Grand Rounds-Maintenance of Certification (MOC): Details You Need to Know

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- Hello, ladies and gentlemen, thank you for joining us for another session of the AANS Operative Grand Rounds. This morning we're very privileged to have with us Dr. Dan Barrow and Dr. Nelson Oyesiku from Emory University. They will be talking to us about the important processes of Oral Boards and Maintenance of Certification. Gentlemen, thank you for joining us and please go ahead.

- What to do now is move on to one of the changes that have occurred in the board certification process over the past several years. And that was the development of the program for Maintenance of Certification. And we're fortunate to have today with us Nelson Oyesiku who is the Chairman of the MOC committee for the ABMS and has done an enormous amount of work in developing this program and tearing it to the level that it is today, and probably knows as much about where this is going as anyone in our specialty.

- Thank you, Dan, it's a pleasure to be on this web conference. And the next segment is really designed to focus on the Maintenance of Certification process of the American Board of Neurological Surgery. As you heard, is really been mandated by the American Board of Medical Specialties, of which the ABMS is a member board. Oftentimes, the key question we hear is what is MOC and why MOC? Well, basically as the term states it's designed to certify not just once but continuously and ensure that diplomates maintain a satisfactory level of standard in neurosurgical care. And therefore, this process doesn't stop that initial certification, but goes on throughout the professional career and practice of the diplomates. It's important to remember that the American Board of Neurological Surgery as a member of Board of ABMS collaborates with a number of medical and surgical specialties as well as other organizations and the main public and other stakeholders. And therefore, the development of ABNS, MOC is not only by the ABNS but as a result of all these interactions involves the contributions of a number of other organizations. And many of the directions in which MOC is going is as a result of the fact that it is not just neurosurgeons that are driving Maintenance of Certification in healthcare and board certification, but a lot of other specialties . MOC has a long and checkered history and even more so a checkered future because there are a lot of things coming down the pike that diplomates need to be aware of and we will address during this presentation. The process started in the late 1990s when the task force was established on competence. And then the general competencies the same that I used in residency training became established that we now have come to know and love are the six core competencies. The four components of MOC was derived from the six competencies. Was then adopted by all ABMS member boards. And we'll go through parts one through four of MOC By 2006 all Member Boards will receive approval of the MOC programs. The ABNS which for a long long time, was one of the holdouts if you will in providing lifetime certification considered this policy in 1999 and ruled out the 10-year time limited certificates such that after the 10-year period, no diplomate can continuously be certified without recertification through the maintenance of certification program which was begun by ABNS in 2006. It is mandatory that all diplomates that were certified after 1999 must hold time-limited certification, and in order to maintain the certification have to participate in Maintenance of Certification. In contrast, diplomates that were certified before that year of 1999, voluntarily participate in MOC. But I would caution and urge diplomates of all stripes before 1999 to participate in this program, just because of the the trends, the mega trends that are in healthcare now that are driving millions of certifications for all physicians, regardless of specialty, regardless of Maintenance of certification..

- Nelson, I have a question for you. And this comes up occasionally. If you're voluntarily participating in MOC, and you don't continue doing it because you're not required. And legally, if you're unfortunate getting sued, is there a chance that the lawsuit can really cause an issue with you not being maintained in the MOC process?

- Thank you, that's a very pertinent question, and one that we get asked quite a bit. As any physician who has sat through a deposition or provided testimony, or evidence would instantly recognize one of the first questions that our legal professionals will throw at you is, what is your certification? Are you certified to practice your specialty? And where did you train and when did you get certified? And so forth. And nothing could be more embarrassing for the litigant or the plaintiff's Attorney to come upon the fact that oh, by the way, you are not currently certified because you don't maintain certification. Or you are certified and unlike the other diplomates, you do not participate in the Maintenance of Certification Program that is designed to assess ongoing delivery of quality care. So I think that's the first issue. And second issue is that the public as a result of the standards promulgated by the ABMS, the public has access on the ABNS website and indeed any other Board Website to find out whether or not their physician is participating in Maintenance of Certification. And so for those two reasons, I think in the medical legal arena, I think it's incumbent on diplomates to do all they can to maintain that veneer of quality care by participating in the Maintenance of Certification.

- Thank you.

