Author + information
- Henry H. Ting, MD, MBA, FACC, Chair, Writing Committee,
- Eric R. Bates, MD, FACC, Writing Committee Member,
- Mary Ellen Beliveau, BS, Writing Committee Member,
- Joseph P. Drozda Jr., MD, FACC, Writing Committee Member,
- John Gordon Harold, MD, MACC, Writing Committee Member,
- Harlan M. Krumholz, MD, SM, FACC, Writing Committee Member,
- Rick A. Nishimura, MD, MACC, Writing Committee Member,
- William J. Oetgen, MD, MBA, FACC, Writing Committee Member,
- Janice B. Sibley, MS, MA, Writing Committee Member and
- James E. Tcheng, MD, FACC, Writing Committee Member
- ACC informational article
- Maintenance of Certification
- Maintenance of Competence
- Maintenance of Licensure
- quality improvement
Educational Quality Review Board Members
Henry H. Ting, MD, MBA, FACC, Chair
Eric R. Bates, MD, FACC
John E. Brush, Jr, MD, FACC
Megan Coylewright, MD
Joseph P. Drozda, Jr, MD, FACC
Robert A. Harrington, MD, FACC
Steven G. Lloyd, MD, PhD, FACC
Frederick A. Masoudi, MD, MSPH, FACC
Rick A. Nishimura, MD, MACC
Sara K. Pasquali, MD
John S. Rumsfeld, MD, PhD, FACC
James E. Tcheng, MD, FACC
The American Board of Internal Medicine (ABIM) is instituting significant changes in the Maintenance of Certification (MOC) requirements that will become effective January 2014 and will apply to all certified physicians. In response, the American College of Cardiology (ACC) formed the Educational Quality Review Board (EQRB) in 2012 with the following charge: 1) communicate to ACC members both the existing and new requirements for MOC of their primary specialty boards: the ABIM, the American Board of Pediatrics, and the American Osteopathic Association; and 2) develop and oversee lifelong learning and quality improvement initiatives for ACC members that satisfy these MOC requirements. It is the intent of the ACC EQRB to develop MOC practice-based learning activities that comply with these specialty certification boards that:
1. Are relevant to cardiologists’ patients and practices;
2. Integrate the activity with routine clinical care and workflow;
3. Minimize the burden of data collection, measurement, and reporting;
4. Enhance the competency of cardiologists in practice-based learning and systems-based practice; and
5. Harmonize the activity with other regulatory requirements such as Maintenance of Licensure (MOL) and continuing medical education (CME) credit.
The purpose of this paper is to communicate ABIM’s changes to its MOC requirements and ACC’s commitment, through the EQRB, to the development of products that enable our membership to meet these new requirements.
Background for Specialty Board Certification by the ABIM
In 1936, the American Medical Association and American College of Physicians formed the ABIM to answer the public call for uniform standards for new physicians entering the profession. The ABIM’s mission is “to enhance the quality of health care by certifying internists and subspecialists who demonstrate the knowledge, skills, and attitudes essential for excellent patient care.” Hence, the ABIM considers itself to be in the service of the profession for the general benefit of the public (1,2).
The ABIM sets the standards for certifying internists and subspecialists, and is physician led, not for profit, and independent of professional societies and the government (3). ABIM certifies 1 of 4 practicing physicians in the United States, and more than 200,000 physicians are currently certified by ABIM in internal medicine and 19 subspecialties. Certifications relevant to cardiology and their inaugural dates include internal medicine (1936), cardiovascular disease (1941), clinical cardiac electrophysiology (1992), interventional cardiology (1999), advanced heart failure & transplant cardiology (2010), and adult congenital heart disease (initial examination available in 2015).
