Online CME – An Update

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  • Caveat about the “number” of sites: I define “sites” in two different ways. For most of my calculations, I have divided some of the larger sites into subsites, based on the fact that the subsites offer different instruction types, or are geared towards different audiences, or focused on different diseases. I will use 229 as the denominator for most of my calculations.
    However, for the purpose of identifying the largest sites, I have eliminated those divisions and use a denominator of 200 sites.
    Beginning with this update, and in keeping with ACCME usage, I have replaced the words “course” and “courses” with “activity” and “activities.”
  • With the June 2002 revision, I have changed the words “course” and ‘courses” to activity and “activities.” I have continued that usage through December 2002.
  • The big jump in numbers of activities and hours is mostly accounted for by the entry of emedicine.com, with about 6500 activities and about 10000 hours.
  • Note that the activities and hours have gone up only slightly since December 2001. Small increases in numbers of sites and activities have been largely offset by the disappearance of the CME component of WebMD.
  • I visited every site in November or December 2002, and wherever possible, manually counted the number of activities and hours at that site on the day of my visit. Achieving an accurate count of the numbers of activities and hours at some of the megasites is very difficult because of problems viewing a list of activities. In those cases, I have taken either the published number, or, lacking that, my best estimate of the number. The number of sites, activities and hours have gone up about 5% since June 2002 and about 9% since December 2001.
    *Caveat about the “number” of sites: I define “sites” in two different ways. For most of my calculations, I have divided some of the larger sites into subsites, based on the fact that the subsites offer different instruction types, or are geared towards different audiences, or focused on different diseases. I will use 229 as the denominator for most of my calculations.
    However, for the purpose of identifying the largest sites, I have eliminated those divisions and use a denominator of 200 sites.
    Beginning with this update, and in keeping with ACCME usage, I have replaced the words “course” and “courses” with “activity” and “activities.”
  • The six largest sites (those with 100 hours or more) accounted for 4000 hours (62% of sites). (Taking into account my counting error, the 6 largest sites should have accounted for about 3000/5500 = about 55% of total hours. The 41 smallest sites (5 or fewer hours) accounted for only 100 hours (2%).
  • The 14 largest sites (those with 100 hours or more) account for 14500 hours (7% of sites, but 83% of hours). The 51 smallest sites (those with less than 5 hours) account for 103 hours (26% of sites, but 1% of hours).
  • The 12 largest sites (those with 100 hours or more) account for 14615 hours (5% of sites, but 80% of hours). The 54 smallest sites (those with less than 5 hours) account for 129 hours (26 % of sites, but <1% of hours).
  • The 14 largest sites (those with 100 hours or more) account for 14888 hours (8% of sites, but 81% of hours). The 46 smallest sites (those with less than 5 hours) account for 125 hours (23 % of sites, but <1% of hours).
    Beginning with this revision, and for the purpose of ranking sites by size, I counted a “site” as the sum of all activities at a given site (therefore a denominator of 200 sites.)
  • Here are the six largest sites (according to the number of hours) in December 2000.
    *The true number for HealthStream should have been about 500.
    **The true number for Medscape should have been about 300 hours.
    ***Milliman/Robertson has since disappeared.
  • Here are the seven largest sites (according to the number of hours) in December 2001.
  • Here are the eleven largest sites (according to the number of hours offered). Numbers of hours for some of these sites is estimated or taken from the published number. I tried to take a “snapshot” of the numbers on the day of my visit (between April 30, 2002 and June 3, 2002)
    * = estimate or published number; the others were actually counted.
  • Here are the sixteen largest sites (according to the number of hours offered). Numbers of hours for some of these sites is estimated or taken from the published number. I tried to take a “snapshot” of the numbers on the day of my visit (between November 15 and December 20, 2002)
    = estimate or published number; the others were actually counted.
  • Almost 50% of sites offer free instruction. The bulk of the fee-instruction falls into the $5-15 per hour range.
  • Almost 50% of sites offer free instruction. The bulk of the fee-instruction falls into the $5-15 per hour range.
  • 50% of sites offer free instruction. The bulk of the fee-instruction falls into the $5-15 per hour range. Remarkably little change over 18 months; the percentage of sites offering free instruction has stayed right at 50%
  • 53% of sites offer free instruction. The bulk of the fee-instruction falls into the $5-15 per hour range. Remarkably little change over 24 months; the percentage of sites offering free instruction has stayed at about 50%
    Using denominator of 229 sites.