- Certification as we know, primary certification is necessary to practice neurosurgery in most jurisdictions. But that alone is not enough to assure that the diplomate continues to participate in the knowledge growth that's in the specialty and continuous assessment of their practice to ensure that they're delivering quality care, that benchmark against standards of care and against other diplomates. And so this emphasis to ABNS MOC is really as a response of ensuring that quality clinical care continues throughout the professional life of a diplomate. In fact, if you ask the public, as Gallup has in fact done recently, about this issue of certification of their physician is when they're asked whether or not the physicians board certification status had expired, and whether this would influence whether or not they can maintain care. Somewhere else 70% said it was very likely and somewhat likely that they would in fact change physicians. And that's a very telling statistic. Furthermore when they're asked if a choice was given between the board certified physician or one that was not board certified, but perhaps was recommended by a friend or neighbor or a family member, 75%, again about the same statistic acted in favor of the board certified physician. So we have here a quality of opinions from both the public and the specialty societies and the boards certification organizations, that board certification is truly an important part of the physicians status in the profession and status in society. Plus it's become standard now for credentialing of positions, much like hospital privileges or state licensure would be regarded as key in establishing and maintaining one's practice. The other question, another question that we get quite a bit is, well that's all fine and then you got, how does this practically affect my practice? In other words, can I go to work Monday through Friday, and deliver the care that I usually do without having legal certification just as long as I provide very good care? And the short answer is that of course you can provide continuously good care, but they are other factors within your practice that then demand you to participate in this. For example, third party payers, for example, have now increasingly be queering whether or not physicians are participating Maintenance of Certification as a means of determining who gets paid for participation and who gets initiatives. Insurance companies, for example, have been known to reduce malpractice premiums through on the basis of whether or not a physician was participating in Maintenance of Certification. State Medical Boards have now been asking the question, in order to maintain your licensure, do you participate in Maintenance of Certification by your certifying board? And if you do not, then that will become grounds for reconsideration of your licensure status. Furthermore, your status amongst professional staff and your status in the community and in the public also could impact the referral practice, particularly in a highly sub specialized areas such as neurosurgery. There have been actual studies that have actually analyzed the impact of Maintenance of Certification in the delivery of care, in terms of actual day-to-day practice. For example, that he found the quality of physician care was published by the Health Affairs Group in August of 2010. And this was a surprise to me, myself, and I will read this quote, "Specialty board certification was associated with lower mortality and shorter stays and in fact the same found that physician performance declined over time as measured from time zero from certification. When you look at things like mortality rates and length of stay, increasing with the number of years since graduation, from medical school. Now, this is a correlation and obviously is not causative but when one looks at this, one cannot begin to query one's mind as to what it is about Maintenance of Certification that makes it more likely that our quality of care is maintained through our practice. And then finally, another issue regarding the impact of practice has now come about from the Centers for Medicare and Medicaid, CMS. CMS has weighed in and has now provided with another incentive for participating in MOC. The amalgam of MOC and the Physician Quality Recording System, PQRS previously known as PQRI. And this allows diplomates under this statute to earn an additional bonus from these payments if they were participating to the tune of 0.5%, in addition to the previous bonus of 1% so total 1.5%. And the idea of Billings for the hospital system, it would be not an insignificant margin, in terms of incentive payments. And in fact, the ABNS the American Board of Neurological Surgery has become conditionally qualified to participate in this program so that diplomates can benefit from participating in MOC in terms of the financial reward from CMS based on these statutes. So three other things that are coming down the pike. They're not here yet, but I would predict that over the next five, perhaps maybe seven or eight years down the line, we might be looking at a scenario where the participation in MOC is a condition for maintenance of state medical licensure. So that if you were not participating in MOC, you couldn't have your state license renewed. The Federation of State Medical Boards has been rattling this chain. And I would not be at all surprised that we were looking at this five years from now. The other trend that's ongoing is this issue of continuous MOC. That is that MOC becomes more of an annual ongoing event rather than every mini cycle as it is, for example, right now with the ABNS we have what's called a three-year mini cycle, that the same things that you do every three years. Continuous MOC would then suggest that you would perform elements of MOC on an ongoing basis every year year and year much like you would for maintenance of your hospital privileges. And the third thing that's coming down the pike is coming from the hospital systems and the American Hospital Association, where it may become the case that physicians who are not participating in MOC may not be able to have their hospital privileges renewed in other words, becomes a requirement for hospital privileges, which would really be a big stake, because lack of hospital privileges for many or surgery, really then impacts the livelihood of a physician, and not having those privileges means they