President’s Perspective: ACR’s Musculoskeletal Ultrasound Certification in Rheumatology Program Helps Healthcare Providers Learn to Use This Tool

Dr. Flood

Many members have asked what our “grand plan” might be for the coming year. My answer is easy: The ACR’s 2013–2016 strategic plan will guide our work in the year that I serve as president and for the next two years as well. From time to time, I will report in this column about our progress in achieving the ACR’s strategic goals.

I would like to focus this month on how the ACR’s Musculoskeletal Ultrasound Certification in Rheumatology program (RhMSUS) aids in the overall goal of developing tools to address evolving payment reforms, increase practice efficiency, and improve quality of care.

Musculoskeletal ultrasound (MSUS) is a modality that has been shown to have many potential benefits for diagnosing and treating patients with rheumatic conditions. RhMSUS supports physicians and health professionals by demonstrating their expertise in using this tool.

How RhMSUS Came About

MSUS has been part of an imaging revolution in rheumatology. Over the past several years, it has been more widely adopted by rheumatologists and health professionals in their care of patients in the U.S., even though it has been used in other parts of the world for many years. Studies have shown the potential benefits of MSUS include faster and more accurate diagnoses, optimized treatment, and improved needle placement accuracy. However, the integration of MSUS into rheumatology practice has also raised questions regarding training, education, reimbursement, utilization, competence, certification, and accreditation.

As part of the ACR’s commitment to Advance Rheumatology!, we gathered experts to examine these questions and provide recommendations regarding the ACR’s role in MSUS. I participated in this exploration as the board liaison to the ACR’s Musculoskeletal Ultrasound Certification Task Force from 2010–2011. I can tell you firsthand that the process of determining whether the RhMSUS program was necessary was not a short or easy one, but a labor of extreme care, consideration, and importance to the ACR.

The ACR’s exploration of certification began in 2010 with the release of the American Institute of Ultrasound in Medicine (AIUM) Training Guidelines for the Performance of Musculoskeletal Ultrasound Examinations. Along with the training guidelines, AIUM developed an accreditation program for MSUS. However, AIUM only accredits the practice or institution, not the individual practitioner, and the program is intended for MSUS in general, rather than its application in rheumatology.

Based on membership surveys conducted by our task force, it became clear that our members wanted a pathway to demonstrate their individual competence in MSUS in rheumatology practice. Our task force determined that the most acceptable way to verify professional expertise was via certification. To be certified as competent, professionals must meet minimum criteria and typically pass an assessment.

More than 80% of survey respondents said the ACR should offer MSUS certification for individual rheumatology healthcare providers, and 84% said they would elect to become certified if there were a program available in the U.S. The most important reasons cited to become certified were to:

• Enhance the effectiveness of treatment or diagnosis;
• Learn new skills or knowledge;
• Increase competence in one’s current job;
• Maintain or improve current skills or knowledge;
• Keep up to date professionally;
• Provide proof of competency to show payers/insurers; and
• Expand services provided by the practice/institution.

With the survey results in hand, the task force worked with Castle Worldwide, Inc.—one of the nation’s leading certification and licensure testing companies—to provide a clear definition of the primary domains of competence, specific task statements, and related knowledge and skills required for competent performance as a certified MSUS professional. These definitions supported the development of a specialty certification program and provided a blueprint for what it should assess.

A scan of the current healthcare environment involving MSUS was also performed, and it became apparent that standards for MSUS would be set. The task force also determined that the ACR should develop and set those professional standards for rheumatology. Standards not set by the ACR would be generalized for all uses of MSUS (sports medicine, podiatry, etc.), not just rheumatology. If the ACR wanted to support its members using MSUS as it applied to rheumatology, then the ACR would need to help its members define and demonstrate competence.

After careful consideration of the definitions of competence, the membership survey, and the environmental scan, the ACR’s board of directors decided to move forward with certification and the following goals were established:

• Promote quality of care and patient safety through certification and demonstration of competency of physicians, physician assistants, and nurse practitioners who perform ultrasound as part of their practice in rheumatology;
• Increase the knowledge and improve the competence of physicians, physician assistants, and nurse practitioners that perform ultrasound as part of their practice in rheumatology; and
• Provide a voluntary pathway for physicians, physician assistants, and nurse practitioners who perform ultrasound as part of their practice in rheumatology to demonstrate competence to patients, peers, and payers/insurers.

