The Current Status of Online CME

• Presented at ASCO Critical Issues Seminar

• Santa Fe, New Mexico

• March 17, 2000

• Bernard Sklar MD

• University of California, San Francisco

• bersklar@netcantina.com

A Talk and a Resource

• This talk is posted on the web at www.netcantina.com/slideshows– There are several versions to choose from, depending

on your browser, speed of connection and your preference for html or PowerPoint

• Please visit the presentation as often as you like, follow the links and study the sites. Feel free to adapt the presentation for your own use. – If you use it, please say ”Adapted from a talk presented

at ASCO Critical Issues Seminar, March 17, 2000, with permission of Bernard M. Sklar, M.D.”

Online CME:Outline of this Talk

• Focus: what is actually “out there”

• (Briefly) History of the CME Movement

• (Briefly) CME today without the Internet

• Findings from my research and surveys

• Speculations on the future of online CME

History of CME in America

• Medical life before mandatory CME• 31 states require 12-50 hours of CME per

year• 11/28 specialty societies require CME for

recertification • Most hospitals require CME to maintain

hospital privileges• Many HMOs and Insurers require CME

CME Accreditation

• All CME is accredited by the ACCME (Accreditation Council for Continuing Medical Education)

• COPE is the optometric equivalent of ACCME

Non-Online CME

• Live (80.4%):– Meetings at the hospital and specialty

conventions – Teleconferences: radio, television or telephone

• Home Study (18.6%):– Reading articles in medical journals– Home Courses which can consist of: Text,

Audiotape, Videotape, CD-ROMs

CME: Meetings

• Most CME presented at meetings is not effective in changing MD behavior.

• Peer-reviewed Journals: Often sponsored by specialty society

CME: Journals

• A common form of home-based CME is reading journal articles and answering quizzes based on these articles.

• Journal reading and quizzes accounted for 30% of all home-based CME in 1998

CME: Home Study

• Home Study courses can be:

• Text and graphics (AAFP) Home Study)

• Audiotape (Audio-Digest Foundation)

• Videotape (AAFP Video Series)

• CD-ROM– ProEd International– ArcMesa Course in Oral Pathology

AAFP-Home Study-Text Only

Audio Digest Audio Tapes

AAFP Video Series

ProEd International CD-ROM

LandesSlezak Multiple Formats

CME Teleconferences

• Physicians can join teleconferences from home, office or hospital

• University or drug-company sponsored

• Interactive with immediate feedback

• Transmitted via telephone, radio or television

• OMEN (Ohio Medical Education Network)

Costs of Non-Online CME

• Can be inexpensive– hospital meetings usually free, journals free to $15 per

hour. Home Study $15 to 20 per hour.

• Can be very expensive– specialty meetings at resorts, $500-1000 for credit, plus

room, travel, meals and time away from practice

• CME is big business– 500,000 physicians x 25-50 hours per year x $10-20 per

hour = $125 to 500 million per year. And it is required.

Online CME: A Solution?

• IF properly produced and implemented, online CME can solve a number of problems:

• Timeliness and ease of production

• Cost and inconvenience to physicians

• Proof of attendance

• Assessment of learning

Online CME My List

Online CME: Types of Instruction

• Text only or Text plus graphics

• Slide-audio or Slide-Video lectures

• Question/Answer

• Guideline-Based

• Non-Interactive

• Interactive

Online CME: Text-Only

• The easiest kind of CME site to put up. Take your print article, convert it to HTML, add a few multiple choice questions, and post.

• Articles can be long-20 to 50 pages.

• Articles are usually in HTML or pdf format.

Medbytes Allergic Rhinitis Text Only

Medicine and Behavior Text Only

Cine-Med Asthma Presentation Text-Graphics

Online CME: Slide-Audio Presentations

• Greater investment in time and technology

• Record speaker during lectures

• American Psychiatric Association: Choosing an Antidepressant

American Psychiatric Assn-Slide Audio

Online CME: Slide-Video Presentations

• This technology works well with fast connections

• Otherwise video picture can be “jittery”

• The picture is also quite small

• MedLecture.com demo

• CME-WebCredits Diabetes

MedLecture.com slide Video

CME WebCredits.com

Online CME: Guidelines

• Several sites present treatment guidelines or “consensus” statements.

• These two are text-only

• NIH Consensus Statements (Brain Injury)

• The “other” ASCO (antiemetics in cancer)

NIH Consensus Statements (Brain Injury)

American Society of Clinical Oncology

Online CME: Interactivity

• Best use (so far) of internet technology

• Program waits for user input before continuing

• Can be text only or can use audio or video

• Examples:– Question/Answer– Case Based

Influenza Vaccine Question/Answer

Influenza Vaccine-Incorrect Answer

Influenza Vaccine-Correct Answer

Teenager with Wheezing, History

• A 12-year-old male soccer player presents to your office because of a persistent cough occurring with exertion. Symptoms are worsened during cool weather. He denies shortness of breath or symptoms at rest. Family history reveals mild maternal asthma.

Teenager with Wheezing, Vital Signs

• Temperature: 98.2Blood Pressure: 115/70Pulse: 76Respirations: 12Lungs: Clear to auscultation bilaterallyHeart: Regular rate and rhythm, no murmurExtremities: No cyanosis

Teenager with wheezing, Question

• What is the most likely diagnosis?

• A) Upper respiratory infection• B) Exercise-induced asthma• C) Chronic bronchitis• D) Pneumonia

Teenager with wheezing, Correct Answer

• If you give correct answer, program says” Correct” and gives no other feedback.