factor that you cannot earn a living as a physician. So that would be a really big statement. Going back to exactly what the elements are the standards upon which we operate right now were promulgated by ABMS in March of 2009. And under those the standards for parts one through four, and these are the standards to which all ABMS member boards must adhere to. This probably indicates that as we go further, the next few years, those standards will be massaged and altered to add new mandates to Maintenance of Certification. So let's go back and remind ourselves about the six general competencies or core competencies if you will, same ones, by the way that we use in residency training. And these six general competencies that Maintenance of Certification measures or assesses or tries to maintain through the process. The first is medical knowledge that is basically the knowledge of the specialty. The second is patient care, and how patient care is delivered in terms of the actual clinical delivery of care. The third is interpersonal and communication skills, skills that are essential for patient, physician communication, or peer-to-peer communication. Professionalism, in other words, how the physician conducts themselves as a professional in rendering care, according to standards that are recognized by the specialty. And then practice-based learning and improvement, the process by which we continuously update our knowledge, and not only update our knowledge, but integrate that knowledge into our delivery of care as a means of improving so the new knowledge, we integrate that new knowledge into our practice, or we measure whether or not as a result of that our practice has improved. And then finally, systems-based practice, essentially is a means by which we utilize the healthcare system in an efficient, cost-effective and appropriate fashion in delivering care whether it's applying procedures, or diagnostic tests. The four key components or parts royalty, for MOC are the feature of this next slide. The first and most basic is the evidence of professional standing. And this is measured essentially by two things. In other words does the physician hold a valid unrestricted medical license and at least one jurisdiction in the country. And second, the so called Chief of Staff questionnaire, where we send a set of interrogatories to the Chief of Staff at the primary facility where the diplomate is practicing. Then those questions as well as the licensure become the basis upon which we assess the evidence of professional standing of the position. We also look at things like dance reports, reports from state medical boards, or any reports that might influence the standing of the professional. And those all come together in determining whether that diplomate has scaled an adequate professional standing. The second part of MOC or part two is the evidence to commitment to lifelong learning by the periodic self-assessment process. Most physicians get around this by accumulating psycho education credits of the standard that's recognized by the ANA, also called category one credits, and other kinds of credits that used to be called category two and three, but also can be used in terms of assessing, continuing lifelong learning. The other part of it that we use for MOC in the board is the self-assessment in neurological surgery which is offered to diplomates gratis by the Congress of Neurological Surgeons. And so diplomates can use that tool on every mini cycle, every three-year mini cycle, to assess their knowledge base, and then implement that with CME credits. Part three of MOC which is the one that I think most people are concerned the most about that generates the most times, if you will, is the evidence of cognitive expertise, which is the actual but I assure our diplomates that they need not worry too much this basically, loss of user test was it an anxiety provoking events is given once a year and it must be passed. It really covers a clinical portion of surgical practice as opposed to basic portions that we see in our written exam on the primary certification level. So for example, we don't have things like neurology or neurophysiology you need to concentrate on clinical practice, it's totally irrelevant and it's really taken from the self-assessment neurosurgery, which is part of what diplomates use every three-year mini cycle in part two. It must be taken by the seventh, eighth or the ninth year so that by the 10th year, the physician does not approach the end of the Maintenance of Certification cycle, with the sword of DaMOCles still hanging on them. And if you frankly, cognitive expertise, or cognitive exam in your 10th year, it could be a very sad event because it may lead to loss of certification. Now, part four of MOC is the evaluation of performance and practice. In other words, a means by which the diplomate can assess their practice against recognized benchmarks. Recognized benchmarks in the specialty, and then recognized benchmarks from one mini-cycle to the next. In order to do this, there two competitors by which specialty or versification groups do this one is by registry and other is by what we call key cases. We're probably moving from key cases to registry in the future bot currently, right now, the means by which we do this, after this assessment of MOC practice, utilizing key cases and I'll describe that in detail essentially involves a personal report of cases that have been done over a unicycle and the diplomate chooses one particular case that we left there in the judging the practice. And declare on those patients on each mini-cycle. And we'll go to that in a little while later. ABNS Excuse me Maintenance of Certification work is actually done by a committee so that the committee is made up our contractors, myself chairing the committee Dr. Daniel as ABNS chair, is ex officio on the committee, as is Fred Meyer who's ABNS Secretary, Dr. Van Der Veer the chair of the Credentials Committee which oversees things like professional standing and so forth on the committee. Dr. Park, Dr. Matthew Howard who is ABNS Treasurer, Dr. Robert Harbaugh, David Roberts who together with Mitchel Berger are co chairs of the MOC written exam. Dave Roberts has the portfolio of actually running the cognitive exam of MOC part three, then Erica Cleveland who is a Coordinator for MOC. And of course, the ever present evergreen Mary Louise Sanderson she's Executive Director