A sea change—that all-purpose metaphor that gets a workout these days describing changes in American medicine—is coming to how physicians demonstrate competency and acquire and maintain certification.
The traditional model of one-time examination or periodic recertification along with accumulation of continuing medical education credits through attendance at symposia and lectures is on its way out. In its place will be a model of "lifelong learning" and a requirement that physicians measure their clinical performance against established standards of care or "performance measures."
It is no mere transitory shifting of tides. These are large changes in certification requirements that will in time be mandatory and will affect how clinicians practice on a day-to-day basis; they are the result of a convergence of factors—the push for electronic medical records, concern about medical errors and the "quality" movement, and efforts by public and private payers to align reimbursement with performance and patient outcomes—creating a perfect storm (another handy image for the tempest that is modern health care).
But APA leaders say the sea change need not be a tsunami and that, with APA's help, psychiatrists can adapt these changes to their advantage and to the advantage of their patients.
APA President-elect John Oldham, M.D., has been involved with the development of performance measures for a decade as APA's representative to the AMA's Physician Consortium for Performance Improvement (PCPI). In an interview with Psychiatric News, Oldham emphasized the following points:
"We are well aware that members of our Association and many others throughout medicine may not really like or welcome what is happening," Oldham said. "We didn't invent this, and it's not being driven by APA. But we'd like to help our members navigate these waters as painlessly as possible, and we think they can."
One critical aspect to ensuring the waters are navigable is making sure the performance measures against which clinicians will be evaluated are clinically meaningful.
"The motto of the PCPI has always been ‘performance measures developed by physicians for physicians,’" he told Psychiatric News. "The idea has been to develop a set of clinically anchored performance measurement sets around diagnostic entities. The scope has been all of medicine, and the point of the effort is to enable doctors to demonstrate that they treat patients based on evidence-based practice guidelines derived from a clinical specialty base, rather than by an insurance company or from actuarial data."
Clinicians keeping track of these developments out of the corner of one eye may wonder—What's the difference between a practice guideline and a performance measure?
A practice guideline is a set of recommendations for diagnosis and treatment of a condition based on the best available evidence; APA has developed guidelines for 14 conditions including major depressive disorder, Alzheimer's, schizophrenia, bipolar disorder, eating disorders, and borderline personality disorder. They can be accessed free on APA's Web site at <www.psych.org/psych_pract/treatg/pg/prac_guide.cfm>.
By contrast, a performance measure is a more specific set of documentable clinical judgments and actions. The PCPI has developed numerous performance measures, three of which primarily pertain to psychiatry; they include performance measures for diagnosis and treatment of major depressive disorder in adults, major depressive disorder in children and adolescents, and substance use disorders. A fourth mental health performance measure on dementia is in the works. The PCPI Web site is <www.ama-assn.org/ama/pub/physician-resources/clinical-practice-improvement/clinical-quality/physician-consortium-performance-improvement.shtml>.
"The performance measure is a way of operationalizing a practice guideline," Oldham explained. "So for instance, when diagnosing a patient with major depressive disorder, you have to document that you have used the DSM-IV-TR definition and criteria to make a diagnosis. Sounds simple and obvious, but that's a performance measure.
"Similarly, the clinician has to show that he or she has evaluated the patient for suicide risk, documented the level of severity, and used a treatment algorithm to decide whether to treat the patient with psychotherapy, medication, ECT, or a combination."
Oldham said he hopes to work with APA's Office of Quality Improvement and Psychiatric Services to develop a one-page tracking sheet corresponding to PCPI-developed performance measures that can be disseminated to the entire membership and easily integrated into a patient's chart to document adherence to performance measures.
But doesn't this all amount to "cookbook" medicine?
"I don't think so," said Oldham, who has been hearing the argument for more than two decades. "We had this debate in the late '80s when we undertook the effort to write practice guidelines. But no practice guideline is worth its salt if it's a straightjacket and says only that you have to do this or that and if you don't you are committing malpractice.
"The art of practicing medicine is to do what you think your individual patient needs from a fully informed position, knowing what the studies have shown work for a statistically significant majority of people while also realizing that [what the studies recommend] may not necessarily be best for that individual patient in your office. Getting in the habit of documenting your rationale for your treatment plan, particularly if it differs from evidence-based practice guidelines, will serve you well and will demonstrate your thoughtful consideration both of the evidence and of your individual patient's needs."
Moreover, Oldham said that going forward, APA will be revising its protocols for developing guidelines to conform to the Institute of Medicine's recommendations that practice guidelines include not only evidence from randomized, controlled trials, but also "clinical consensus"—in other words, the wisdom of clinicians who actually treat the individual patients who don't necessarily show up for research trials.
Oldham, a psychoanalyst by training, added, "We have good data to show that psychotherapy is effective and changes the brain. We couldn't have gotten there if we didn't pay attention to the research."
So where is all this heading? What's the ultimate vision?
Where this is heading is a time when physicians in all specialties will measure their clinical performance against evidence-based guidelines, integrating the use of electronic medical records so that the demonstration of competence is continuous and almost, as it were, in real time.
And it's not a day in the distant future: in 2013, the American Board of Psychiatry and Neurology will require clinicians to complete a Performance-in-Practice clinical module—essentially a chart review of five or more patients with comparison of the clinician's performance against recommended standards of care—as part 4 of its maintenance of certification process (see Big Changes Afoot in Education).
The clincher is that demonstrating adherence to performance measures will eventually be tied to payment. Oldham noted that "value-based purchasing" is being pursued in the public sector in the form of the "pay for performance" demonstration project of the Centers for Medicare and Medicaid Services (CMS).
The Patient Protection and Affordable Care Act passed by Congress earlier this year includes financial incentives in 2011 and 2012 for physicians who use electronic medical records to voluntarily submit clinical data to CMS's Physician Quality Reporting Initiative (and, in 2015, penalties for failure to do so).
Oldham emphasized that although requirements for maintenance of certification and licensure are not controlled by APA, the Association can help minimize the burden to practitioners imposed by these new requirements.
"Ideally, this can be done in a way that truly helps psychiatrists provide better care to their patients," he said.