  • 24% of the instruction hours are free. 68% of the instruction falls into the $5-15 per hour range.
  • 11% of the instruction hours are free. 85% of the instruction falls into the $5-15 per hour range.
  • 10% of the instruction hours are free. 84% of the hours fall into the $5-15 per hour range. The number of free hours has stayed about the same, but the percentage has dropped (largely because of the appearance of emedicine and the disappearance of WebMD). 75% of the instruction is in the $5 to $15 per hour range.
  • 12% of the instruction hours are free. 83% of the hours fall into the $5-15 per hour range. The number of free hours has gone up by about 500 hours). $5 to $15 per hour remains the dominant charge for fee-based instruction.
    Using denominator of 19105 hours.
  • Commercial companies (almost entirely pharmaceutical) support 32% of sites. Universities and Medical Schools support 40% of sites. Many sites have multiple sources of support.
  • Commercial companies (almost entirely pharmaceutical) support 50% of sites. Universities and Medical Schools support 42% of sites. 24% of sites are supported by medical specialty associations. Many sites have multiple sources of support.
  • Commercial companies (almost entirely pharmaceutical) support 54% of sites. Universities and Medical Schools support 41% of sites. 28% of sites are supported by medical specialty associations. Most sites have multiple sources of support. A gradual upward trend in the percentage of sites with commercial support.
  • Commercial companies (pharmaceutical or surgical instrument) support 52% of sites. Universities and Medical Schools support 38% of sites. 31% of sites are supported by medical specialty associations. Most sites have multiple sources of support. The upward trend in the percentage of sites with commercial support seems to be leveling off.
  • Primary Care (especially Family Practice and Internal Medicine) are the predominant target audiences.
  • Primary Care (especially Family Practice and Internal Medicine) are the predominant target audiences.
  • Primary Care (especially Family Practice and Internal Medicine) remain the predominant target audiences. About 60% of sites have instruction for primary care doctors, with family practice and internal medicine the dominant groups.
  • Primary Care (especially Family Practice and Internal Medicine) remain the predominant target audiences. About 54% of sites have instruction for primary care doctors, with family practice and internal medicine the dominant groups.
  • Neurology, Psychiatry and Cardiology are relatively high target audiences.
  • Neurology, Psychiatry and Cardiology are relatively high target audiences.
  • Cardiology, Psychiatry and Oncology are relatively high target audiences. Oncology sites have increased from 13 to 17.
  • Cardiology, Psychiatry and Oncology are relatively high target audiences. There has been little change in the number of specialty sites since June 2002.
  • There has been an increase (from 26 to 33) in the number of sites offering instruction of general interest.
  • There has been an increase (from 26 to 33) in the number of sites offering instruction of general interest.
  • I would guess that this practice improves usership, but I have no proof.
  • I would guess that this practice improves usership, but I have no proof.,
  • You can find my definitions of these terms at http://www.cmelist.com/Instruction_Types_defined.htm
  • Bear in mind that some sites offer more than one type of instruction, so that the percentages add up to greater than 100%.
  • Many sites offer more than one type of instruction, so that the percentages add up to greater than 100%.
  • Many sites offer more than one type of instruction, so that the percentages add up to greater than 100%. The numbers of sites offering each of the various instruction types has gone up; the percentages have stayed about the same.
  • Many sites offer more than one type of instruction, so that the percentages add up to greater than 100%. The numbers of sites offering each of the various instruction types has gone up; the percentages have stayed about the same. Except that there may be a trend towards more case-based-interactive instruction (27 sites; 18 % in December 2000 vs. 41 sites; 18 % in December 2002)
  • As best I can tell, a “physician-registrant” is one physician registering for one activity.
  • As best I can tell, a “physician-registrant” is one physician registering for one activity. Since an activity can be greater than one hour, it does not tell how many hours were earned, but I think the trend is meaningful.
  • * Although studies are showing a rapidly increasing usage of the Internet, for medical and non-medical purposes, by physicians.
  • The Discrepancy Between Numbers of Visitors and Numbers of Credits Awarded
    The growth in the number of credits awarded has not been nearly as great as the growth in the number of courses and credits available. Many sites experience a large number of "hits" or page views in contrast to a very small number of CME credits awarded.
    There is a series of "gates" affecting the journey from visiting a site to receiving CME credit. A large number of physicians visit sites, take a look around, and if they find nothing of interest or have difficulty navigating the site, they leave. If they stay, the next step at most sites is to register. Registration frightens away some portion of physicians who do not wish to give any information about themselves, especially medical license numbers, social security numbers or credit card information.
