MOC Part IV: Your Guide to Making it Happen.

MOC Part IV: Your Guide to Making it Happen. Joseph P. Drozda, Jr., MD, F.A.C.C. Mercy, MO Paul D. Varosy, MD, F.A.C.C., FAHA, FHRS University of Colorado Denver School of Medicine, CO

Disclosures Course Directors: Joseph P. Drozda, Jr., MD, FACC Director, Outcomes Research Mercy, MO Commercial Interest : Nothing to Disclose Paul D. Varosy, MD, FACC, FAHA, FHRS Associate Professor of Medicine University of Colorado Denver School of Medicine, CO Commercial Interest : Nothing to Disclose

Disclosures Course Faculty: H. Vernon Anderson, MD, FACC Professor of Cardiovascular Medicine The University of Texas, TX Commercial Interest : Nothing to Disclose Deepak Bhakta, MD, FACC Associate Professor of Clinical Medicine Indiana University, IN Commercial Interest : Nothing to Disclose

Dr. Joseph P. Drozda, Jr., MD, FACC ABIM S MOC PROCESS: BACKGROUND & 2014 CHANGES

ABMS & ABIM All 24 of the medical boards that comprise the American Board of Medical Specialties (ABMS) are in the process of implementing a more continuous approach to Maintenance of Certification To meet new requirements outlined by ABMS, the American Board of Internal Medicine (ABIM) is changing its MOC program ABMS and ABIM believe that a more continuous MOC program helps you keep pace with the changes in the science of medicine and assessment

ARS Question #1 Are you currently enrolled in ABIM s Maintenance of Certification process? 1 YES 2 NO

ARS Question # 2 Have you completed any Part IV (performance improvement) activity? 1 YES 2 NO

ARS Question # 3 Are you or your institution a participant in one of the NCDR (National Cardiovascular Data Registries)? 1 One registry 2 More than one registry 3 Do not participate in any registries 4 Don t know

ACC s Role 1. Interpret ABIM s materials that describe their new MOC program and communicate the key themes to our members 2. Provide educational products and other support that help our members to: Study for ABIM s Cardiovascular Disease MOC exam ( the Boards ) Secure Self-Evaluation of Medical Knowledge credits (MOC Part II) Undertake Self-Evaluation of Practice Assessment modules (MOC Part IV)

Certification Process Up to 2006 Pre- 1990 Certification Secure exam after completing fellowship Lifetime certification with NO end date 1990-2006 Recertification Secure exam after completing fellowship Time-limited certification WITH an end date Recertification exam every 10 years

Maintenance of Certification 2006-2013 2006-2013 Maintenance of Certification (MOC) Secure exam after completing fellowship Time-limited certification with an end date Maintenance of Certification exam every 10 years Completion of: Self-Evaluation of Medical Knowledge Modules Self-Evaluation of Practice Assessment Modules

Components of MOC: 2006-2013 Licensure and Professional Standing (aka Part I) Proof of current and active state license Self-Evaluation of Medical Knowledge (aka Part II) Live or on-line educational activities Cognitive Expertise / Secure Examination (aka Part III) Pass Board Exam Self-Evaluation of Practice Assessment (aka Part IV) Approved quality improvement module

MOC Points: 2006-2013 100 Points Every 10 years Part II = Self-Evaluation of Medical Knowledge modules Part IV = Self-Evaluation of Practice Assessment modules

MOC 2014 AND BEYOND

MOC 2014 and Beyond 2014- Maintenance of Certification Changes Two Separate Designations: 1. Board Certified 2. Meeting MOC Requirements Certification represents passing initial exam Meeting MOC Requirements is a new and separate obligation

What Will Be New in 2014 MOC now applies to all diplomates (including grandparents) 100 MOC points now have to be secured on a 5 year cycle with some activity required every 2 years Patient Safety & Patient Survey requirements 20 MOC points awarded for every first exam attempt within each specialty