Although board certification and MOC have been widely adopted by the profession and accepted by the public, unresolved challenges include assessing physician competence relevant to individual scope of practice, accounting for different practice and organizational contexts, and achieving this in a cost-effective manner (4–8). There is modest evidence that board certification and MOC are surrogates for higher levels of physician competence and performance (9–13). According to a study by Norcini et al. (11), among 16,629 patients hospitalized with acute myocardial infarction treated by 2,277 physicians, patients under the care of board-certified physicians had a 19% lower risk for in-hospital mortality. In another study of Medicare patients (N = 24,581) treated by 3,660 physicians, Pham and colleagues (12) demonstrated that board-certified physicians were more likely (27% to 34%) to perform mammography and colon cancer screening. Finally, Holmboe et al. (13), found that among Medicare patients (N = 220,000) treated by 3,602 physicians, physicians scoring in the top quartile of MOC examinations were more likely (14% to 17%) to perform diabetes preventive care and mammography screening.
Despite this evidence, MOC programs face scrutiny by the profession (are programs relevant in scope and effective in enhancing quality?), by the public (is certification a credible marker of physician competence and performance?), and by policymakers and payers (does MOC promote care that is safe, timely, effective, efficient, equitable, and patient-centered?). The lack of acceptance by the profession derives from the observation that <1% of practicing physicians holding lifetime certification (pre-1990) chose to participate in MOC. A recent online poll conducted by the New England Journal of Medicine revealed that 64% of physicians in the United States would opt not to participate in the MOC program if given a choice (7). Conversely, MSNBC conducted a similar poll with the public and asked whether all specialists should be required to take tests to renew their certificates. Results showed that 80% responded affirmatively, indicating that they believe renewing certification shows that physicians are staying up to date with current techniques and research (1,8).
Existing Requirements for ABIM MOC
Historically, ABIM requirements for certification and MOC have reflected 3 distinct eras and sets of standards: pre-1990, 1990 to 2005, and 2006 to 2013. The pre-1990 period is known as the “grandparent” era, during which physicians completed a secure examination after completion of their training and were given lifetime certification with no end date. The 1990 to 2005 period is known as the “recertification” era, during which physicians completed a secure examination after completion of their training, were given time-limited certification with an end date after 10 years, completed medical knowledge modules, and took a recertification examination every 10 years. The 2006 to 2013 period is known as the “maintenance of certification” era, during which physicians completed a secure examination after completion of training, were given time-limited certification with an end date after 10 years, completed required medical knowledge module and quality improvement projects, and took an MOC examination every 10 years in order to maintain certification.
The American Board of Medical Specialties (ABMS) is the oversight organization that sets guidelines for certification and MOC for the 24 specialty certification member boards. The ABMS MOC program is intended to ensure that physicians stay up to date in their specialty by promoting lifelong learning and continuous professional development. In 2006, all 24 member boards received ABMS approval of their MOC program plans, and each board is now in the process of implementation. MOC consists of 4 parts: licensure and professional standing (Part I), self-evaluation of medical knowledge (Part II), cognitive expertise (Part III), and self-evaluation of practice assessment (Part IV).
Part I—Licensure and Professional Standing
ABIM board-certified physicians must hold a valid, unrestricted medical license in at least 1 state or jurisdiction in the United States, its territories, or Canada. Currently, maintenance of licensure (MOL) is largely tied to meeting individual state requirements for CME; in the future, MOC will likely be aligned with MOL requirements.
Part II—Self-Evaluation of Medical Knowledge
Physicians participate in educational and self-assessment programs that meet standards set by their member board. Most self-evaluation of medical knowledge MOC activities are open-book, multiple-choice questions that can be completed in individual or group settings. Typically, cardiologists have completed 25- to 30-question self-evaluation medical knowledge modules offered by ABIM or self-assessment programs offered by ACC. Another option for Part II credit is participation in the I-Card simulations that have been available at the ACC Annual Scientific Sessions since 2011.
Part III—Cognitive Expertise
Physicians demonstrate that they have the core knowledge and skills to provide quality care in their specialty through a secure and proctored examination. MOC examinations are currently required every 10 years to maintain certification.