    If the physician decides to register, or if the site allows further viewing without registering, there are some additional gates to pass. These gates depend on whether the courses are free, "pay-as-you-go," or by annual subscription fee.
    If the instruction is free, a smaller number of physicians look at individual courses and then leave. A smaller number start to view one or more courses, decide that it does not meet their needs and leave without completing the course. An even smaller number complete the course and leave without completing the post-instruction quiz or questionnaire. And the smallest number complete all of the preceding steps and apply for the CME certificate.
    If the instruction is "pay-as-you-go," the path through the gates is the same as above, except that at the last gate, a physician must submit his or her credit card information online. The fear of revealing this information further reduces the number of physicians receiving credit.
    If the site charges fixed fee for all the credits a physician can earn in a given period (usually one year), the physician has another choice. Should he or she pay in advance for instruction he may not use? Or pay in advance for instruction he may not even look at without paying? Most fixed fee sites allow viewing of a "demo" course to help with this decision, but surprisingly, some do not. 
    A further complication is that each site has its own registration and payment procedures that must be mastered in order to participate. An active user of online CME sites can end up with several dozen user names and passwords.
  • These are my opinions. I do not have research data on user motivations.
  • This has not yet come to pass. SKOLAR awards CME credit for studying resources that the doctor chooses out of her current cases or areas of interest. LDH Hospital (Salt Lake) or Regenstrieff (Indiana) have systems where warnings and alerts come up in the course of ordering medications or procedures. Several electronic medical record companies, now no longer operational, were trying to integrate information on a particular "real" case with little pieces of CME.
  • A growing number of researchers are trying to establish these kinds of proof.
  • *
  • Online CME – An Update

    1. 1. Online CME – An UpdateOnline CME – An Update Review of December 2002Review of December 2002 Bernard M. Sklar, M.D., M.S.Bernard M. Sklar, M.D., M.S. www.cmelist.com/list.htmwww.cmelist.com/list.htm bersklar@netcantina.combersklar@netcantina.com
    2. 2. Plan of PresentationPlan of Presentation Results of Recent and Past SurveysResults of Recent and Past Surveys Types of InstructionTypes of Instruction Physician Use of CME and Online CMEPhysician Use of CME and Online CME Obstacles to Physician UseObstacles to Physician Use
    3. 3. Master’s ThesisMaster’s Thesis This review is based on a recent update of theThis review is based on a recent update of the database that I created for my master’s thesis,database that I created for my master’s thesis, The Current Status of Online Continuing MedicalThe Current Status of Online Continuing Medical Education (June 2000). Find the thesis online atEducation (June 2000). Find the thesis online at http://http://www.cmelist.com/mastersthesiswww.cmelist.com/mastersthesis The thesis was based on a review of the CMEThe thesis was based on a review of the CME literature and a survey of online CME done inliterature and a survey of online CME done in February 2000.February 2000.
    4. 4. How Was the Survey Done?How Was the Survey Done? Internet search of multiple search enginesInternet search of multiple search engines using search string “online + continuing +using search string “online + continuing + medical +education”medical +education” Following up leads from those searchesFollowing up leads from those searches Information from ACCMEInformation from ACCME Email from viewers and CME providersEmail from viewers and CME providers
    5. 5. Description of the ListDescription of the List Each entry shows the name and URL ofEach entry shows the name and URL of the site, when I last visited, how manythe site, when I last visited, how many credit hours are available, who awards thecredit hours are available, who awards the credit, the cost per unit, when thecredit, the cost per unit, when the educational material was last updated, aeducational material was last updated, a description of the site and its contents anddescription of the site and its contents and links to individual courses found at thelinks to individual courses found at the site.site.
    6. 6. Extensive UpdatesExtensive Updates I have been maintaining the list for aboutI have been maintaining the list for about six yearssix years The list was updated for my master’sThe list was updated for my master’s thesis in February 2000, again in Augustthesis in February 2000, again in August and December 2000, in December 2001,and December 2000, in December 2001, in June 2002 and December 2002.in June 2002 and December 2002.
    7. 7. Annotated List of Online CME SitesAnnotated List of Online CME Sites
    8. 8. Database Created from ListDatabase Created from List Based on examining each site, I createdBased on examining each site, I created an Access database of the 229* sitesan Access database of the 229* sites offering CME in December 2002. The DBoffering CME in December 2002. The DB contains the number of activities, numbercontains the number of activities, number of hours of instruction, types of instruction,of hours of instruction, types of instruction, specialty audiences, cost to users,specialty audiences, cost to users, sources of financial support and othersources of financial support and other parameters.parameters.