of the board is also on that committee. So the committee really is charged with doing the work of the Board of MOC, and basically discharging the mandates that were given by ABNS. And in fact ABNS has a minister of committee Minister Certification Committee called COLNOC that basically review standards of MOC and decides what goes into MOC or not. So let's go a little bit back on the four components of MOC. And let's take exactly what the assessment methods are and then the frequency. This is a practical way now, actually tons of diplomates of what they're supposed to do. So in terms of professional standing, I alluded to this already, that the two things that we love the most right now are evidence of the products to continuously hold an unrestricted license to practice in one of the jurisdictions. So if you have one state license if you practice in more than one state, you don't have to have more than one license for the purpose of MOC, you need just one. The Chief of Staff questionnaire which is sent by our MOC Coordinator, to the primary facility, where the diplomate participates, and has these interrogatories that I talked about. the assessment of professional standing, which had been mandated by ABMS COLNOC the Consumer Assessment of Healthcare Providers Survey, the same kind of service that we see in our practice currently, many physicians may recognize this as the Press Ganey survey, it's a similar survey. And then a peer communication survey, which is a peer-to-peer assessment of the 360 communication survey that has also been mandated by coma. These are two standards now that are currently developmental standards, but will be initiated probably within the next year 2012 as a pilot, from the ABNS to diplomates. The frequency that is required for this evaluation by ABNS is every three years in other words, nameless a certification cycle is a total of 10 years, that it's divided into three, what we call mini cycles. And each of those mini cycles, there are specific requirements that must be fulfilled before you can go to the second mini cycle and the third mini cycle. So this professionalism component is required every two years or once every mini cycle. The second piece, the lifelong learning and self-assessment component of MOC part two. Part two requires two things currently. You require evidence of the accumulation of continuing medical education credits, that's divided into at least 150 credits that must be accumulated in this three-year period, if you have 200 so the good, but we need at least 150. I guess 150 has to be divided into a minimum of 60 category one credits. Where you could have all 150 credits be category one if you wish, but at the minimum 60 must be category one, and then the 90, the other 90 could be category one or other credits. If you perform the science of self-assessment, you automatically get 24 credits. So performing that self-assessment, in and of itself helps the diplomate accumulate the relevant number of CME credits 'cause you get 24 right off the bat. One assessment tool that is coming down the pike for part two of MOC is something called a patient safety assessment. The patient safety assessment has been mandated by ABMS for all diplomates who participate in Maintenance of Certification. Of course, this issue has been in the medical care arena for several years, ever since the IOM report on to Earth human and so this drive has entered into the medical arena of ensuring that what we do first and foremost, is safe for the patient. So the ABNS under this mandate has developed its own patients safety modular in collaboration with the AANS Maintenance of Certification committee that allows us to provide diplomates with a means of learning what the key elements of patient safety are, we make sure that this patient safety module is tailored specifically to neurosurgery and it's clinically relevant for neurosurgeons. That module has been developed now, and has been pointed to coma. And so we should be getting approval of that module pretty soon. And once that rule has been given that a pilot of that module will be set out to diplomate, after it'll become an integral part of MOC. So look to this into the arena sometime late next year. And it will be required every three mini cycle as well. And we anticipate that this will be done online and will be a web-based tool. And so you complete the module and then get, you will also be able to get to CME credits for doing so. And the assessment will be first. The third part of MOC we discussed already is the written examination. This written examinations developed by the ABNS-MOC vision committee, in collaboration with the National Board of Medical examiners, much like our primary nomination is, and is subject to the same ground rules and psychometrics and statistical relevance, that the primary exam is. As I said before, although it does provoke a lot of angst and need not be so because it really is a clinically relevant examination. And it does not rehash elements of basic science that were already examined at the time of the primary written examination. We strongly encourage and admonish diplomates to take the written exam well before the 10 years are up. So you're taking your eighth or ninth year, if you don't do so well in the eighth year you can take it again in the ninth year. There is a charge for the written examination, which is the only part of MOC that there is a charge for right now, everything else is provided gratis. The cost of the cognitive examination is $800 and is administered only at designated sites, typically academic medical centers or residency training programs across the country, at the same time that the primary written examination is administered in late march, I think the third week of March. And the diplomates have to go to that particular center, and it's given on a computer and it's monitored, and is the usual security that accompanies the primary examination that's also apply to the cognitive examination. If you fail the cognitive examination after taking again, we will assess you another $800 unfortunately, that's just the cost as required for administering your examination. And then the final but not the least importance of MOC is the performance in practice. As I said earlier this performance in practice is a means of allowing the diplomate, to assess their practice, relevant to each mini cycle during the MOC process. So you fill in the reports