Physicians understand the intrinsic value of lifelong learning as they seek to deliver high-quality care in daily practice. Maintenance of certification (MOC) requirements are intended to help in that regard. Indeed, the hours spent on substantive learning are well worth it, assuming that the learning is relevant to the practice of the physician. But tasks such as data collection for quality improvement can sometimes be a time sink without directly translating into better care for patients.

A new study aims to test a new approach to simplifying MOC for family physicians. The study, known as TRADEMaRQ (TRial of Aggregate Data Exchange for Maintenance of certification and Raising Quality), will assess a method for physicians to automatically record data from all of their patients for the quality-improvement portion of MOC.

I asked Dr. Robert L. Phillips, TRADEMaRQ’s principal investigator and Vice President of Research and Policy at the American Board of Family Medicine (ABFM), to discuss the details of the study and the simplified method of data collection that it will test.

Steven DeMaio: Briefly describe the primary aim of your study and why you decided to launch a project aimed at simplifying MOC for family physicians.

Robert Phillips: TRADEMaRQ has three aims:

  • To assess whether quality measures of family physicians’ entire patient panel can be shared easily with a certifying board
  • To study whether family physicians’ ability to view quality measures and comparisons with their peers will affect the types of self-assessment modules and quality improvement (QI) efforts they choose
  • To study whether viewing quality measures and comparisons with peers will influence the degree to which QI efforts improve future performance

We decided to launch TRADEMaRQ because many of our 85,000 certified family physicians already use quality measures to assess and guide QI and patient-panel management in their practices. It made little sense for them to have these whole-panel measures and then be required to enter quality measures for 10 of their patients by hand in our MOC website as part of a QI MOC module. Both for them and for us at the ABFM, the burden was high and the value was low. Our study partners, whom I name below, saw the benefit (for their physicians) in reporting these measures and also hoped that it would give them broader access to more-targeted QI materials.

The ABFM no longer believes that it is sufficient for MOC to be simply summative. Certifying boards must move toward helping physicians critically assess and improve patient care and, when possible, also help solve other burdens in their lives. We have already gone on record as saying that, in the future, family physicians participating in a process like TRADEMaRQ may not have to take a recertification examination. If we can effectively assess the scope and quality of their practice, and if they are demonstrating self-assessment and improvement, we won’t have to test their knowledge as a proxy for quality.

DeMaio: How are you recruiting participants for TRADEMaRQ?

Phillips: We are working with partners at GroupHealth in Seattle; Kaiser of Colorado; OCHIN, a 23-state health center network headquartered in Oregon; and South East Texas Medical Associates in Beaumont, Texas. We hope to recruit at least 800 family physicians from these four clinical networks.

DeMaio: For physicians trying to fulfill quality-improvement requirements for MOC, how would the automatic method of data collection work?

Phillips: TRADEMaRQ is the passive arm of what will become a clinical registry for family medicine. That means that family doctors who are in health systems or practices that can already produce clinical measures from their electronic health records (EHRs) will have a path to submit those same data automatically for MOC. We will pull those measures into their electronic MOC portfolios, where they can compare their performance with that of peers all over the country. The active arm, called DAIQUERI (Data Abstraction Intelligence QUality Engine for Research and Improvement), involves extracting data from EHRs and turning those data into clinical measures. Piloted in the summer of 2015, DAIQUERI will enable family physicians to use the extracted measures in improving clinical practice and to send them on as they seek to fulfill MOC and other reporting requirements.

DeMaio: How will you assess whether this data-collection method actually saves physicians time without compromising the quality and value of the collected data?

Phillips: We will ask them! Part of our evaluation is to have participating physicians tell us whether TRADEMaRQ improved their MOC and quality improvement experiences. Given that our four study-partner organizations are already using quality measures internally, we know that being able to share these whole-panel measures will be a drastic improvement over the 10-patient, hand-entered measures that physicians now use for MOC. In fact, our four partners found it easier to report quality measures on a regular basis, not just when physicians were starting or stopping a QI project. This means we’ll have longitudinal quality measures. So in addition to our three aims, we will also have longitudinal data that will help us understand how long it takes for a QI effort to show up as a change in quality, how long it is sustained, and (possibly) whether QI efforts have staying power.

Another benefit is that it will allow the American Board of Family Medicine (ABFM) to assess the benefits of various QI efforts. Currently, about half of family physicians maintaining their certification do an approved MOC quality improvement project designed by someone other than the ABFM. We have no way of knowing whether or not those projects affect quality, given that they usually offer MOC credit via attestation. Now, we’ll have longitudinal clinical measures that will allow us to assess the value of various MOC projects.

DeMaio: What is the time trajectory for your study? At what stage are you now?

Phillips: We launched in October 2014. Data will start to flow in March 2015. The Agency for Healthcare Research and Quality funding is for 2 years, but we plan to request a no-cost extension to go a full 3 years, which is a full MOC cycle for family physicians.

DeMaio: What groups and other constituencies do you think will be most interested in the results of TRADEMaRQ, once they become available? What groups have already expressed interest in the project?

Phillips: We are hopeful that the Veterans Health Administration and the Department of Defense Health System might be in the next wave to join. We will also welcome other health care systems, particularly those that already sponsor MOC quality improvement modules. We continue to talk with other primary care boards, beyond family medicine, about adopting similar tools. TRADEMaRQ and DAIQUERI are designed to reduce the MOC burden, minimize the burden of quality measure reporting for payment, and improve certifying boards’ capacity to support QI, but we expect that they will also help us provide leadership in developing more meaningful measures of primary care.

DeMaio: Do you anticipate any opposition to your research efforts, political or otherwise? If so, from whom?

Phillips: We have already heard from both ends of the spectrum. One state family medicine organization immediately put up a hand for the DAIQUERI pilot; another asked what we were doing getting into the room with the physician and patient. The ABFM recognizes that it will have to demonstrate sufficient value to family physicians to overcome doubt or suspicion. We also understand that the TRADEMaRQ study will ideally demonstrate effectiveness for federal supporters. The ABFM is the first board to sponsor a registry, but we glean faith from the success of several specialty societies that rapidly attracted physicians to their registries. In that regard, we also hope to help those other registries make inroads to MOC to reduce the reporting burden more broadly.

DeMaio: How is the study being funded?

Phillips: The U.S. Agency for Healthcare Research and Quality, our main supporter, will provide roughly one-third of the funding for TRADEMaRQ; the ABFM and its Foundation will support the remainder. We see it as an important reinvestment of our family physicians’ resources to improve the value of MOC for them.

DeMaio: Is there anything you’d like to say specifically to readers here at NEJM Knowledge+? And what would you like to hear back from our readers?

Phillips: Just that, for us at the ABFM, TRADEMaRQ is an important foray into a broader effort to make MOC less burdensome, more meaningful, and a source of information that supports understanding and improvement in family medicine. The ABFM committed more than $6 million to developing a registry over the next 3 years and is actively seeking partners to help turn the data into tools that enhance primary care’s impact on health. We welcome questions, concerns, advice, or offers to collaborate from your readers.

Robert L. Phillips, Jr., MD, MSPH, is Vice President for Research and Policy at the American Board of Family Medicine.


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