    9. 9. Results of Study IResults of Study I The number of sites and activitiesThe number of sites and activities continues to increasecontinues to increase April 1997 – 13 sitesApril 1997 – 13 sites December 1997 – 18 sitesDecember 1997 – 18 sites August 1998 – 61 sitesAugust 1998 – 61 sites May 1999 – 69 sitesMay 1999 – 69 sites December 1999 – 87 sitesDecember 1999 – 87 sites
    10. 10. Results of Study IIResults of Study II February 2000February 2000  96 sites,96 sites, 18741874 activitiesactivities, 3064 credit hours, 3064 credit hours August 2000August 2000  135 sites, 3659135 sites, 3659 activitiesactivities, 5659 credit, 5659 credit hourshours December 2000December 2000  150 sites, 3510150 sites, 3510 activitiesactivities, 6553 credit, 6553 credit hourshours  Because of overlap, duplication, andBecause of overlap, duplication, and miscounting , the “true number” of hoursmiscounting , the “true number” of hours should have been about 5500.should have been about 5500.
    11. 11. Results of Study IIIResults of Study III December 2001December 2001 197 sites197 sites 12026 activities12026 activities 17523 hours17523 hours
    12. 12. Results of Study IVResults of Study IV • June 2002 • 209 sites • 10952 activities • 18266 hours
    13. 13. Results of Study VResults of Study V • December 2002 • 229* sites (200 sites for certain counting purposes) • 11485 activities • 19105 hours
    14. 14. Size of Sites – December 2000Size of Sites – December 2000 No. of Credit-No. of Credit- HoursHours Number ofNumber of SitesSites NumberNumber of Hoursof Hours % of% of SitesSites % 0f% 0f HoursHours Greater than 100Greater than 100 66 40824082 44 6262 50-9950-99 1212 779779 88 1212 25-4925-49 2121 717717 1414 1111 10-2410-24 4141 681681 2727 1010 5-95-9 2929 193193 1919 33 < 5< 5 4141 100100 2727 22 TotalTotal 150150 65536553 100100 100100
    15. 15. Size of Sites – December 2001Size of Sites – December 2001 No. of Credit-No. of Credit- HoursHours Number ofNumber of SitesSites NumberNumber of Hoursof Hours % of% of SitesSites % 0f% 0f HoursHours Greater than 100Greater than 100 1414 1458714587 77 8383 50-9950-99 99 596596 55 33 25-4925-49 2929 10461046 1515 66 10-2410-24 5656 918918 2828 55 5-95-9 3838 271271 1919 22 < 5< 5 5151 103103 2626 11 TotalTotal 197197 1826618266 100100 100100
    16. 16. Size of Sites – June 2002Size of Sites – June 2002 No. of Credit-No. of Credit- HoursHours Number ofNumber of SitesSites NumberNumber of Hoursof Hours % of% of SitesSites % 0f% 0f HoursHours Greater than 100Greater than 100 1212 1461514615 55 8080 50-9950-99 1616 11191119 88 66 25-4925-49 3131 11371137 1515 66 10-2410-24 6262 10361036 3030 66 5-95-9 3333 227227 1616 11 < 5< 5 5454 129129 2626 <1<1 TotalTotal 209209 1826318263 100100 100100
    17. 17. Size of Sites – December 2002Size of Sites – December 2002 No. of Credit-No. of Credit- HoursHours Number ofNumber of SitesSites Number ofNumber of HoursHours % of% of SitesSites % 0f% 0f HoursHours Greater than 100Greater than 100 1616 1540415404 88 8181 50-9950-99 1818 12531253 99 77 25-4925-49 3535 12301230 1717 66 10-2410-24 4646 785785 2323 44 5-95-9 3939 304304 2020 22 < 5< 5 4646 125125 2323 <1<1 TotalTotal 200200 1910519105 100100 100100
    18. 18. The Largest Sites December 2000The Largest Sites December 2000 Name of SiteName of Site No. of ActivitiesNo. of Activities No. of HoursNo. of Hours HealthStream*HealthStream* 907907 13601360 ChallengerChallenger 77 901901 CMEWebCMEWeb 507507 759759 Medscape**Medscape** 539539 726726 ArcMesaArcMesa 6363 232232 Milliman/Robertson***Milliman/Robertson*** 66 104104