on 10 consecutive cases, much like the patient operative log that we asked of you at the time of your primary certification. The same kind of log provides information about the patient, why the operation was done, what was done, what the outcomes were, and what kind of complications occurred? And then as those reports are filed online, the diplomate gets back from the case report benchmarks we've been doing in the second mini cycle, they get benchmarks well into their first mini cycle, and can see whether or not the improvements in outcomes have been met, then they do the same thing in their third mini cycle and at this point that continues to show evidence of improvement in these benchmark reports. Furthermore, the benchmark reports can be benchmark against national standards of all diplomates, who also utilize the same key case to report their practice. And again, the key cases are required every three years. Up until last year, it was the case that the key cases had to be the same every three years, but recognizing the fact that sometimes diplomates also they practice the directors of board allowed key cases to be altered in a second or third mini cycle. So if you decide to take anterior cervical diskectomy, your first mini cycle, and you wish to change it to surgery for gliomas in the second mini cycle, you could do that. Two more parts of our that are gonna be coming down the pike are Consumer Assessment of Healthcare Providers survey that I mentioned the Patient Care Survey, and then the Peer Communication Survey. And as I said earlier, this is probably going to be here a year from now. The current cohort of MOC has continued to accumulate, as you might imagine, as the years go by, it's gonna get more and more busy and the committee is exceedingly engaged in monitoring the progress of MOC participants. And as you can see, through applications we have on cohort statistics is about 2000. Little bit more detail about some of these issues part one through four allow the audience to look through this. This is the Chief of Staff questionnaire. They're not asking personal questions of you. they're asking questions that are already available in the public domain of the hospital records. For example, do you have a license? Do you have privileges? Are you in good standing? Do you practice or participate in the policy management process in your hospital? Do you use electronic medical records or PACs? And this is a way of getting around the overall professional standing of the public diplomate. I mentioned already about the self-assessment. And this is a slide showing exactly in more detail the types of CME that are required every three-year mini cycle. Again, 60 AMA PRA professional recognition award category one credit, and then the other 90 could be category one or other. Patient safety module is coming down the pike a year or so from now. Now the self-assessment for neurosurgery again provided, as I said earlier on gratis by the Congress of Neurological Surgeons, they have a large committee of neurosurgeons that work on this and continuously update the size of our product, which has been a real boom for their surgeons is used actually by residents as well as surgeons in practice. There are now three modules. So you can pick from either a general module which basically covers all of the neuro surgical topics. The beauty of science is that it's accompanied by little tiny vignette, blogs, if you will expert critiques and federal hyperlinks to peer reviewed articles in the literature, and other learning sources that can expand your data base. So participating in science not allows you to get an assessment of what you know, but also provides you with a venue for determining where to get additional information. There's a spine module that takes some general material, but also adds a large potential sprinkling of spine. Then there's also a pediatric module that again focuses on pediatrics. So if you sub specialize in spine or pediatrics, and you wish to concentrate your fire just on those three areas, you can do that. Category One credit is granted for participating in science once every three mini cycles. The patient safety self-assessment, as I alluded to, has been mandated by ABNS and by 2012, we will be constrained to provide that to all diplomates. The cognitive knowledge examination, again, must be done thoroughly in the eighth or ninth year, to prevent that 10 year rush, so that you do not face the potential of not getting through the cognitive exam in the 10th year because that will result in loss of certification and needless to say it, one cannot overemphasize this issue, because it's a sad day when all what you've worked for for years and years, goes down the toilet just because you flunked an examination and you had no further recourse because you were in your 10th year. This slide basically should allay all anxiety about this examination. It was first offered in March of 2007. As you see there 27 candidates all passed. The second time, it was offered was in 2008. And at this time, we had almost three times the number of candidates and still all of them passed. By five year of its offering in 2009, we had 142 candidates and we had only one failure of 442. Last year 150 candidates took the examination, and we only had two failures. So the moral of the story is that this is an exceedingly favorable examination for diplomates and there should be little or no anxiety in participating and participating early as a means of getting on with it. Now, I'd like to detail some of these key cases because this is another question we get a lot of, what are the key cases? Why did you choose this key case? What is my favorite case is not in the key case list? Ex cetera and so on. So the directors who came up with the key cases worked on this long and hard. It's a very expensive and really agonizing process to produce this type of material. The key cases we currently have in our list is 60 key cases, and they've been selected because they represent a lot of neurosurgical practices, you'll see there. Front and center is anterior cervical discectomy and fusion, share decompression, clipping out of aneurysms, craniotomy for gliomas, craniotomy for seizure surgery and vascular embolization, mobile diskectomy, management of head trauma, management of low back pain, management of trauma and low back pain are non-surgical key case material. Dr. Daniel has a question, doctor?