Part IV—Self-Evaluation of Practice Assessment
Physicians demonstrate that they can assess the quality of care they provide compared with peers and national benchmarks. This activity includes defining an existing gap in quality of care; measuring baseline performance; analyzing factors contributing to performance; implementing interventions; remeasuring performance; and assessing impact, lessons learned, and a plan to sustain improvements. In order to meet Part IV requirements, cardiologists have typically completed ABIM Practice Improvement Modules (PIM) that consist of some combination of patient surveys, peer surveys, and/or a review of medical records. Newer options for Part IV credit offered by ABIM include the Approved Quality Improvement (AQI) Pathway and the Completed Projects PIM—both of which recognize quality improvement work in which physicians have already meaningfully participated and completed (www.abim.org).
New Requirements for ABIM MOC
ABIM has endeavored to make certification and MOC a more continuous, rather than episodic, activity performed by physicians once every 10 years. In the “continuous MOC” era, which begins in January 2014 for ABIM board-certified physicians, the term recertification is no longer used or relevant. To that end, the changes to ABIM’s MOC program requirements in 2014 are designed to engage all diplomates in activities on a more frequent and continuous basis to demonstrate that physicians are maintaining their competency by meeting MOC requirements.
The new requirements for MOC apply to all physicians, including those from the eras of grandparents (pre-1990), recertification (1990 to 2005), and MOC (2006 to 2013), as well as newly certified physicians (2014 and beyond). All physicians with a current and valid license will remain certified through the end date of their current certification. Beginning in January 2014, in order to be reported as “meeting MOC requirements,” physicians must be duly licensed (Part I) and:
1. Complete at least 1 MOC activity to earn ABIM MOC points by December 31, 2015 and every 2 years thereafter.
2. Earn a total of 100 points in the correct distribution (20 points in medical knowledge, 20 points in practice assessment, 60 points in either medical knowledge or practice assessment, and complete a patient survey and a patient safety module) by December 31, 2018, and every 5 years thereafter. The patient survey and patient safety modules are new requirements as of January 2014; additional details will be forthcoming from ABIM on these new requirements. Points earned every 2 years are included in this 5-year total. (MOC points can be earned by completing any of the products that ABIM accepts for MOC credit, as well as for the physician’s first examination attempt in each certification area being maintained. Points earned after January 2014 will apply both to points the physician needs to maintain the existing certification and to be meeting MOC requirements.)
3. Pass an MOC examination every 10 years.
Additionally, beginning in 2014:
1. The ABIM public website (www.abim.org) will show 2 separate designations for all physicians: 1) valid board certification; and 2) whether the physician is or is not “meeting MOC requirements.”
2. Board certification refers to completing a formal, accredited training program in a specialty and passing the initial board certification examination after residency or fellowship training. In the new program, newly issued certificates will be contingent upon meeting MOC requirements (i.e., continuously engaging in MOC activities) and will not have a 10-year certification period.
What does this mean for the physicians who were certified in the “grandparents” era (before 1990)?
Physicians of the “Grandparents” era who maintain a valid license will remain board certified. In January 2014, in order to be reported as “meeting MOC requirements,” these physicians will need to enroll in MOC and indicate which certificates they choose to maintain by March 31, 2014; complete an ABIM-approved MOC activity to earn 10 points by December 31, 2015, and every 2 years thereafter; earn 100 MOC points in the correct distribution (20 points in medical knowledge, 20 points in practice assessment, 60 points in either medical knowledge or practice assessment) and complete a patient survey and a patient safety module every 5 years; and pass the MOC examination by December 31, 2023 (within 10 years).
What does this mean for physicians who were certified in the “recertification” era (1990 to 2005) and “MOC” era (2006 to 2013)?
Physicians originally certified in 1990 to 2005 or 2006 to 2013 will continue to be certified for the length of their current certification(s), assuming they hold current and valid licenses. These physicians will need to meet the existing requirements by the expiration date on their current time-limited certification(s). Upon meeting the requirements of those certification(s), they will receive a new certification that is contingent upon meeting MOC requirements (i.e., continuously engaging in MOC activities) and will not have a 10-year certification period.