    19. 19. The Largest Sites December 2001The Largest Sites December 2001 Name of SiteName of Site No. of ActivitiesNo. of Activities No. of HoursNo. of Hours eMedicine CMEeMedicine CME 65006500 1000010000 CMEWebCMEWeb 976976 14001400 ChallengerChallenger 1010 897897 cmecourses (HS)cmecourses (HS) 300300 500500 WEBMD Just in TimeWEBMD Just in Time 14001400 350350 Medscape CMEMedscape CME 200200 300300 ArcMesaArcMesa 8080 293293
    20. 20. The Largest Sites June 2002The Largest Sites June 2002 Name of SiteName of Site No. of ActivitiesNo. of Activities No. of HoursNo. of Hours eMedicine CME*eMedicine CME* 65006500 1000010000 CMEWeb*CMEWeb* 976976 14001400 ChallengerChallenger 1414 964964 TheAnswer.com*TheAnswer.com* 55 300300 cmecourses (HS)*cmecourses (HS)* 300300 500500 JournalBytes (All Spec)JournalBytes (All Spec) 108108 372372 Medscape CME*Medscape CME* 200200 300300 ArcMesaArcMesa 8080 293293 Radcourses (HS)Radcourses (HS) 2828 128128 RSNA Educ. ExhibitsRSNA Educ. Exhibits 127127 127127 Natal UNatal U 8383 122122 Mypatient.comMypatient.com 109109 109109
    21. 21. The Largest Sites December 2002The Largest Sites December 2002 Name of SiteName of Site No. of ActivitiesNo. of Activities No. of HoursNo. of Hours eMedicine CME*eMedicine CME* 65006500 1000010000 CMEWeb*CMEWeb* 10261026 15431543 Challenger*Challenger* 2020 10001000 JournalBytes (All Spec)JournalBytes (All Spec) 108108 348348 TheAnswer.com*TheAnswer.com* 55 300300 Natal U^Natal U^ 200200 300300 Medscape CME*Medscape CME* 200200 300300 ArcMesaArcMesa 8080 293293 Cleveland Clinic All SitesCleveland Clinic All Sites 171171 284284 RSNA All SitesRSNA All Sites 275275 268268 Cyberounds*Cyberounds* 143143 143143 NEJM Weekly CME*NEJM Weekly CME* 140140 140140 American Acad FP All SitesAmerican Acad FP All Sites 4747 135135 Radcourses (HS)Radcourses (HS) 2828 128128 MCP Hahnemann All SitesMCP Hahnemann All Sites 7878 122122 Cmecourses (Healthstream)*Cmecourses (Healthstream)* 5050 100100
    22. 22. Fee Structure by Site Dec 2000Fee Structure by Site Dec 2000 Dominant or Average FeeDominant or Average Fee Number of SitesNumber of Sites % of Sites% of Sites FreeFree 7474 4949 <$5 per hour<$5 per hour 22 11 $5 per hour$5 per hour 66 44 $6-9 per hour$6-9 per hour 1616 1111 $10 per hour$10 per hour 1414 99 $11-14 per hour$11-14 per hour 66 44 $15 per hour$15 per hour 1010 77 $16-19 per hour$16-19 per hour 55 33 $20 per hour$20 per hour 66 44 $21-24 per hour$21-24 per hour 22 11 $25 per hour$25 per hour 55 33 >$25 per hour>$25 per hour 44 33
    23. 23. Fee Structure by Site Dec 2001Fee Structure by Site Dec 2001 Dominant or Average FeeDominant or Average Fee No. of SitesNo. of Sites % of Sites% of Sites FreeFree 9898 5050 <$5 per hour<$5 per hour 66 33 $5 per hour$5 per hour 66 44 $6-9 per hour$6-9 per hour 1313 77 $10 per hour$10 per hour 2222 1111 $11-14 per hour$11-14 per hour 99 55 $15 per hour$15 per hour 1919 1010 $16-19 per hour$16-19 per hour 33 22 $20 per hour$20 per hour 55 33 $21-24 per hour$21-24 per hour 22 11 $25 per hour$25 per hour 1010 55 >$25 per hour>$25 per hour 44 22
    24. 24. Fee Structure by Site June 2002Fee Structure by Site June 2002 Dominant or Average FeeDominant or Average Fee No. of SitesNo. of Sites % of Sites% of Sites FreeFree 105105 5050 <$5 per hour<$5 per hour 55 22 $5 per hour$5 per hour 66 33 $6-9 per hour$6-9 per hour 1313 55 $10 per hour$10 per hour 2424 1111 $11-14 per hour$11-14 per hour 88 44 $15 per hour$15 per hour 2525 1212 $16-19 per hour$16-19 per hour 44 11 $20 per hour$20 per hour 33 11 $21-24 per hour$21-24 per hour 11 <1<1 $25 per hour$25 per hour 1010 44 >$25 per hour>$25 per hour 55 22