MOC Points 2014 Complete an MOC activity every 2 years Earn total of 100 points every 5 years 20 points Part II 20 points Part IV 20 points Either Part II, III or IV 20 points Either Part II, III or IV 20 points Either Part II, III or IV Patient Safety Module Patient Survey Module Part II = Self-Evaluation of Medical Knowledge Part III = MOC secure exam Part IV = Self-Evaluation of Practice Assessment

New Patient Safety & Patient Survey Requirements Patient Safety Some ABIM MOC modules currently meet this requirement ABIM will be adding more options in the future ABIM is developing a process so that diplomates can use patient safety activities at their institution to meet this requirement Patient Survey Some of ABIM s existing Performance Improvement Modules (PIMs) [Part IV activities] include patient surveys ABIM will offer options to meet requirement without doing a full PIM ABIM is developing a process so that diplomates can use patient survey activities at their institution to meet this requirement

If You Certified Prior to 1990 ( Grandparents ) 1. Starting January 2014, new MOC requirements apply to you 2. To be reported as Meeting MOC Requirements : Enroll in the MOC program by March 31, 2014 Complete an MOC activity to earn MOC points every 2 years Earn 100 MOC points every 5 years Complete patient survey & patient safety modules every 5 years Pass ABIM s Cardiovascular Disease MOC Examination ( the Boards ) by December 31, 2023 (10 years) 3. Your initial certification in Cardiovascular Disease does not expire. You will remain certified whether or not you are Meeting MOC requirements. However, if you choose not to undertake all required MOC activity, you will be reported as Certified. Not Meeting MOC Requirements.

If You Are In A 10-Year MOC Cycle 1. Starting January 2014, new MOC requirements apply to you 2. Finish out your individual 10-year MOC cycles for Parts II & IV, and the MOC exam. Any points earned after January 2014 will apply both to those you need to earn to maintain your existing certification and to be Meeting MOC Requirements 3. To be reported as Meeting MOC Requirements : Enroll in the MOC program (if not currently enrolled in MOC) by March 31, 2014 Complete an MOC activity to earn MOC points every 2 years Earn 100 MOC points every 5 years Complete patient survey & patient safety requirements every 5 years

If You Become Newly Certified In/After 2014 1. Starting January 2014, the new MOC requirements apply to you 2. To be reported as Meeting MOC Requirements : Activate your MOC program by March 31, 2014 Complete an MOC activity to earn MOC points every 2 years Earn 100 MOC points every 5 years Complete patient survey & patient safety requirements every 5 years Pass the ABIM Cardiovascular Disease MOC Examination ( The Boards ) every 10 years

Sub-Specialty Certification As in previous years, diplomates must still hold a current, valid ABIM certification in Cardiovascular Disease to be eligible for renewal of certification in: Advanced Heart Failure and Transplant Cardiology Clinical Cardiac Electrophysiology Interventional Cardiology If you have more than one ABIM certification, all MOC points earned will apply to all certifications you are actively maintaining If you are maintaining certification in Interventional Cardiology, you will need to continue to attest to meeting additional program-specific requirements You will receive 20 MOC points for completion of one MOC exam per certification area being maintained

ABIM/ABMS Reciprocal Credit for Dual- Boarded Diplomates ABIM-certified physicians who are maintaining certification through another of the ABMS s 24 member boards (e.g. the American Board of Pediatrics) may be eligible to receive points for Self-Evaluation of Medical Knowledge and Self-Evaluation of Practice Assessment To receive credit, ABIM diplomates will need to attest that they are current and participating in the other Board s MOC program For more information, please call ABIM at 1-800-441- ABIM

Doctors of Osteopathy (D.O.s) D.O.s must certify with the American Osteopathic Board of Internal Medicine (AOBIM) which introduced new Osteopathic Continuous Certification (OCC) January 1, 2013

Resources ABIM MOC Microsite: http://moc2014.abim.org ABIM Diplomate Services: 1-800-441-ABIM (2246) ACC ACC s MOC Information Hub: ww.cardiosource.org/moc