Any MOC points earned after January 2014 will apply both to those needed to maintain the existing certification and to those required to be listed as “meeting MOC requirements.” The new MOC requirements will apply to all physicians certified from 1990 to 2005 and 2006 to 2013. In order to be reported as “meeting MOC requirements,” they will need to enroll in MOC and indicate which certificates they are choosing to maintain in their MOC program by March 31, 2014; complete an ABIM-approved MOC activity to earn 10 points by December 31, 2015, and every 2 years thereafter; earn 100 MOC points in the correct distribution (20 points in medical knowledge, 20 points in practice assessment, 60 points in either medical knowledge or practice assessment) and complete a patient survey and a patient safety module every 5 years; and pass the MOC examination before the expiration of their current certificate and every 10 years thereafter. Note that the physician’s initial attempt at an MOC examination in each certification area is now worth 20 points and counts toward the 100 total MOC points.
What does this mean for physicians who are certifying for the first time after January 1, 2014?
Board certification for physicians certified for the first time after January 1, 2014, is contingent upon meeting MOC requirements (i.e., continuously engaging in MOC activities) and will not have a 10-year certification period. The new MOC requirements will apply to all newly certified physicians, and in order to be reported as “meeting MOC requirements,” they will need to activate their MOC program (indicate which certificates they are choosing to maintain) within 3 months of initial certification; complete at least 1 MOC activity to earn ABIM MOC points by December 31, 2015 and every 2 years thereafter; earn 100 MOC points in the correct distribution (20 points in medical knowledge, 20 points in practice assessment, 60 points in either medical knowledge or practice assessment) and complete a patient survey and a patient safety module every 5 years; and pass the MOC examination every 10 years. Note that the physician’s initial attempt at an MOC examination is now worth 20 points and counts toward the 100 total MOC points.
ACC Educational Quality Review Board
Within the realm of education, the ACC’s mission is to help its membership meet board certification requirements through the development of lifelong learning and quality improvement programs that advance cardiologists’ knowledge, skills, and attitudes and, in turn, promote high-value health care and the triple aim of better patient care and experience, better population health, and more affordable care. Meaningful participation by cardiologists in these ACC practice-based learning activities will make them eligible for MOC credit from ABIM and other certifying boards.
The ACC Board of Trustees created the EQRB in 2012 to develop the strategy and operations to support ACC members in meeting MOC requirements. Membership consists of experts in education and lifelong learning, quality improvement, and outcomes research, as well as representatives of the ACC Board of Governors, ACC Board of Trustees, ACC National Cardiovascular Data Registry (NCDR), and senior staff from the ACC Science, Education and Quality Division. As stated earlier, the ACC EQRB is charged to: 1) communicate existing and new requirements for MOC to ACC membership; and 2) develop and oversee lifelong learning and quality improvement initiatives to satisfy MOC requirements for ACC members (see Appendices 2 to 4). In response to the first task, this article represents part of ACC EQRB’s communication plan. This information will also be shared at www.CardioSource.org, ACC conferences, board review courses, symposia, and chapter meetings and will be disseminated through print, electronic, and social media communication channels. The ACC EQRB acknowledges that the MOC process can be perceived as complex and confusing. Therefore, the College aims to demystify the multiple abbreviations and requirements in a concise and clear manner tailored to what each individual cardiologist certified by ABIM needs to know and to do in order to be certified and meet MOC requirements. The second task of the ACC EQRB (i.e., developing and overseeing lifelong learning and quality improvement programs that satisfy MOC requirements for all ACC members) is under development and includes the following:
1. ACC EQRB will hold group learning sessions to teach and coach cardiologists regarding how to acquire Part IV MOC points. ABIM offers 2 existing options for cardiologists to obtain Part IV points including the Self-Directed PIM module, for which existing data and performance measures from NCDR can be used, and the Completed Project PIM module, for which existing data and performance measures from quality improvement projects previously performed in the cardiologist’s own practice or hospital can be used.