- No go ahead.

- And then these two modules eight and nine key cases eight and nine allow for the non-surgical management of these conditions. So that we saw patients in the hospital, you'll see lots of patients in the hospital that fall into this category, but don't require surgery. This is a means of reporting on those. And then of course, the other ones are outlined, as you see right there. The two other key cases in development. One is the cervical spine trauma, and one is lumbar spinal stenosis. Now, if you do not see your key case in the news, there is a method for overage, you can petition the board, the MOC committee will listen to and consider our petitions now we haven't been done so. Recognizing the fact that some of them are surgeons, but some diplomates have unique practice patterns. Allow areas that are not on the key cases. And the next slide basically have some of those areas of unique or special practices where diplomates have petitioned the board for consideration of Ad hoc review of key case material. So for example, we've due 12 requests in the last couple of years, one for surgery for intramedullary tumor, one for piriformis syndrome, surgery for Acoustic Neuroma, spinal tumors, and so on and so forth. And increasingly, we're seeing more in the area of functional surgery. For example, we've done two recently for DBS dimension for Parkinson's disease, and other movement disorders surgeries. Were not in the original key case, the only functional one and the original key cases probably was surgery for mesial temporal sclerosis for seizures. As we go further along, we will probably add more cases as I said, it's not easy coming up with these it's very costly. The process for producing it is long and arduous and so it's done only with due deliberation and consultation. The next slides are basically screenshots if you will, from our partners that provide this computer support for key cases. When you sign on to enter key case, you'll see a screen that looks very much like this. And you'll see a list of key cases and then basically user and work base key cases prompt the diplomate to enter the demographic information about the patient, the age, gender, date of surgery. And then the diagnostic elements that lead to the consideration for surgery, clinical symptom presentation, test results, post imaging results, and so forth. And then those are entered progressively, as you go along, and all that data is entered, the surgical outcome, the type of operation and so forth, it's all entered, and then the diplomate will save the case and each case must be saved until you get a total of 10 cases, and then you submit all 10 cases and you complete that key case requirement for part four of MOC for that specific current mini cycle. Now, once that's been done, you'll get pop-up menu saying, oh, by the way, you successfully submitted your data. And then you'll be prompted to look at your benchmarking reports. You have to redo those benchmarking reports in order to receive full credit for participation in the key cases. And in order to do that, you will click on the Reports tab and once you do that, you will get these benchmarking reports. And there'll be, you can look at the specific outcome. In this particular case, the surgeon was reporting on his Chiari decompression series, and you can look at outcomes of a particular symptom you like, and you can benchmark your outcomes over the past mini cycle relevant to other diplomate who chose that same condition for the key case reports. And they're very easy to read. They're coming from bar graphs and pie charts. And this is the kind of material that is . The MOC portal has been recently revamped. And this is a program summary that you will see, when you enter data. In this particular case, you can see that this candidate, this diplomate here, completed cycle one, completed cycle two, all the stuff in the stuff that he marked there, and there's some pending items here. And then the stuff that's already been satisfied is there, as you can see that he's still awaiting his cognitive examination. There are few other things I wanted to mention about MOC. And this first issue is the issue of clinical inactive category. We both recognizes that careers change as we all evolve, bypasses on that and is very possible that a diplomate may decide for whatever reason to go into politics or research or administration, or take a vacation or sabbatical for an extended period of time for whatever reason. And in those cases, diplomate who wishes to set out of routine clinical practice can do so and notify the board on that intention and not be penalized for not participating in