Editor’s Note: Humayun Chaudhry, D.O., of the Federation of State Medical Boards (photo and bio above) is a participant in today’s National Press Club briefing on meaningful use of health IT, cosponsored by Health Affairs and the Health Industry Forum at Brandeis University. The post below highlights salient points of Chaudhrys presentation and supplements his discussionn

In addition to Chaudhry, authors of this post include Martin Crane, M.D., the immediate past chair of the board of directors of the Federation of State Medical Boards (FSMB); Freda Bush, M.D., the current chair of the FSMB board of directors; and Frances Cain, director of the Post-Licensure Assessment System at FSMB.

As part of the solemn professional obligation they take upon graduation from medical school, physicians commit to lifelong learning in order to maintain their skills and acquire new knowledge affecting their medical practices and the care they provide their patients. Maintenance of Licensure (MOL) provides a framework by which the boards may assure the public of a physician’s ongoing clinical competence as a condition for renewal of medical licensure. As the Federation of State Medical Boards (FSMB) works with its member boards in the months and years ahead to implement MOL, it is clear that health information technology, generally, and electronic health records, in particular, will be of value as doctors fulfill that professional obligation and demonstrate ongoing clinical competence.

The United States lags behind other industrialized nations in the adoption of health information technology, defined as the utilization of computer applications in the practice of medicine. However, those numbers are sure to increase as: (1) the hardware and software for such systems improve and become more adaptive, (2) as interoperability among and between systems in doctors’ offices and hospitals improves, and (3) as “meaningful use” criteria for the adoption of electronic health record (EHR) systems enable doctors to receive financial incentives in the years ahead to harness the benefits of recording, sending, receiving and assessing medical data electronically. While some doctors and health systems have jumped ahead to adopt EHR systems, it is inevitable that more will do so in time. The implementation of MOL by state licensing boards for the nation’s actively licensed physicians offers one more reason for doctors to adopt health information technology. The evolution of MOL as a framework for licensure renewal, the components that make up its framework and the ways in which health information technology could be used by doctors to demonstrate those components are the subjects of this article.

The FSMB is a non-profit organization founded in 1912 that represents all 70 state medical and osteopathic licensing boards in the United States and its territories. It supports its state licensing boards through policy development, licensure and discipline data storage and sharing, and the development of tools to support the evaluation of physicians’ competence for initial medical licensure and licensure renewal. In partnership with the National Board of Medical Examiners, the FSMB is perhaps best known as a sponsor of the United States Medical Licensing Examination (USMLE) and the Post-Licensure Assessment System (PLAS). The USMLE is a three-step examination that assists state licensing boards in deciding whether to issue an initial medical license. Osteopathic physicians who have graduated from colleges of osteopathic medicine in the United States take the Comprehensive Osteopathic Medical Licensing Examination (COMLEX-USA) that is also made up of three parts and serves the same purpose. Since its creation in 1991, the examination sequence of the USMLE has become firmly embedded within the medical education continuum, with most physicians taking the first and second steps during their undergraduate medical education (medical school) and the third step during residency training. The PLAS is an evaluation tool that is valuable to state boards for continuing licensure determination and often required of physicians seeking licensure in a new state or seeking reentry to clinical practice after a period of time of clinical inactivity.

Since its establishment nearly a century ago, the FSMB has worked to develop what today serves as the nation’s most comprehensive central repository of U.S. physician licensing, disciplinary and credentialing information. At the core of this repository are a Federation Physician Data Center (FPDC) and the Federation Credential Verification Service (FCVS). In an effort to facilitate and ease the process by which physicians obtain licensure, many state licensing boards during the past few years have implemented FSMB’s Uniform Application (UA) for medical licensure. The UA is a single application form common to all participating states, but it also accommodates state-specific addenda, allowing each board to tailor the form to the needs of their jurisdiction while harnessing the efficiencies associated with a common electronic application.

Though medical licensure by the states dates to the early 1800s and is preserved in the tenth amendment to the Constitution, state medical and osteopathic boards traditionally have had more requirements for initial licensure than for licensure renewal. Sixty-two state boards currently require physicians to engage in a prescribed number of accredited continuing medical education (CME) credit hours for medical license renewal, though they do not require that such educational activity be in a physician’s area of practice or specialty. Many state boards require CME in specific content areas such as infection control practices, domestic abuse recognition or end of life care as a supplementary requirement. Physicians attest to the completion of these CME credit hours as part of the license renewal process and most states audit a small percentage of licensees’ renewal applications each year to verify compliance. States also review malpractice claims, peer review information and disciplinary actions as part of that process.

Taking Responsibility For Ensuring Ongoing Physician Competence

In 2004, the FSMB’s House of Delegates approved a seminal policy statement that acknowledged the responsibility of state licensing boards to ensure the public of “the ongoing competence of physicians seeking re-licensure.” In the ensuing years, the FSMB has worked with its member boards, all of the stakeholders across the continuum of medical education and with practicing physicians to develop a framework for maintenance of licensure that state medical and osteopathic boards could use to evaluate the continued competence of physicians for license renewal. In April 2010, the FSMB’s House of Delegates approved a framework for MOL that recommends that physicians, as a condition of license renewal, “should provide evidence of participation in a program of professional development and lifelong learning that is based on the general competencies model.” The general competencies were originally adopted by the Accreditation Council for Graduate Medical Education (ACGME) in 1999 for physicians in training and have since been adopted by many other organizations and will be incorporated into the USMLE. They were also adopted by the American Board of Medical Specialties (ABMS) and the American Osteopathic Association (AOA) as core competencies for quality clinical care. The six competencies include: medical knowledge, patient care, interpersonal and communication skills, practice-based learning, professionalism and systems-based practice.

