Meeting the Challenge of MOC

Part 2: Passing the first two required elements.

BY ANDREW RABINOWITZ, M.D.

In this three-part series, Andrew Rabinowitz, M.D., discusses the professional and personal challenges he is facing in meeting the requirements to maintain his standing as a board-certified ophthalmologist and his experience with the Maintenance of Certification (MOC) process. In the first installment, which appeared in the April issue of Ophthalmology Management, Dr. Rabinowitz outlined the four primary areas in which he must show evidence of proficiency and the resources that he is using to prepare for these tests. The second segment in this series will cover his efforts to pass two of the areas of proficiency, the Online Record Review (ORR) and the submission of CME, both of which are mandatory to achieve Maintenance of Certification.

As I stated in part 1 of this series, I did not look forward to sacrifice family or professional time to achieve the requirements necessary to maintain certification. While I consider the MOC program as currently structured to be an unnecessary imposition on me and many other qualified physicians, I also recognize that if the medical community does not find ways to maintain and monitor professional performance, the government will do it for us. Therefore, through this series of articles I will attempt to ease the path of those who will follow in my footsteps during the coming years. I hope that those who follow can pursue the MOC process with less anxiety than those of us who are among the first to take these steps.

Tackling the ORR

The ORR requires the participant to collect a total of 15 patient charts. Applicants must first choose three areas of interest for their chart review. The American Board of Ophthalmology (ABO) Web site (www.abop.org) now provides a list of 37 specific patient categories, covering such areas as cataract, glaucoma, pediatric ophthalmology, neuro-ophthalmology, refractive surgery and retina. Once an applicant selects three patient categories, he or she must then collect five patient charts from each category. The applicant is encouraged to select the patient charts prior to participating in the ORR.

I selected three topics within my area of expertise: Glaucoma Suspect, Stable Glaucoma and Advanced Glaucoma. I then had my office staff generate a master list of all of my patients with a diagnostic code that fell under one of my three chosen areas of interest. The patients in each category that I selected had to conform to the following profiles:
■ Open-Angle Glaucoma Suspect: The patient must be 18 years or older with suspicion of open-angle glaucoma on the basis of elevated IOP, or suspicious disc or field, followed by you for a minimum of 2 years and seen by you at least once in the past 12 months.
■ Stable Primary Open-Angle Glaucoma: The patient must be 18 years or older and the patient's care must have been initiated and followed by you for a minimum of 2 years and seen by you at least once in the past 12 months. The patient's glaucoma must fit into the following status:
► stable, mild to moderate disc and/or visual field damage (no more than nasal step or arcuate scotoma in one hemisphere)
► therapeutic adjustments may have been made, but none within the past 12 months.
■ Advanced/Uncontrolled Primary Open-Angle Glaucoma: The patient must be 18 years or older and can either be referred or be your primary patient. You must have managed this patient for a minimum of 2 years and examined this patient at least once in the past 12 months. The patient's glaucoma must fit into the following status:
► at some point in your management of the patient at least one therapeutic adjustment was required.
► disc damage that produces a cup-to-disc ratio that is greater than 0.7. Visual field loss inside the central 10° or any field loss in both the superior and inferior fields.

From my master list, I then pulled 15 charts that fit each of the three patient profiles. I collected 45 charts in total. From these 45 charts, I ultimately had to select my final 15 (five from each of my three chosen areas of interest).

Documentation Is Key

The ABO Web site provides the applicant a list of the information that must be present for a patient chart to be judged as providing adequate documentation to be considered a completed medical record. The required information that must be present in each chart is quite significant. The board also requires some basic, non-identifying information about the patient records to be used, including year of birth, initial visit date and most recent visit date. The online ORR program will guide you through entering the required information. Once the patient information is entered, you will be prompted to begin reviewing the 15 patient records. Thus, it is imperative to find charts within your practice that are thoroughly and properly constructed.

I scoured through the 15 charts I had chosen in each area of interest and determined which five had the most thorough documentation. I then proceeded to select the 15 charts that I believed to be ideal for submission to the ORR. I enrolled for the ORR through the ABO Web site and paid the $750 registration fee.

Once I had paid the registration fee, I proceeded to spend the next 2 days going through each of my 15 charts. The ORR can be completed by applicants over any 30-day period once they pay their registration and submit their first chart. I chose to complete my 15 charts over the better part of a 3-day weekend. When all of the charts were submitted, the ORR quickly and automatically generated a "grade" for my work. I am happy to announce that I achieved a passing grade.

Meeting the CME Requirement

Subsequent to successfully completing the ORR, I addressed another component of the MOC process, specifically the submission of all of the required CME. The ABO provides an online portal to submit the mandated CME. The CME required is 30 hours per year between certifications.

Specifically, each applicant becomes eligible for recertification 8 years after initially becoming board certified. Thus if an applicant takes the demonstration of cognitive knowledge (DOCK) exam required for MOC at year 8, he or she needs 240 hours of CME (30 × 8) to achieve MOC. At least three of the credits must be in ethics. If an applicant takes the DOCK exam at year 10, he or she needs 30 × 10 (300 hours) of CME.

A word of advice: I can offer personal experience that it is never too early to begin stockpiling CME hours. In my state of Arizona, you are not required to record any CME credits in the first 3 years after being board-certified. The totally reasonable rationale for this policy is that a newly board-certified physician is up to date in his or her specialty and has no immediate need for additional CME credits. I took full advantage of this rule and recorded exactly zero CME hours in the 3 years following my board certification in 1998.

Starting in my fourth year following being board-certified, I was required to take a minimum of 25 CME hours per year to fulfill the Arizona requirement. Of course, I took the bare minimum of CME credits. Thus, when I was faced with the MOC process, I was already about 100 hours short in terms of CME hours.

"Bank" Some CME Hours

I had to scramble to obtain the required number of CME hours required for MOC. Fortunately, the American Academy of Ophthalmology (AAO) Web site (www.aao.org) offers numerous opportunities to obtain CME credits online. These courses do carry a price tag. I spent approximately $1,000 to catch up on my CME and obtain the required number of hours. I also had good records of my CME hours over the past decade, which helped make the process tolerable for me.

Even if you do not have to confront the MOC process in the next year or two, take advantage of any and all opportunities to put CME hours in the bank. You can earn the bulk of these credits by regularly attending the major annual meetings, such as AAO, the American Society of Cataract and Refractive Surgeons and, if you are a retina specialist, the American Society of Retina Specialists and Retinal Physician Symposium meetings.

With my CME credits submitted and my Online Record Review behind me, my next goal is to hunker down and put in some solid hours studying for my late September date with the DOCK exam. OM