ACEP, SAEM, SCUF, CUTF Certification in Clinical Ultrasound Update
September 12, 2017
Background and Scope
Emergency medicine has led the development point-of-care ultrasound (POCUS) training and practice. At this time, there is a need to ensure two items for POCUS trained emergency physicians, and for those with a higher level of training: The quality of that training and an organized recognition of POCUS skills.
Timeline:
2007
The ACEP Ultrasound Section Committee for Subspecialty Development was formed.
· To endorse a certification or board examination process for the subspecialty
· To standardize fellowship training for sub-specialists in emergency ultrasound
2011
ACEP published the information paper on Emergency Ultrasound Fellowship Guidelines. The emergency ultrasound community voted to pursue ACGME as a model for subspecialty development.
2012
ABEM formalized a clinical ultrasound task force (CUTF) with nominated representatives from ACEP, SAEM, and leadership within the emergency medicine community.
The CUTF prepared documentation and applications for ABMS and ACGME. A fellowship Core Curriculum was published
2017
In March, ABMS approved a recognition called a Designation of Focused Practice (DFP). DFP was initially created for hospitalist medicine – both internal medicine and family medicine have their own DFP for hospitalist medicine. ABEM released a statement stating that either full ACGME subspecialty certification or a DFP are both potential options for clinical ultrasound.
· ABEM will be conducting a survey of the emergency ultrasound community to inform what pathway is most desired and appropriate.
· The ultimate decision regarding ABMS direction rests with ABEM.
Three potential pathways
- ABMS/ACGME subspecialty certification
- Designation Focused Practice (DFP)
- Neither or alternate
ABMS/ACGME Subspecialty Certification
· Often considered the “gold standard” of training, this was the initial charge of the CUTF.
· Current ABMS subspecialty recognitions within EM include:
o Informatics, toxicology, pediatric EM, hyperbaric medicine, sports medicine, and EMS.
o Co-sponsorship with with other specialty boards is possible as with pain medicine, palliative medicine, critical care medicine.
· “Clinical ultrasonography” would require one or more sponsoring boards, but would be open to members of different boards like the above cross-specialty recognitions.
· ABEM would be the sponsoring board; other boards could be invited to join in sponsoring.
· If Clinical Ultrasound were established as an ABMS subspecialty it would be recognized as an area of expertise across specialties within ABMS.
· Board-certified clinical ultrasound specialists could have more recognition for leadership roles in implementing and overseeing POCUS within larger system-wide entities and across medical specialties.
· Prevents other specialties from starting their own Clinical Ultrasound Fellowships through ABMS with differing requirements.
· Establishment and maintenance of a subspecialty fellowship program would require increased administrative oversight and paperwork.
· Establishment of an ABMS subspecialty would lead to levels of federal and institutional oversight that could limit the flexibility currently allowed by ultrasound fellowships in terms of structure, reimbursement, and clinical hours.
· When a fellowship becomes ACGME-accredited, it can no longer receive Medicare reimbursement for patient care services provided by the fellow that are delivered in the context of the fellowship.
o This may mean that the fellow simply cannot bill for ultrasounds performed but can still bill for patient care.
o This does not preclude supervising US faculty for billing for the ultrasound services.
o Actual financial & salary impact of ABMS subspecialty status may vary by institution, and is typically determined by the interpretation of ACGME rules by the institutional representative (ACGME Designated Institutional Officer, or DIO).
o See FAQ below for additional information on ultrasound billing.
Designation of Focused Practice (DFP)
· A DFP is in addition to one’s primary certification and not a stand-alone certification or designation.
· A DFP is established by a member board within ABMS (i.e. a single specialty), but does not provide cross specialty recognition.
· The DFP in Clinical Ultrasound for Emergency Medicine would be administered by ABEM and would only apply to emergency physicians.
· A concern of the DFP pathway is that other specialties could approach ABMS to create their own version of an ultrasound DFP. It is not clear whether ABMS would demand a similar level of requirement for that specialty’s ultrasound DFP. If ABMS allows variation in DFP requirements from one specialty to another, it may dilute the acceptance and recognition of this pathway for EM.
· The criteria to obtain the DFP would be determined by ABEM and the emergency ultrasound community.
· While DFP could require fellowship training in ultrasound, it could also recognize alternate ways of attaining this expertise.
o ABEM could choose to outsource criteria for completion and development of examination tools to a third party organization.
· Establishment and maintenance of the DFP may require increased administrative oversight and paperwork.