Dr. Paul D. Varosy, MD, FACC MOC PART IV: ABIM S SELF-DIRECTED PIM

Overview This session will familiarize attendees with ABIM s Self- Directed PIM and describe key steps involved in using data from ACC s NCDR registry From ABIM s website, order the Self-Directed PIM Please refer to the hand-out: ACC s Condensed Instruction Guide to ABIM s Self-Directed PIM Appendices are available on line at: www.cardiosource.org/partiv

Performance Improvement: Steps Select a data source Analyze data, identify a target metric/measure Assemble a performance improvement team Develop and implement an action plan Remeasure the target metric/measure

Self-Directed PIM: Part A - Orientation

Self-Directed PIM: Part B Measures & Data

Part B - Measures and Data Three sections of Part B: 1. Tell us about your care setting Select Inpatient or Outpatient 2. Describe your data Reporting period (month/quarter of baseline NCDR data) Where did baseline data come from? 3. Enter baseline NCDR Registry data

NCDR Registries Registry ACTION Registry - GWTG CARE Registry CathPCI Registry ICD Registry IMPACT Registry PINNACLE Registry PVI Registry STS/ ACC TVT Registry Clinical Focus Acute coronary syndrome (ACS) Carotid artery revascularization and endarterectomy procedures Diagnostic cardiac catheterizations and percutaneous coronary interventions Implantable cardioverter defibrillators and leads Pediatric and adult congenital treatment Coronary artery disease, hypertension, heart failure and atrial fibrillation in the outpatient setting Peripheral vascular intervention procedures Transcatheter aortic valve replacement (TAVR) procedure

Access Registries at www.ncdr.com

Is My Institution Participating in an NCDR Registry? Navigate to: www.ncdr.com OR In the top navigation bar click Registries by Name Select Registry from the drop-down menu Find and click View a list of current Registry participants Institutions are listed alphabetically by state Call NCDR at 1-800-257-4737

How Do I Know If I Have NCDR Data? Tips: If you are an EP and your hospital is reimbursed by CMS for what you do, you have the ICD registry If you work in a cath lab, talk to your cath lab Director to find out if you have CathPCI Almost every hospital in the US submits ACS data to the ACTION-GWTG Registry Your practice may submit data to PINNACLE, the ambulatory cardiology registry

Access to Registry Reports Registry Site Manager (RSM) Ask RSM for web access to or a hard copy of the Outcome Report (both Executive Summary & Detail Sections) Explain you need the performance measures and other metrics in the report to complete a performance improvement module to maintain your certification as a cardiologist

Log In to the NCDR Website

Where To Find the Data On NCDR.com Via secure log-in Registry specific Registries with Dashboard: Dashboard Registries without Dashboard: Reports

Registry Landing Page (example ICD)

Executive Summary & Detail Section Executive Summary Detail Section

How to Read the Report

Selecting Performance Measures Identify performance rates below the 50 th percentile Identify performance rates below the 90 th percentile Use Volume/Risk model to identify high volume and high risk populations with poorer outcomes Ask where there is most potential to affect change / improvement Identify measures of particular interest to your institution or team

Back to the PIM Part B - Measures & Data

ABIM s Measures Library www.abim.org/ml More than 500 clinical quality measures relevant to internists and subspecialists for use in ABIM's Self- Directed, Completed Project and other Practice Improvement Modules (PIMs) in their MOC programs Search the library to see if your measures have been included You can download and print a listing of the measure set titles from ABIM s Measures Library Orientation or from www.cardiosource.org/partiv

Structure of ABIM s Measures Library SETTING CONDITION MEASURE SET (# measures) AMI (29) Inpatient Cardiac Patient Experience /Satisfaction Cardiac CHF (10) Stroke & Stroke Rehab (17) VTE (11) H-CAHPS Survey (10) AF & Flutter (3) CAD (12) HF (13) VTE - Outpatient Management (6) Outpatient Chronic Illness HF - Outpatient Management (13) IVD (9) Patient Experience ABIM Locum Tenens Survey (10) /Satisfaction CAHPS Clinical & Group Survey (28) Prevention Primary Prevention of Cardiovascular Disease (13)

