straightforward. Part I is Professional Standing, which simply means you must hold a current, active, valid, full, unrestricted, unqualified license to practice medicine in the United States, its territories, or Canada. If you hold more than one license, the additional license(s) must be full, unrestricted, and unqualified.
Part II of ABEM MOC is Lifelong Learning and Self-Assessment (LLSA). First started in 2004, this component involves reading a set of articles selected by your peers and taking a test based on the readings. The designated articles are considered “must reads” for practicing emergency physicians. Since the emphasis of the LLSA component is on learning new material, and not testing, diplomates take an online, open-book test after completing the readings. In fact, it is perfectly acceptable for a group of emergency physicians to take the test and discuss the questions and answers together. As of 2011, emergency physicians can earn AMA PRA Category 1 CreditsTM for successfully completing a CME activity related to the online tests. Diplomates must complete four LLSAs every five years to stay in compliance with ABEM MOC. A recent addition to Part II is a CME requirement. Beginning with certificates that expire in 2014, Part II will require that diplomates earn an average of 25 AMA PRA Category 1 CreditsTM each year, eight of which must be self-assessment. The ABEM LLSA CME activity counts as self-assessment CME. Since most hospitals and many states require similar (or frequently, more stringent) CME credits, this should not place an additional burden on the average emergency physician.
Part III of ABEM MOC is called Assessment of Cognitive Expertise. While this sounds imposing, it is just the recertification exam (termed the ConCert exam) shortened to fit the MOC environment. As in the past, this comprehensive, secure, proctored examination must be successfully completed every 10 years. You schedule the exam online and then go to a Pearson VUE professional computer-based testing center to take the exam. Successfully passing all of the LLSA tests will no longer be a requirement to take the ConCert examination, starting in 2013. Also, there is no longer a portion of the ConCert exam specifically dedicated to the LLSA readings. However, you must still successfully complete the LLSA tests to maintain certification (ie, to meet the requirements of ABEM MOC). CME credits are also available from the American Medical Association for successfully passing the ConCert exam.
Assessment of Practice Performance
It is the most recently implemented component, Part IV–Assessment of Practice Performance, that has prompted many questions, concerns, and rumors over the past two years. This component focuses on practice-based learning and improvement, particularly in the areas of patient care, interpersonal and communication skills, and professionalism. It is probably easiest to think of APP as consisting of two activities—one a Patient Care Practice Improvement (PI) activity, and the other a Communication/ Professionalism (CP) activity. You need to complete one of each every five years. So, one PI and one CP activity must be completed in years 1 through 5, and one of each in years 6 through 10.
So what are PI and CP activities? They are both fairly simple, and you likely are already fulfilling both of these requirements, but just not calling them by these names.
For the CP activity, there must be some form of measurement of your interactions with patients in three areas: communication/listening skills; providing information; and showing concern for the patient. If your hospital uses Press Ganey or CAHPS (Consumer Assessment of Healthcare Providers and Systems) surveys and your patients are included, then you already meet the CP activity requirement. If you are not participating with such a patient survey, you can download a survey form developed by ABEM from their Web site at no cost. You do not send ABEM the completed surveys or raw data. Rather, you simply sign in to ABEM MOC online and attest to the completion of the CP activity. You will also need to provide the name of an individual who can verify that you have completed the CP activity. To ensure compliance, a random sample of attestations will be audited each year and the verifier contacted.
For the PI activity, once you have identified a process you would like to improve, four steps must be completed: (1) measurement; (2) comparison to standards; (3) improvement; and (4) re-measurement to evaluate the implemented improvement. What does this mean? The process you want to improve must be clinically oriented. Examples of such activities include “time to ECG” for adult patients presenting with chest pain; or compliance with obtaining pre- and post-bronchodilator peak flow measurements in patients with an acute asthma attack; or compliance with ordering serum lactate concentration in patients with suspected sepsis. There are literally thousands of potential PI projects; the only requirement is the project must be part of the Model of the Clinical Practice of Emergency Medicine. The model, first developed in 2001 by all of the major organizations in emergency medicine (ie, ABEM, ACEP, SAEM, EMRA, RRC-EM and CORD-EM), serves as the scientifically derived and commonly accepted description of our specialty. All ABEM exams are based on the model, which is updated every two years by representatives of the six EM organizations (to view click here). Your PI project can be an individual effort or a group effort (probably easier). Once you have selected a process for improvement, each physician participating in the activity needs to contribute a minimum of 10 patients to the data pool. For high-acuity/low-frequency conditions (ie, acute myocardial infarction), the number of patients can be less. So Step 1 would simply involve collecting your baseline data. Next (Step 2), you compare your baseline data to established standards such as evidence-based guidelines, national standards, or expert consensus. Basically, you perform a gap analysis, then develop a plan to improve the practice issue measured (ie, Step 3). What system or process changes can you make to improve your outcome? Once the new plan is implemented, you review the new data (again, each physician needs to contribute 10 patients to the new data pool) and determine if improvement has been made (or, at a minimum, maintained). You have now satisfied Step 4 and the PI portion of your APP activity. Similar to the CP activity, you do not send ABEM your data, but instead go online and attest to the completion of the PI activity.
Hopefully, this answers many of your questions around the recent changes to the ABEM MOC. You are probably already doing many of these activities, but just not thinking of them as ABEM MOC. If you have additional questions, please go to the MOC section of the ABEM website where you will find FAQs and further information.
Dr. Counselman is a director of the American Board of Emergency Medicine and associate editor-in-chief of EMERGENCY MEDICINE. He is also distinguished professor of emergency medicine, chairman of the department of emergency medicine at Eastern Virginia Medical School, and attending physician with Emergency Physicians of Tidewater in Norfolk.