Alternative pathway:
e.g. Fellowship certification through the Society of Clinical Ultrasound Fellowships (SCUF)
e.g. Emergency physician certification through ACEP
e.g. Other
· Establishment of quality benchmarks and recognition could be accomplished through existing organizations (e.g. ACEP, SAEM, SCUF) exclusive of ABMS or ABEM.
· Selecting an alternative pathway does not mean that everything will stay the same.
· May not be as widely accepted or recognized as an ABEM or ABMS certification.
· Creation of a certification pathway and testing the structure is a substantial undertaking, that would take time and effort from the entire ultrasound community.
· Creation of assessment tools would require significant involvement from psychometricians and test developers to ensure validity and reproducibility of the certification process. No emergency medicine organizations (ACEP, SAEM, SCUF) currently have the infrastructure to create or administer a certification examination.
· Other non-emergency medicine societies are attempting to provide this pathway. This confuses emergency physicians, who seek to determine which is most appropriate pathway.
FAQs
What are the immediate steps for ACGME/ABMS and for DFP?
· ABEM must submit an application to the ABMS and the ACGME and undergo a rigorous review process. Review will take a minimum of six months and will involve all 23 ABMS Member Boards, a period of public comment, and three ABMS committees.
· In the case of subspecialty certification, ACGME must first agree to accredit fellowships before ABMS would consider approving this pathway.
What is the experience of EMS, the most recent ABEM ACGME-accredited subspecialty?
· EMS became an ABEM subspecialty in 2012, following a three-year application and review process.
· Of the 93 EMS fellowships prior to 2012, 53 have become ACGME-accredited.
· Additional EMS programs have the opportunity to achieve ACGME accreditation.
· EMS fellows in most programs bill as attendings for clinical care in EM outside of medical control.
· In 2015, ABEM conducted a survey of emergency physician members of the ACEP Emergency Ultrasound Section, AEUS, and SCUF . A little over half of the CU fellowship directors respondents said they are “very likely” to seek ACGME accreditation for their CU fellowship.
What are the consequences for CU billing if ACGME or DFP is pursued?
· The effect of certification in any form is unknown but there is a potential for a negative impact regardless of any decision.
· Any higher certification for ultrasound has the potential to create barriers for emergency physicians, who use ultrasound in their practice to bill.
· There is no documented precedent for restriction of global practice or billing by pursuing a certification process.
For the following questions the program directors from five different programs (Carolinas, Yale, UMass, Cook County & Kaiser Permanente San Diego) have shared the results of discussing with his or her Designated Institutional Officer.
How will fellow salary be affected by each pathway?
All programs found that a similar fellowship salary would be likely maintained within a DFP structure and salary would likely be a PGY4 or PGY5 salary under ACGME accreditation.
How will fellowship billing be affected by eath pathway?
At programs where fellows can currently bill for ultrasounds, most reported no change within the DFP pathway. One program (UMASS) indicated that billing would be unaffected under ACGME. Three programs (Yale, Carolinas and Cook County) found that US billing would not be possible by the fellow under ACGME unless supervised by a credentialed attending. Billing for all other EM services would be unaffected in all pathways.
How will the number of fellowship spots be affected?
Most programs reported that a similar number of spots would be available for a DFP as is currently offered (range 1-3). The number of spots for ACGME accreditation would be dependent on local arrangements and spots made available by your ACGME office which may vary between programs.
How will fellowship recruitment be affected by each pathway?
Currently all five programs surveyed work within the framework provided by eusfellowships.com (SCUF). SCUF plans to move towards an NRMP matching process. There would likely be a similar process for both DFP and ACGME pathways.
I’m still not sure what is the right choice. What steps can I take to help me decide?
· You’re not alone.
· At the time of this email we will be pointing everyone to a discussion forum at acep.org/ultrasound (Under “EUS Training”) – please check in frequently and participate!
· Attend the ACEP EUS Section meeting in Washington DC in October where this topic will be discussed in a town-hall style meeting.
· Reach out to your colleagues and mentors to discuss, debate and exhaust the issue.
· If you are a fellowship director, make an appointment with your DIO to see how each pathway would affect your program.
· Overall, consider not just what is best for your local fellowship or fellowship experience, but what is best for the specialty and emergency medicine as a whole.
Contributers to this document:
ACEP - Matt Fields
SAEM - Rachel Liu
ACEP/SCUF - John Bailitz
SCUF - Romolo Gaspari
CUTF – John Kendall, Resa Lewiss, Chris Moore, Vivek Tayal