Choosing Performance Measures from ABIM s Measures Library

Variation in Measure Definition - Minor ACEI or ARB for LVSD ABIM Measures Library (Cardiac; Inpatient; AMI) Definition: Percentage of AMI patients with Left Ventricular Systolic Dysfunction who are prescribed an Angiotensin Converting Enzyme Inhibitor (ACEI) or Angiotensin Receptor Blockers (ARB) at discharge. ICD Registry National Outcomes Report (Executive Summary) Definition: Proportion of patients with left ventricular systolic dysfunction who were prescribed ACE-I or ARB therapy.

Variation in Measure Definition - Significant Chronic Anticoagulation Therapy ABIM Measures Library (Cardiac; Outpatient; AF & Flutter) Definition: Percentage of patients aged 18 years and older with a diagnosis of nonvalvular AF or atrial flutter at high risk for thromboembolism who were prescribed warfarin during the 12 month reporting period. PINNACLE Registry National Outcomes Report (Executive Summary) Definition: Prescription of warfarin, or another oral anticoagulant drug that is FDA-approved for the prevention of thromboembolism, for all patients with nonvalvular AF or atrial flutter at high risk of thromboembolism according to CHADS 2 risk stratification.

Enter Performance Data

What if My Measures Aren t in the Measures Library? Don t worry you can submit your own measures/metrics to ABIM for approval Requires filling out a simple form Generally requires a few days for approval process Eventually, all NCDR report metrics/measures will be in the ABIM measures library In the short term, some may require submission of this form.

Performance Improvement Team Physician(s) Nurse Leader(s) Administrative Leaders Quality Improvement Specialist(s) Coding Specialists

How to Develop and Implement an Action Plan Assemble the Performance Improvement team Determine a plan for understanding the reasons for the performance gap Suboptimal clinical care Systems issues Documentation Data abstraction Develop a plan to address these issues Specifics will vary based on your situation! Implement the plan

How and When to Re-Measure Re-measure performance using a later period of data to compare to their first cycle of data. Key: AFTER implementing action plan! How often should you re-measure? After you expect to see the impact of the implementation plan Process measures: relatively soon Outcome measures: longer remeasurement period Depends on registry and data availability cycle

Available Data Registry Outcomes Report Web-Based Dashboard ACTION Registry - GWTG Hospital level data - Issued quarterly Hospital level data - Refreshed weekly - Benchmarked quarterly CARE Registry CathPCI Registry ICD Registry IMPACT Registry PINNACLE Registry PVI Registry STS/ ACC TVT Registry Hospital level data - Issued quarterly Hospital level data - Issued quarterly Hospital level data - Issued quarterly Hospital level data - Issued quarterly Hospital level data - Issued quarterly Hospital level data - Issued quarterly Hospital level data - Issued quarterly N/A Hospital level data - Refreshed weekly - Benchmarked quarterly Individual practitioner data - Quarterly Hospital level data - Refreshed weekly - Benchmarked quarterly N/A Hospital level data Individual practitioner data - Refreshed / benchmarked monthly N/A N/A

Review: Performance Improvement Steps: Select a data source Analyze data, identify a target metric/measure Assemble a performance improvement team Develop and implement an action plan Remeasure the target metric/measure

Key Take-Home Message: NCDR Data can be used to support Performance Improvement, including for ABIM Self-Directed PIMs for MOC Credit Handout: ACC s Condensed Instruction Guide to ABIM s Self-Directed PIM Appendices are available on line at: www.cardiosource.org/partiv