maintenance of certification. And this categorization is designated in the clinically inactive category. The board has this language and the mechanisms for which a diplomate can become clinically inactive. In other words languish power or clinical activity only surgically inactive in other words, still perform clinical tasks that do not require operative intervention, like seeing patients in an office or performing medical examinations or something like this. And in fact, we have granted one such request last year. In order to keep everybody on the bar and keep everyone on the straight and narrow, there are some penalties that are out there for non-participation in MOC. For example, if you jump out of the mini cycle, because you didn't complete certain elements of the mini cycle that will allow in which you are then mandated to complete those elements of that mini cycle, or else you will fall out of that grace period. And if you fall out of extended grace period on the second mini cycle, you get another six months, but we only allow you to call up to grace periods over the course of the whole 10-year mini cycle. So you have two shots at the grace period. If you thought of the grace period, for the first grace period you're charged a fee of $500. And the second grace period is $1,000. If you drop out completely of MOC there a very steep penalty cost $2,500 to get back into MOC. The worst case scenario, if you do not complete MOC and your 10-year cycle expires, and you do have a certificate, you will fall out of the MOC process, your certification will expire, and your certification will be withdrawn beyond happy event. So this algorithm basically illustrates what I was talking about a minute ago, is the consequence of falling out of grace period. Actually out of the process, you can pay reinstatement fee and get back in before that clock runs out on you. But the clock runs out and the 10 years are up and you lose your certification. For example, in 2009 we had as you see on the slide, we had 157 diplomates who fell into that grace period. And as you see as the years have gone by, they're fewer and fewer diplomates requesting the grace period option. I think that's because we've been able to deliver the information and send out as much information by means of emails and phone calls and newsletters, and E blast and so forth, that have increased the overall level of information out there to diplomates and neurosurgeon so that people recognize that MOC is here, it's here to stay and other consequences for not participating can be very serious. So as you see, people are beginning to turn the line in better numbers than the past. Number two on this slide tells you what the board has done in terms of wielding this authority to certify. Four diplomates who was certified in 1989, were certificates, did not complete the MOC process and consequently are no longer board certified. So this is a rather unfortunate event, but it is mandated from the ABMS and rules are here to stay. Finally in terms of these developmental standards that I mentioned, the surgical Consumer Assessment of Healthcare Practitioners is the patient care survey tool. This has been approved as a potential tool that we will use. The other tool under consideration is the tool by Press Ganey and currently the board is looking at both of these tools. And we'll advice diplomates which one will go with, hopefully within the next six to eight months. The patient assessment rule is gonna comprise of several modules, modules that will teach elements of patient safety include things such as sterile technique, issues of patient positioning and how to avoid injuries that arise from patient positioning. The alerts that go along with the preoperative screening, a call to order the checklist, the interactions, drug interactions, and so forth. But we also taught in this module, how to avoid wrong level, wrong side surgery, which is a very serious issue in neurosurgery, and indeed all of this there is a module on communicating critical results, which is a very important part of communication and interpersonal skills. And then, finally there is much on discharge communication, and post operative care. So, with that, I will conclude early. And then my delivery on MOC and the final slide, as you see here tells you that MOC is really working progress. Today's MOC will not be tomorrow's MOC. Today's MOC certainly was not my grandfather's MOC. And so we will continue to evolve and as we do will continuously update SQ forms such as this, of what's coming down the pike next year, and there after. So thank you very much and I'd happy to take some questions if you have some.