    25. 25. Fee Structure by Site December 2002Fee Structure by Site December 2002 Dominant or Average FeeDominant or Average Fee Number of SitesNumber of Sites % of Sites% of Sites FreeFree 122122 5353 <$5 per hour<$5 per hour 66 33 $5 per hour$5 per hour 44 22 $6-9 per hour$6-9 per hour 1515 77 $10 per hour$10 per hour 2020 99 $11-14 per hour$11-14 per hour 99 44 $15 per hour$15 per hour 2727 1212 $16-19 per hour$16-19 per hour 55 22 $20 per hour$20 per hour 44 22 $21-24 per hour$21-24 per hour 11 <1<1 $25 per hour$25 per hour 88 44 >$25 per hour>$25 per hour 88 44
    26. 26. Hourly Fee Structure Dec 2000Hourly Fee Structure Dec 2000 Dominant or Average FeeDominant or Average Fee No of HoursNo of Hours % of Hours% of Hours FreeFree 15871587 2424 <$5 per hour<$5 per hour 103103 22 $5 per hour$5 per hour 223223 33 $6-9 per hour$6-9 per hour 11831183 1818 $10 per hour$10 per hour 10501050 1616 $11-14 per hour$11-14 per hour 524524 88 $15 per hour$15 per hour 15051505 2323 $16-19 per hour$16-19 per hour 170170 33 $20 per hour$20 per hour 5151 11 $21-24 per hour$21-24 per hour 1818 00 $25 per hour$25 per hour 6161 11 >$25 per hour>$25 per hour 7979 11
    27. 27. Hourly Fee Structure Dec 2001Hourly Fee Structure Dec 2001 Dominant or Average FeeDominant or Average Fee No of HoursNo of Hours % of Hours% of Hours FreeFree 19781978 1111 <$5 per hour<$5 per hour 365365 88 $5 per hour$5 per hour 1028510285 5959 $6-9 per hour$6-9 per hour 17121712 1010 $10 per hour$10 per hour 14471447 88 $11-14 per hour$11-14 per hour 470470 33 $15 per hour$15 per hour 845845 55 $16-19 per hour$16-19 per hour 5555 <1<1 $20 per hour$20 per hour 8787 <1<1 $21-24 per hour$21-24 per hour 99 <1<1 $25 per hour$25 per hour 114114 11 >$25 per hour>$25 per hour 155155 11
    28. 28. Hourly Fee Structure June 2002Hourly Fee Structure June 2002 Dominant or Average FeeDominant or Average Fee No of HoursNo of Hours % of Hours% of Hours FreeFree 17631763 1010 <$5 per hour<$5 per hour 566566 33 $5 per hour$5 per hour 1020310203 5656 $6-9 per hour$6-9 per hour 21532153 1212 $10 per hour$10 per hour 16431643 99 $11-14 per hour$11-14 per hour 434434 22 $15 per hour$15 per hour 10091009 55 $16-19 per hour$16-19 per hour 137137 11 $20 per hour$20 per hour 5757 <1<1 $21-24 per hour$21-24 per hour 77 <1<1 $25 per hour$25 per hour 115115 <1<1 >$25 per hour>$25 per hour 177177 11
    29. 29. Hourly Fee Structure December 2002Hourly Fee Structure December 2002 Dominant or Average FeeDominant or Average Fee No of HoursNo of Hours % of Hours% of Hours FreeFree 22362236 1212 <$5 per hour<$5 per hour 542542 33 $5 per hour$5 per hour 1021710217 5454 $6-9 per hour$6-9 per hour 23652365 1212 $10 per hour$10 per hour 855855 55 $11-14 per hour$11-14 per hour 450450 22 $15 per hour$15 per hour 18931893 1010 $16-19 per hour$16-19 per hour 189189 11 $20 per hour$20 per hour 7171 <1<1 $21-24 per hour$21-24 per hour 77 <1<1 $25 per hour$25 per hour 9090 <1<1 >$25 per hour>$25 per hour 190190 11
    30. 30. Financial Support Dec 2000Financial Support Dec 2000 Source of SupportSource of Support No. of SitesNo. of Sites % of Sites% of Sites Commercial CompaniesCommercial Companies 4343 3232 University/Medical SchoolUniversity/Medical School 5454 4040 GovernmentGovernment 77 55 Medical/Specialty AssociationMedical/Specialty Association 1313 1010 FoundationFoundation 77 55 Insurance or Managed CareInsurance or Managed Care 44 33 User Fees/Partial or CompleteUser Fees/Partial or Complete 7676 5151
    31. 31. Financial Support Dec 2001Financial Support Dec 2001 Source of SupportSource of Support No. of SitesNo. of Sites % of Sites% of Sites Commercial CompaniesCommercial Companies 9999 5050 University/Medical SchoolUniversity/Medical School 8383 4242 GovernmentGovernment 1111 66 Medical/Specialty AssociationMedical/Specialty Association 4747 2424 FoundationFoundation 1717 99 Insurance or Managed CareInsurance or Managed Care 55 33 User Fees/Partial or CompleteUser Fees/Partial or Complete 9999 5050