H. Vernon Anderson, MD, FACC USING CathPCI DATA FOR MOC PART IV

STEMI Process Review & Redesign 2007/2008

Background and Setting Large urban hospital with active STEMI program

Goals Improve STEMI care processes ER, Transport, Cath Lab, CCU Reduce D2B time Reduce mortality

Data Institutional data for 2006, 2007, 2008 (12 quarters) Cannot show actual data signed confidentiality agreement

STEMI Related Metrics 3, 4, 5, 6 18, 19 22

Table of Contents NCDR Institutional Report

Section Headers in Report

Example of Detail Page by Line Numbers

Important Selectors Learning experience: Found later to be of great interest

Other Important Elements from Report

Discharge Section

Other Variables Examined But Not the Major Focus

Other Variables Examined Not in NCDR Report Time of day: Day = 7 AM 5 PM Night = 5 PM (Related to scheduling of lab staff and call teams)

Analysis Line # Name 2006 n (%) 2007 n (%) 2008 n (%) 1441 STEMI as indication 210 205 188 1476 PPCI for STEMI 202 194 182 1469 CS <24 h or at start of PPCI 19 (9.4) 23 (11.9) 27 (13.7)

D2B Time: Non-Transfer Patients 2006 2007 2008

D2B Time: Cardiogenic Shock Patients 2006 2007 2008

Mortality Line 2010: Dead; unadjusted, excluding CABG or other major surgery 2006 2007 2008

Mortality Cardio. Shock Patients: Unadjusted, no CABG or other major surgery 2006 2007 2008

Some Conclusions (Out of Many Others) Process redesign was successful. Largest changes (improvements) were in the sickest patients, STEMI with cardiogenic shock. Many additional insights were acquired along the way! Write up of part of this was submitted for MOC Part IV credit in 2009.

Deepak Bhakta MD FACC FACP FAHA FHRS CCDS USE OF NCDR DATA (ICD REGISTRY )

Patient Characteristics: ICD Implantation Q1 2009 Drug therapy Clinical History Clinical Assessment Patient #: Aspirin? Beta-blocker? ACE-inhibitor? ARB? CAD? CHF? NYHA class LV assessment? 1 Yes Yes Yes No Yes Yes III Yes 10 2 No Yes Yes No Yes Yes II Yes 44 3 No Yes No No No No I Yes 50 4 Yes Yes Yes No Yes No I Yes 60 5 No No Yes No No Yes II Yes 33 6 Yes Yes Yes No Yes Yes II Yes 30 7 Yes Yes Yes No Yes Yes II Yes 35 8 Yes No Yes No Yes Yes II Yes 24 9 Yes Yes Yes No Yes Yes II Yes 33 10 Yes Yes Yes No No Yes II Yes 20 11 Yes Yes Yes No Yes Yes II Yes 34 12 Yes Yes Yes No Yes Yes III Yes 36 13 Yes Contraindicated Yes No No Yes III Yes 15 14 No Yes Yes No No Yes II Yes 21 15 Yes Yes Yes No No Yes II Yes 33 16 Yes Contraindicated Contraindicated Contraindicated Yes Yes Not recorded Yes 25 17 Yes Yes Yes No Yes Yes III Yes 34 18 No Yes No No No Yes III Yes 25 19 Yes Yes Contraindicated Contraindicated Yes Yes II Yes 35 LVEF (%)

Performance Improvement: Action Plan - Development Drug therapy: 1) Aspirin use in CAD patients 2) ACE-I/ARB use in patients with LVEF <0.40 3) Beta-blocker use in patients with LVEF <0.40 Clinical assessment: 1) NYHA assessment in CHF patients 2) LV assessment/lvef in CHF patients