- I think you very well mentioned the process. Obviously, it's a complex one, but it is absolute requirement, it's gonna only become more strict. And then I think it's something that we all have to take very seriously. And Dan do you have any other thoughts about this process you would like to let us know, please?

- A couple of comments. First of all, with regard to the cognitive exam, Nelson gave the statistics showing that a very, very small number of people have failed. And that should certainly alleviate anxiety for those who are in the process. The reverse of that the other side of that issue is that outside agencies and outside public agencies look upon that high pass rate, and question whether or not it's really a valid exam, if nobody fails, or if one person fails, are we creating an examination that really doesn't demonstrate somebody's proficiency. And our response as a board to that is that for God's sake, we would expect the high pass rate. That somebody has completed a neurosurgical training program in an accredited training program. They passed a written examination, they've had their credentials reviewed, they pass an oral examination, and they have successfully completed a Maintenance of Certification process. It's nearly a decade long, we would expect the high pass rate. And so frankly, I personally, and I think I speak for the board don't have a problem with a high pass rate. I think it indicates that we have a certification process that's working. The second observation I'd like to make, and I'd love to have Nelson's as well that his final slide shows that this is a work in progress. And I think that the importance of MOC is going to increase with time rather than diminish. Because of a lot of changes that are occurring in the field of medicine as a profession. My 82-year old father is going to retire from practice on October 27th of this year, which will be 50 years to the day that he began his practice. As I look for his career, he lived through an era that was very different. His judgment and the quality of his practice, were rarely if ever questioned by his patients. And that era of trust us I think today is over certainly, in part, for a lot of reasons. There are a lot of questions about our profession, raised by the public. And despite the study that Nelson showed, there are other studies that demonstrate that the information that you can get about your physician is readily available. Number one, why did you go to medical school? Number two, what is your malpractice history? And number three, are you board certified? That information that's readily available doesn't really correlate very well with that physicians adherence to generally accepted medical practice. And as a consequence, we live in an era where there is a demand by the public for information on assessment and quality of physician practice. And I'm sure like the two of you, I get inundated with phone calls from friends and friends of friends wanna know what's the best orthopedic surgeon to fix my knee? Who's a good rheumatologist? Patients are demanding this information. And I see MOC and the Board Certification process, possibly as a solution to that demand. Because if we don't do it in the field of medicine, if we don't take it upon ourselves, to provide that information to the public, others are going to do it, in fact are doing it. I'll share with you just a small anecdote that occurred. One of the outside agencies that is very well funded and very popular is a website called Where you can go, you can look up your position and find out how he or she is ranked by whatever patients wanna go in and communicate that information. I've worked myself up recently just to see how I was assessed. And I was initially very pleased to see that out of five stars, either four and a half stars on every category in my practice. And I thought, well, this is really nice. I was curious to see that one of the other neurosurgeons that was in my area had five stars, and that happened to be one of my residents who has not yet even finished with his training. I then looked and saw that the three most common operations listed for me are three operations that I never ever do. The point being is that if we let outside agencies provide this answer to the demand for public, public demand for assessment of physicians, we're gonna get full information. And so I see MOC as a mechanism whereby we can truly assess diplomates performance, and find a way to appropriately share that with the public. I think that if we look at MOC today, and you look at the overview that Nelson just provided, probably the weakest area of MOC is part four, where we have the key cases. And despite the fact that that has taken an enormous amount of work, to put those together, and it's been expensive, the data that we get is not as robust as we would like. For somebody to turn in 10 cases every three years that is unaudited and that is self-recorded, probably doesn't give us a real clear indication of whether that particular position is adhering to standard accepted medical practices. The next step I see moving forward is to create a national data bank very much like the thoracic surgeons have done, where we submit all of our cases into a national data bank. And we truly can benchmark ourselves against and with our colleagues so that we can actually truly improve our practice by understanding whether we are at below or above those benchmarks. And today, I think we have the platform in place the word along with a WNS. Through the pioneering efforts of Bob Harbaugh, I've created what's called Neuro Point Alliance, NPA. NPA is a platform that will provide an opportunity for all neurosurgeons to submit their data on an ongoing basis, not just 10 cases every three years. And I think that if we go about this properly, I think that our profession, the board, the senior society, the ANS and CNS, the RSC board sessions can come up with ways for physicians to demonstrate that they're proficient in their areas of focus subspecialty, or whether it's spinal neurosurgery, neuro oncology cerebrovascular, and we can find ways to share that with the public so that we in our profession, are giving answers to the public addressing their demand for information rather than letting outside agencies do it, that as I demonstrated from my anecdotes, don't do it very well.

- You know, I think Dan you mentioned the meat of the matter. That this is just coming down the pike and if we don't do it other people will do it. I've had exact same experience with Healthgrades. When you mentioned it, it was like, boy, this is exactly what happened to me. And the patients go there and you're assessed for things that you never do. I don't do spine and I was assessed only on spinal procedures. And I got exact grade if anything, I got it four out of five gredes. Anyway sorry go ahead please.

- Say that listed is the second most up common operation I do was the insertion of bone morphogenic protein into the spine. I wouldn't get if somebody brought me on morphogenic protein on a plate for breakfast this morning I wouldn't know what it looks like. And that's how we get and I think the point is that we in our profession cannot allow outside agencies to do this very important job for us, which is to help inform the public. We do owe something to the public in terms of making sure that they have access to high quality care. And I think we could do a better job.

- Very well said, Nelson, do you have any other comments in that department please?

- I would echo all of that. And I think the issue will then become, let's assume that we can get this done through our registry is then how we disseminate that information to the public who is thirsting for this kind of information. I think that would be the next challenge as to how we get that information out there. So that we can then drown out if you will, the other kinds of information that's more misinformation than information.

- Okay, thank you, Nelson.

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