    32. 32. Financial Support June 2002Financial Support June 2002 Source of SupportSource of Support No. of SitesNo. of Sites % of Sites% of Sites Commercial CompaniesCommercial Companies 113113 5454 University/Medical SchoolUniversity/Medical School 8686 4141 GovernmentGovernment 1515 77 Medical/Specialty AssociationMedical/Specialty Association 5858 2828 FoundationFoundation 1515 77 User Fees/Partial or CompleteUser Fees/Partial or Complete 104104 5050
    33. 33. Financial Support December 2002Financial Support December 2002 Source of SupportSource of Support No. of SitesNo. of Sites % of Sites% of Sites Commercial CompaniesCommercial Companies 119119 5252 University/Medical SchoolUniversity/Medical School 8989 3838 GovernmentGovernment 1717 77 Medical/Specialty AssociationMedical/Specialty Association 7171 3131 FoundationFoundation 1414 66 User Fees/Partial or CompleteUser Fees/Partial or Complete 107107 4747
    34. 34. Specialty – Primary Care December 2000Specialty – Primary Care December 2000 No. of SitesNo. of Sites % of Sites% of Sites Primary Care SitesPrimary Care Sites 9393 6262 including:including: Family PracticeFamily Practice 8383 5555 Internal MedicineInternal Medicine 8080 5353 PediatricsPediatrics 2222 1515 Obstetrics/GynecologyObstetrics/Gynecology 2222 1515
    35. 35. Specialty – Primary Care Dec 2001Specialty – Primary Care Dec 2001 No. of SitesNo. of Sites % of Sites% of Sites Primary Care SitesPrimary Care Sites 114114 5858 including:including: Family PracticeFamily Practice 9595 4848 Internal MedicineInternal Medicine 8686 4444 PediatricsPediatrics 2929 1515 Obstetrics/GynecologyObstetrics/Gynecology 2525 1313 Multiple SpecialtiesMultiple Specialties 66 33
    36. 36. Specialty – Primary Care June 2002Specialty – Primary Care June 2002 No. of SitesNo. of Sites % of Sites% of Sites Primary Care SitesPrimary Care Sites 123123 5959 including:including: Family PracticeFamily Practice 9898 4747 Internal MedicineInternal Medicine 9191 4444 PediatricsPediatrics 3737 1818 Obstetrics/GynecologyObstetrics/Gynecology 2929 1414 Multiple Specialties (>6)Multiple Specialties (>6) 1010 55
    37. 37. Specialty – Primary Care DecemberSpecialty – Primary Care December 20022002 No. of SitesNo. of Sites % of Sites% of Sites Primary Care SitesPrimary Care Sites 123123 5454 including:including: Family PracticeFamily Practice 110110 4848 Internal MedicineInternal Medicine 9999 4343 PediatricsPediatrics 3636 1616 Obstetrics/GynecologyObstetrics/Gynecology 2323 1010 Multiple Specialties (>6)Multiple Specialties (>6) 1010 44
    38. 38. Subspecialties Dec 2000Subspecialties Dec 2000 Subspecialty sitesSubspecialty sites Number of SitesNumber of Sites % of Sites% of Sites including:including: 113113 7575 NeurologyNeurology 2121 1414 PsychiatryPsychiatry 2323 1515 CardiologyCardiology 2020 1313 OncologyOncology 1313 99 Infectious DiseaseInfectious Disease 1313 99 Radiology*Radiology* 1010 77 DermatologyDermatology 77 55 GastroenterologyGastroenterology 77 55 PulmonaryPulmonary 99 66 SurgerySurgery 77 55 General InterestGeneral Interest 2626 1717
    39. 39. Subspecialties Dec 2001Subspecialties Dec 2001 Subspecialty sitesSubspecialty sites Number of SitesNumber of Sites % of Sites% of Sites including:including: 140140 7171 NeurologyNeurology 1414 77 PsychiatryPsychiatry 2121 1111 CardiologyCardiology 1919 1010 OncologyOncology 1010 55 Infectious DiseaseInfectious Disease 1414 66 RadiologyRadiology 1212 66 GeriatricsGeriatrics 1212 66 PulmonaryPulmonary 99 55 SurgerySurgery 66 55 General InterestGeneral Interest 2626 1717