Performance Improvement: Action Plan: Development Patient CAD? #: Aspirin? Beta-blocker? ACE-inhibitor? ARB? CAD? CHF? NYHA class LV assessment? Yes 1 Yes Yes Yes No Yes Yes III Yes 10 Drug Therapy 1) Aspirin use in CAD patients 2) ACE-I/ARB use in patients with LVEF <0.40 3) Beta-blocker use in patients with LVEF <0.40 Yes 2 No Yes Yes No Yes Yes II Yes 44 No 3 No Yes No No No No I Yes 50 Yes 4 Yes Yes Yes No Yes No I Yes 60 No 5 No No Yes No No Yes II Yes 33 Yes 6 Yes Yes Yes No Yes Yes II Yes 30 Yes 7 Yes Yes Yes No Yes Yes II Yes 35 Baseline data: 11/12 (91.7%) Yes 8 Yes No Yes No Yes Yes II Yes 24 Yes 9 Yes Yes Yes No Yes Yes II Yes 33 No 10 Yes Yes Yes No No Yes II Yes 20 Yes 11 Yes Yes Yes No Yes Yes II Yes 34 Yes 12 Yes Yes Yes No Yes Yes III Yes 36 No 13 Yes Contraindicated Yes No No Yes III Yes 15 No 14 No Yes Yes No No Yes II Yes 21 No 15 Yes Yes Yes No No Yes II Yes 33 Yes 16 Yes Contraindicated Contraindicated Contraindicated Yes Yes Not recorded Yes 25 Yes 17 Yes Yes Yes No Yes Yes III Yes 34 No 18 No Yes No No No Yes III Yes 25 Yes 19 Yes Yes Contraindicated Contraindicated Yes Yes II Yes 35 LVEF (%)

Performance Improvement: Action Plan - Development LVEF (%) Beta-blocker? ACEinhibitor/ARB? 10 Yes Yes 44 Yes Yes 50 Yes No 60 Yes Yes 33 No Yes 30 Yes Yes 35 Yes Yes 24 No Yes 33 Yes Yes Drug Therapy 1) Aspirin use in CAD patients 2) ACE-I/ARB use in patients with LVEF <0.40 3) Beta-blocker use in patients with LVEF <0.40 Baseline data (ACE-I/ARB) : 15/16 (93.8%) Baseline data (beta-blocker) : 14/16 (87.5%) 20 Yes Yes 34 Yes Yes 36 Yes Yes 15 Contraindicated Yes 21 Yes Yes 33 Yes Yes 25 Contraindicated Contraindicated 34 Yes Yes 25 Yes No 35 Yes Contraindicated

Performance Improvement: Action Plan - Development CHF? NYHA class LV assessment? LVEF (%) Yes III Yes 10 Yes II Yes 44 No I Yes 50 No I Yes 60 Yes II Yes 33 Yes II Yes 30 Yes II Yes 35 Yes II Yes 24 Clinical Assessment 1) NYHA assessment in CHF patients 2) LV assessment/lvef in CHF patients Baseline data: 16/17 (94.1%) Yes II Yes 33 Yes II Yes 20 Yes II Yes 34 Yes III Yes 36 Yes III Yes 15 Yes II Yes 21 Yes II Yes 33 Yes Not recorded Yes 25 Yes III Yes 34 Yes III Yes 25 Yes II Yes 35

Performance Improvement: Action Plan - Implementation Metric Baseline performance Target performance Aspirin use in CAD patients 11/12 (91.7%) >95% ACE-I/ARB use in patients with LVEF <0.40 Beta-blocker use in patients with LVEF <0.40 15/16 (93.8%) >95% 14/16 (87.5%) >95% Action Plan 1) Review, documentation and initiation of pharmacotherapy in outpatient ICD referral patients (including drug contraindications/intolerance) at the time of visit or implantation 2) Review, documentation, and initiation of appropriate drug therapy in inpatient ICD recipients (including drug contraindications/intolerance) 3) Communication with primary cardiovascular caregiver regarding details of pharmacotherapy 4) Re-measurement of selected metrics using above action plan

Performance Improvement: Recommendations ABIM-derived metrics Self-derived metrics Evidence and guideline based Registry based Relevant to your practice Realistic metrics and interventions Involvement of all team members Document your steps!