2. ACC EQRB will partner with the ACC Clinical Quality Committee and NCDR to identify specific areas of need for quality improvement. The Science, Education and Quality Division—with oversight from the EQRB—will develop and implement those initiatives and submit the initiatives and associated MOC Part IV components to ABIM for approval. The EQRB will strategically lead the ACC approved quality improvement initiatives (AQIs) submitted to ABIM through their AQI Pathway, coordinating the efforts of lifelong learning, the Science and Quality Division, and NCDR. Regional or national quality improvement initiatives can be submitted to ABIM through the AQI Pathway for review and approval; and, if approved, every cardiologist who meaningfully participates in the project is eligible to receive Part IV MOC points. An example of this model is the ACC Door-to-Balloon (D2B): An Alliance for Quality that was an ABIM-approved AQI in which over 1,000 cardiologists who meaningfully participated were awarded Part IV MOC points.
The EQRB will be leading the ACC’s efforts to translate the College’s major quality initiatives into programs that can be implemented at the practice level that will not only assist members in satisfying MOC requirements, but also support them in continuously improving their care processes and in achieving the best possible outcomes for their patients.
In summary, under the leadership of the ABMS, the ABIM is instituting significant changes in the MOC process and requirements that will become effective January 2014. All ABIM diplomates should familiarize themselves with the new requirements and should take steps to remain compliant with them if they wish to be recognized as “meeting MOC requirements” on the ABIM website. This recognition will require specific proactive steps on the part of diplomates within the first 3 months of 2014 and within 2 years after January 2014. The ACC’s EQRB is actively monitoring the new ABIM requirements and is designing educational offerings that will allow ACC members, who so choose, to gain and retain the “meeting MOC requirements” recognition.
ABIM = American Board of Internal Medicine.
|Product Name||# Part II MOC Points||Date Launched||Date of Expiration||URL|
|ACCSAP 8 (MOC points offered via Modules 2–9 below)||80||March 2012||March 2015||www.cardiosource.org/ACCSAP8|
|Type 2 Diabetes and Cardiovascular Disease SAP||10||April 2011||December 2013||www.cardiosource.org/DiabetesSAP|
|ACCF's MOC Collection Module 1||10||January 2012||January 2015||www.cardiosource.org/MOCmodule1|
|ACCF's MOC Collection Module 2||10||March 2012||March 2015||www.cardiosource.org/MOCmodule2|
|ACCF's MOC Collection Module 3||10||March 2012||March 2015||www.cardiosource.org/MOCmodule3|
|ACCF's MOC Collection Module 4||10||March 2012||March 2015||www.cardiosource.org/MOCmodule4|
|ACCF's MOC Collection Module 5||10||June 2012||June 2015||www.cardiosource.org/MOCmodule5|
|ACCF's MOC Collection Module 6||10||June 2012||June 2015||www.cardiosource.org/MOCmodule6|
|ACCF's MOC Collection Module 7||10||June 2012||June 2015||www.cardiosource.org/MOCmodule7|
|ACCF's MOC Collection Module 8||10||June 2012||June 2015||www.cardiosource.org/MOCmodule8|
|ACCF's MOC Collection Module 9||10||June 2012||June 2015||www.cardiosource.org/MOCmodule9|
|ACCF's MOC Collection Module 10||10||September 2012||September 2015||www.cardiosource.org/MOCmodule10|
|ACCF's MOC Collection Module 11||10||September 2012||September 2015||www.cardiosource.org/MOCmodule11|
|ACCF's MOC Collection Module 12||10||January 2013||January 2016||www.cardiosource.org/MOCmodule12|
|ACCF's MOC Collection Module 13||10||March 2013||March 2016||www.cardiosource.org/MOCmodule13|
|CathSAP 4 (provides MOC points via Modules 1–8 below)||80||November 2012||November 2015||www.cardiosource.org/CathSAP4|
|ACCF's MOC Collection Module 1: IV Cardiology||10||December 2012||December 2015||www.cardiosource.org/MOCmodule1IV|
