AAMC Reporter: March 2008

National Physician Portfolio System in Early Development Stages

The AAMC and several other groups are working to develop a national, standardized physician portfolio system they hope will help doctors better track their training needs and accomplishments.

The system—known as an eFolio—could help stimulate lifelong physician learning and eventually improve patient safety and the quality of care.

"An eFolio that is flexible and interoperable would allow the individual physician to document his or her performance from entry into medical school to the end of medical practice," said AAMC Executive Vice President and Chief Academic Officer, Carol A. Aschenbrener, M.D. In October, the Accreditation Council for Graduate Medical Education (ACGME), the National Board of Medical Examiners (NBME), and the Federation of State Medical Boards (FSMB) met with AAMC representatives to discuss existing and future portfolio systems. Several medical schools and residency programs are using different portfolio systems, but there is no standardization between them. The groups agreed to continue studying and discussing the programs in 2008. There is currently no timetable for when a national eFolio system might be created or implemented.

"We wanted a venue where people could share their individual ideas and experiences, and where we could all work together to create something that is greater than the sum of its parts," said M. Brownell Anderson, senior associate vice president in the AAMC's Division of Medical Education.

The conversation continued at the December summit of the Physician Accountability for Physician Competence, where stakeholders discussed ways to determine, measure, and assure the public of physician competence. Essentially, the eFolio system would function as a hub, connecting users in real time to data repositories containing physician test scores, résumés, self-reflections, goals, patient outcomes, and other professional development measures. Keeping a running record of these metrics could foster more self-assessment, mentoring, and performance improvement among physicians, and make relevant data available to regulatory bodies that certify and license physicians, and track their continuing medical education (CME) activities, Anderson said.

The eFolio system would likely have public and private areas. The private area accessible only to physicians would be a compartment for "housing confidential items," such as personal opinions. The public area would allow certain agencies and organizations to see board scores, CME materials, and other requirements so that these organizations can issue or renew certification in a more streamlined manner than currently exists.

"As it stands now, it can take hospitals six months to a year to collect information necessary for physician licensure in a new state," said Anderson. "If all of these are in one source, that can happen in a day."

Mentors may also see the public area to offer feedback on self-assessments. However, the physician must grant permission before anyone else looks at their eFolio. While conversations and pilot programs have garnered excitement, there are several implementation issues for creating an eFolio. For one, development costs will be in the millions, Galbraith said, although he suspected operational expenses would be much less prohibitive. Creating a system that is sufficiently user-friendly so physicians will find time to use it is another challenge. Arguably the biggest concern is security.

"Physicians are going to be asking, 'Here is a lot of information collected about me. How do I know it is not going to end up on the street and into the wrong person's hands?'" Galbraith said.

As such, the eFolio system will require state-of-the-art security protocols and assurance that any shared information is sent to identified and approved recipients only. Even with effective security measures in place, developers must factor in time to allow skeptics to gain trust of the new system.

Medical educators already working with portfolios say they are a useful tool. Erik Driessen, Ph.D., an educational psychologist who has worked with portfolios in both the undergraduate and graduate medical education setting at the University of Maastricht Faculty of Medicine in the Netherlands, said they supplement other teaching devices.

"Portfolios help teach and assess softer skills like collaboration, professionalism, and reflection," he said. "These are important skills, but not always in the forefront of medical education."

At the University of Maryland Medical Center, Carol Carraccio, M.D., M.A., associate chair of education, started the portfolio system in the pediatrics residency program in 2002 to assess the ACGME competencies of patient care, medical knowledge, practice-based learning, interpersonal and communications skills, professionalism, and systems-based practice.

"It empowers residents to drive their own learning and assessment, and gives their mentors an opportunity to provide formative and summative feedback," Carraccio said.

The ACGME has begun taking steps to develop its own physician portfolio system as a means of tracking resident training. Preliminary testing began last August, and a more comprehensive pilot program is scheduled to begin no sooner than July 2009. The council hopes to unveil a broad, voluntary system a few years later. As for the eFolio, proponents cite the elements of self-appraisal, improved patient care, and convenience as major advantages for users throughout their careers.

"Reflection is a process of looking at data and seeing where you can do better," said Robert M. Galbraith, M.D., M.B.A., executive director of the NBME's Center for Innovation. "This can pull up a list of patients a physician saw in the last month by diagnosis, and he or she can ask, 'Did I follow the standards of care?' Did the patients get better in the prescribed amount of time?' Right now, physicians don't get this information in such an aggregate way."

—By Elissa Fuchs

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