RhMSUS’s Launch and First Year

In 2012, development of the certification program started and an oversight committee chaired by John FitzGerald, MD, MD, MBA, MPH, PhD, interim chief of rheumatology and associate clinical professor of medicine of the University of California at Los Angeles, was established. With the continued expert consultation of Castle Worldwide, the committee developed policies and procedures following the guidelines of the National Commission for Certifying Agencies and set up the program’s eligibility criteria. Ralf Thiele, MD, associate clinical professor of medicine at the University of Rochester, chaired the examination development groups that developed the secure examination, as well the ACR’s MSUS Task Force.

The design of the certification program requires applicants to first demonstrate that they have participated in educational training that is both didactic and practical, and that explores MSUS usage for diagnosis, treatment, and guidance in the practice of rheumatology. At least 150 MSUS scans must have been completed prior to applying. It also declared this to be a certificate program by and for rheumatologists, and that all applicants must be trained in and practice rheumatology.

Eligible candidates must sit for a 100-question secure examination. Applications for certificates are accepted on a rolling basis. There are two annual month-long examination windows, one in the spring and the other in the fall. The fall testing window overlaps with the ACR/ARHP Annual Meeting dates so that candidates can schedule testing before, during, or after the annual meeting, and testing centers are located near each annual meeting site.

With content that is based on established definitions of competence, the examination is designed to be rigorous but fair. Ensuring the competence of MSUS users is one way that the ACR can help meet its goal of improving quality of care.

The RhMSUS program launched at the 2012 ACR/ARHP Annual Meeting when its candidate handbook was issued, and the application process began in February 2013. At the end of its first year the, program had 103 candidates, and 88 of them have successfully become RhMSUS certificate designees.

Those who achieve the certificate have demonstrated competency in MSUS through their education and training, and by passing an examination that tests the skills and knowledge needed to perform MSUS. The ACR is working through both its certification department and practice management and coding departments to ask for appropriate recognition of this program and its designees from payers and healthcare systems.

Beyond RhMSUS, the ACR’s Support for MSUS

Certification is not the only way the ACR supports its members and the rheumatology community in MSUS:

• Education and training: The ACR holds several small workshops at the ACR/ARHP Annual Meeting each year; two two-day fundamentals courses, and one three-day intermediate course with an interventional cadaver workshop. In addition, the ACR held two eight-month-long “Train-the-Trainer” programs to try to ensure that each rheumatology training program accredited through the Accreditation Council for Graduate Medical Education has one faculty member who is appropriately trained in MSUS to provide adequate instruction to fellows-in-training. Plans for online activities are currently being developed. Topics covered during these programs include: image acquisition and ultrasound technique; technique of ultrasound guidance; and billing, coding, and report generation.
• Reimbursement: The ACR’s staff and committees actively work on reimbursement and coding issues, including denials for MSUS and inappropriate payer policies. They are also involved with processes for the American Medical Association Current Procedural Terminology and Relative Value Scale Update Committee (RUC).
  At the time I was writing this column, cuts to ultrasound guidance reimbursement contained in the “final rule” revisions to the Medicare Physician Fee Schedule for 2014 were being addressed by the ACR. The ACR is working with other specialty societies as we advocate that the Centers for Medicare and Medicaid Services (CMS) wait until after the RUC can properly survey these codes before any change is finalized.
  The ultrasound guidance cuts were a unilateral decision by CMS based on estimates of ultrasound equipment costs and changes in practice expense related to equipment, facilities, and other elements. The change affects the practice expense as well as the clinical labor time for billing injection codes that were originally used to establish the direct practice expense inputs for the service. The ACR will continue to meet with CMS leaders and will discuss with lawmakers this and other issues impacting rheumatologists.
• Utilization: The “American College of Rheumatology Report on Reasonable Use of Musculoskeletal Ultrasonography in Rheumatology Clinical Practice” evaluated the reasonable use of MSUS as an additional procedure in the setting of a rheumatologic evaluation and supported use of MSUS in 14 clinical scenarios.

The RhMSUS program, along with the series of educational programs and advocacy efforts, helps ACR members improve quality of care and access to care.

I encourage all of you who are interested in MSUS to attend one of our programs to expand your ability to use this important modality in rheumatology, or just to gain an appreciation of the capabilities of MSUS and to see the novel imaging of the literal “spaces” in which we work. I did the latter and am very impressed with the new view of rheumatology I saw. MSUS is an important tool in our work to Advance Rheumatology!

Dr. Flood is a rheumatologist at the Columbus Arthritis Center and adjunct associate professor at The Ohio State University College of Medicine and Public Health, both in Columbus. Contact him at [email protected].