The MOL framework as envisioned by the FSMB comprises three individual but interrelated components which serve as the basis for activities physicians should engage in to demonstrate their ongoing competence as part of the license renewal process: (1) reflective self-assessment, (2) assessment of knowledge and skills and (3) demonstration of performance in practice. For physicians, these components can be framed as three clear-cut questions: (1) What improvements do I need to make?; (2) What do I need to know and be able to do?; and (3) How am I doing?

The Impact Of Health IT On Maintenance Of Licensure Requirements

Although all three components of Maintenance of Licensure will be positively impacted by the adoption of health information technology by physicians, it is the first and the third components – reflective self-assessment and the demonstration of performance in practice – that will likely be impacted most by an electronic health record. As an illustration, completion by physicians of MOL Component 1 could be greatly facilitated by the availability of aggregate patient data from an EHR system to assess areas of strength and areas needing further inquiry or attention. Likewise, completion of MOL Component 3 could be aided by a physician’s progress with a plan of improvement and performance in practice. Utilizing health information technology to continually improve the care that patients receive from them, physicians under MOL could also use their aggregate practice data to compare with the aggregate practice data of peers within their area of practice.

For MOL Component 2, the FSMB is recommending to state licensing boards that physicians could substantially comply with this component through their active participation in the ABMS’ Maintenance of Certification (MOC) program or the AOA Bureau of Osteopathic Specialists’ Osteopathic Continuous Certification (OCC) program. For those physicians who are not specialty board certified, have time-unlimited specialty board certificates, or are not seeking specialty recertification; state licensing boards will need to consider additional options to assess knowledge and skills within a physician’s area of practice.

The FSMB, through the work of its Advisory Group on Continued Competence of Licensed Physicians, created by one of the authors (Martin Crane), has developed a list of recommended activities that physicians could engage in to meet the criteria for each component of Maintenance of Licensure. A sample of such activities as contained in the Advisory Group’s report is provided below. A copy of the full report is included in a Maintenance of Licensure resource area on the FSMB’s website.

Reflective self-assessment External measures of knowledge, skills, performance Self-review tests

  • Home study
  • Web-based
  • Medical society-based

Others approved by the state licensing board

  • Review of medical literature
  • CME
Assessment of knowledge and skills Structured, valid, practice relevantProduce data to identify learning opportunities Practice-relevant MCQ exams (e.g., MOC/OCC)Standardized patientsComputer-based case simulationsPatient and peer surveysPerformance improvement CME & projects (SCIP, AMI, IHI, HEDIS)Procedural hospital privilegingOthers approved by state licensing boards
Performance in practice Incorporates data to assess performance in practice and guide improvement 360 degrees evaluationPatient reviewsAnalysis of practice dataAOA CAPABMS MOC IVCMS measuresOther performance projects

Legend: ABMS (American Board of Medical Specialties), AMI (American Medical Institute), AOA (American Osteopathic Association), CAP (Clinical Assessment Program), CME (Continuing Medical Education), CMS (Centers for Medicare and Medicaid Services), HEDIS (Healthcare Effectiveness Data and Information Set), IHI (Institute for Healthcare Improvement), MCQ (Multiple-choice questions), MOC IV (Part 4 of the Maintenance of Certification program of the ABMS), OCC (Osteopathic Continuous Certification program of the AOA), SCIP (Surgical Care Improvement Project).

Further development around these activities are being revised and refined by the FSMB’s Maintenance of Licensure Implementation Group – aided by an advisory council of health care leaders chaired by one of the authors (HJC) – which is developing recommendations for how state medical and osteopathic boards could implement the proposed MOL framework. A draft of the Implementation Group’s final report will be distributed for commentary and feedback to state boards, stakeholder organizations and the public in fall 2010.

The FSMB’s MOL framework adheres to five guiding principles: (1) it should support physicians’ commitment to lifelong learning and facilitate improvement in physician practice, (2)it should be administratively feasible and developed in collaboration with other stakeholders but with the authority for its establishment remaining within the purview of state medical and osteopathic boards, (3) it should not compromise patient care nor create barriers to physician practice, (4) the infrastructure to support physician compliance with requirements must be flexible and offer a choice of options for meeting requirements, and (5) MOL processes should balance transparency with privacy protections.

These guiding principles also envision an evolutionary, rather than a revolutionary, process of implementation over time. As “meaningful use” regulations to promote electronic health records and health information technology advance, and as data-driven changes in physician practice gain acceptance and are recognized for the value they offer, MOL should also become easier to demonstrate. The MOL framework approved by the FSMB, whose mission is to promote excellence in medical practice, licensure and regulation as the national resource and voice on behalf of state medical boards in their protection of the public, may be a new concept but it is one that is consistent with state licensing boards’ desire to protect the public and promote quality health care.