Teenager with wheezing, Incorrect Answer

• Answer B. The overall incidence of exercise-induced asthma is approximately 12% to 15%. Typical presentation may include a. coughing, wheezing, dyspnea, or chest discomfort with exercise; b. symptoms that vary by season or outdoor temperature; c. decreased or altered exercise regimen; d. complaints of limited endurance; and e. decreased problems in warm, moist environments. Patients at risk for exercise-induced asthma include those with: a. known asthma, b. allergic rhinitis, c. family history of asthma, and d. history of viral bronchitis.

Interactive Online CME

• Here’s a few more simple examples of interactive online CME for you to look at later if you wish

• VLH Menstrual Disorders

• Family Residents Interactive Abdominal Pain

• Case Study in Congestive Heart Failure

MS Thesis

• I searched the web for online CME repeatedly over 3 years

• As of early February 2000:– 96 sites– Over 3000 hours of CME credit– The number of sites found grew from 18 in

December 1997 to 96 in February 2000

MS Thesis: Size of Sites

• 3/96 sites have greater than 200 hours

• 6/96 sites have 50 to 100 hours

• 56/96 sites have 5-49 hours

• 31/96 sites have 5 or fewer hours

MS Thesis: Types of Instruction• 27/96 (28%) Text-Only

• 38/96 (38%) Text-and-Graphics

• 22/96 (23%) Slide-Audio Lecture

• 7/96 (7%) Slide-Video Lecture

• 7/96 (7%) Guideline-Based

• 4/96 (4%) Question/Answer

• 16/96 (17%) Interactive

MS Thesis: Fee Structure

• 38/96 sites offered free instruction

• 28/96 charged $10 or less per credit-hour

• 20/96 charged $11-20

• 10/96 charged $21 or more

MS Thesis: Physician Usage I

• If you build it, will they come?• Requested usage information from all sites (43)

offering 10 or more hours of credit• 23/43 responded with some useful information• A few commercial sites seem to doing well:

– HealthStream– MedScape– Virtual Lecture Hall– ArcMesa

MS Thesis: Physician Usage II

• A few of the government sites seem to be doing well– MMWR– NIH Consensus Statements

• One University Site doing OK– Cleveland Clinic, now allied with HealthStream

MS Thesis: Physician Usage III

• ACCME Report shows growth from 1997 to 1998

• 1997 - 13,115 physician-registrants • 1998 - 37,879 physician-registrants • 1999 not yet available

MS Thesis

• Many more details available by looking at the text of the thesis.

• I’ll be happy to share those details

• Contact me at bersklar@netcantina.com

Quality Issues

• I will discuss three systems for ensuring or measuring quality:HON (Health on the Net)

Medical Matrix

Silberg and Lundberg

Health on the Net (HON) Code of Conduct

• Authority• Complementarity• Confidentiality• Attribution• Justifiability• Transparency of authorship• Transparency of sponsorship • Honesty in advertising and editorial policy

Medical Matrix Star System

• Has a 5 star system to rate overall quality• Considers 6 qualities in its resource rating

– Peer Review– Application– Media– Feel– Ease of Access– Dimension

Silber and Lundberg

• Does the Site:– require registration by the user?– identify the author?– provide clear published references for the

content?– disclose sponsorship?– Are the pages date-stamped?– Is there peer review?– Is there testing of the user?– Does the instruction give feedback to the user?

A Few Optometry Sites I

• Pacific University CE Internet series • Five courses presently available:

Retinal Manifestations of Systemic Disease; Overlooking The Effect Of The Eyelids In Your Dry Eye Patients???; You've Got Some Nerve! A Clinical Guide to the Funny Looking Disc; Assessment and Low Vision Management of the Visually Impaired Child; and Issues In Rehabilitative Optometry: Prescribing For Diplopia. Instruction is by text and graphics (mostly photographs).

Retinal Manifestations of Systemic Disease

A Few Optometry Sites II

• Indiana University School of Optometry

• Three courses are offered: Routine Optometric Examination of the Infant (2 hours); Getting the Angle on Heterophoria (2 hours); and BLUNT SIGHT: Optometric Care of the Amblyopic Patient(Part I) (1 hour). Instruction is by text with a few graphics.

Getting the Angle on Heterophoria

A Few Optometry Sites III

• University of Missouri, St Louis• Laser Basics ( 2 hours) covers the basic physics of

lasers and the characteristics of laser light that make it so important in optometric applications. There are two classic presentations: Practical Applied Optometry by A.M. Skeffington (1949) (2 hours) and The Early Adaptive Syndrome by Appell & Streff (1963). (1 hour). Instruction is by text and a few graphics.

Laser Basics

CME: Effectiveness I

• Review of effectiveness of CME (Davis, JAMA, Sept1, 1999). Conclusions:

• Didactic sessions do not:– Immediately change physician’s behavior

• Didactic sessions may:– Change Knowledge, skills or attitudes– Predispose to change– Improve patient care

CME: Effectiveness II

• Davis says that instruction can be effective when it is:– Interactive, enhances participant activity– Provides opportunity to practice skills– Case Discussion, role-play, hands-on– Sequential; “learn-practice-learn”

Online CME: Predictions

• CME is here to stay

• Distance CME will increase

• Online multimedia interactive CME will become the standard

• Effectiveness will be proven

• Online CME will become integrated with other live and distance methods

A Talk and a Resource

• This talk is posted on the web at www.netcantina.com/slideshows– There are several versions to choose from, depending

on your browser, speed of connection and your preference for html or PowerPoint

• Please visit the presentation as often as you like, follow the links and study the sites. Feel free to adapt the presentation for your own use. – If you use it, please say ”Adapted from a talk presented

at ASCO Critical Issues Seminar, March 17, 2000, with permission of Bernard M. Sklar, M.D.”

Thanks for Listening

Questions?

Comments?

Broken Links?

Please contact me.

Thanks.