|ACCF's MOC Collection Module 2: IV Cardiology||10||December 2012||December 2015||www.cardiosource.org/MOCmodule2IV|
|ACCF's MOC Collection Module 3: IV Cardiology||10||December 2012||December 2015||www.cardiosource.org/MOCmodule3IV|
|ACCF's MOC Collection Module 4: IV Cardiology||10||December 2012||December 2015||www.cardiosource.org/MOCmodule4IV|
|ACCF's MOC Collection Module 5: IV Cardiology||10||September 2013||September 2016||www.cardiosource.org/MOCmodule5IV|
|ACCF's MOC Collection Module 6: IV Cardiology||10||September 2013||September 2016||www.cardiosource.org/MOCmodule6IV|
|ACCF's MOC Collection Module 7: IV Cardiology||10||September 2013||September 2016||www.cardiosource.org/MOCmodule7IV|
|ACCF's MOC Collection Module 8: IV Cardiology||10||September 2013||September 2016||www.cardiosource.org/MOCmodule8IV|
|ACCF's MOC Module 1: Electrophysiology||10||September 2012||September 2015||www.cardiosource.org/MOCmodule1EP|
ACCF = American College of Cardiology Foundation; ACCSAP = American College of Cardiology Self-Assessment Program; CathSAP = Catheterization Self-Assessment Program; MOC = Maintenance of Certification.
|Cardiovascular Conference at Snowmass|
Medical Knowledge Points: 10
ACCF Study Session for ABIM MOC: Interventional Cardiology Updates
Amelia Island, FL
Medical Knowledge Points: 20
ACCF Cardiovascular Board Review for Certification and Recertification MOC Cardiovascular Disease Updates
Medical Knowledge Points: 20
Annual Scientific Session
Medical Knowledge Points: Varies by year
ACCF = American College of Cardiology Foundation; ACCSAP = American College of Cardiology Self-Assessment Program; MOC = Maintenance of Certification.
|PI-CME Activity |
Anticoagulation Performance Improvement Module
ACC Education Division in collaboration with the TEAM-A Partnership
Original Release Date: June 2013
Closing Date: December 2014
Performance Improvement Points: 20
Performance measure data from this module can be used to undertake ABIM's
Completed Project PIM.
Performance Improvement Activities
IMAGING in FOCUS: Formation of Optimal Cardiovascular Imaging Strategies
ACC Science and Quality Division Performance Improvement Module
Performance Improvement Points: 20
ABIM Self-Directed Practice Improvement Module
ACC members may utilize the ACC-NCDR® measures or other data they collect to complete ABIM's Self-Directed PIM.
Performance Improvement Points: 20
ABIM Essentials of Quality Improvement Performance Improvement Module
Fulfills the Practice Performance requirement only for physicians who have no direct or indirect patient responsibility and no direct or indirect supervisory or administrative responsibility for patient care:
ABIM = American Board of Internal Medicine; ACC = American College of Cardiology; NCDR = National Cardiovascular Data Registry; PI-CME = Performance Improvement–Continuing Medical Education; PIM = Performance Improvement Module.
The American College of Cardiology requests that this document be cited as follows: Ting HH, Bates ER, Beliveau ME, Drozda JP Jr., Harold JG, Krumholz HM, Nishimura RA, Oetgen WJ, Sibley JB, Tcheng JE. Update on the American Board of Internal Medicine Maintenance of Certification Program: A Report of the American College of Cardiology’s Educational Quality Review Board. J Am Coll Cardiol 2014:63:92–100.
See Appendix 1 for author disclosures for this article.
Copies: This document is available on the World Wide Web site of the American College of Cardiology (www.acc.org). For copies of this document, please contact Elsevier Inc. Reprint Department, fax (212) 633-3820, e-mail .
Permissions: Modification, alteration, enhancement and/or distribution of this document are not permitted without express permission of the American College of Cardiology.
- American College of Cardiology Foundation
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