    40. 40. Subspecialties June 2002Subspecialties June 2002 Subspecialty sitesSubspecialty sites Number of SitesNumber of Sites % of Sites% of Sites 123123 5959 including:including: CardiologyCardiology 2323 1111 PsychiatryPsychiatry 2020 1010 OncologyOncology 1717 88 NeurologyNeurology 1515 77 RadiologyRadiology 1414 77 Infectious DiseaseInfectious Disease 1313 66 UrologyUrology 1111 55 EndocrineEndocrine 1010 55 PulmonaryPulmonary 1010 55 GeriatricsGeriatrics 99 44 SurgerySurgery 99 44
    41. 41. Subspecialties December 2002Subspecialties December 2002 Subspecialty sitesSubspecialty sites Number of SitesNumber of Sites % of Sites% of Sites including:including: CardiologyCardiology 2525 1111 PsychiatryPsychiatry 2020 99 OncologyOncology 1717 77 NeurologyNeurology 1818 88 RadiologyRadiology 1616 77 Infectious DiseaseInfectious Disease 1515 77 UrologyUrology 77 33 EndocrineEndocrine 1010 44 PulmonaryPulmonary 1515 77 GeriatricsGeriatrics 1010 44 SurgerySurgery 99 44
    42. 42. Sites by Specialty-2001- OtherSites by Specialty-2001- Other 26 sites (13%) offer subjects of interest to many26 sites (13%) offer subjects of interest to many different specialties; for example, ethics, legal,different specialties; for example, ethics, legal, practice management, genetics, and basic sciencepractice management, genetics, and basic science Many other specialties were included at 5 or fewerMany other specialties were included at 5 or fewer sitessites
    43. 43. Sites by Specialty-June 2002- OtherSites by Specialty-June 2002- Other 33 sites (16%) offer subjects of interest to many different33 sites (16%) offer subjects of interest to many different specialties: for example, ethics, legal, practice management,specialties: for example, ethics, legal, practice management, risk management, tobacco cessation, genetics, basic sciencerisk management, tobacco cessation, genetics, basic science Many other specialties are included at 5 or fewer sitesMany other specialties are included at 5 or fewer sites
    44. 44. Sites by Specialty-December 2002- OtherSites by Specialty-December 2002- Other 36 sites (16%) offer subjects of interest to many different36 sites (16%) offer subjects of interest to many different specialties: for example, ethics, legal, practice management,specialties: for example, ethics, legal, practice management, risk management, tobacco cessation, genetics, basic sciencerisk management, tobacco cessation, genetics, basic science Many other specialties are included at 5 or fewer sitesMany other specialties are included at 5 or fewer sites
    45. 45. Five “Different” Sites IFive “Different” Sites I CECE MedicusMedicus has no CME of its own, but offers accesshas no CME of its own, but offers access without fee to about 550 activities at five sites (apparentlywithout fee to about 550 activities at five sites (apparently by special arrangement)by special arrangement) DigiscriptDigiscript contains many hundreds of audio and video slidecontains many hundreds of audio and video slide lectures recorded at medical meetings. The yearly charge islectures recorded at medical meetings. The yearly charge is $400. Some$400. Some activities offer CME and others do not. The siteactivities offer CME and others do not. The site is searchable by medical topic and by sponsoringis searchable by medical topic and by sponsoring organization. You may have to pay an additional fee fororganization. You may have to pay an additional fee for CME credit by any given sponsor.CME credit by any given sponsor. Doctor’s GuideDoctor’s Guide also has no CME of its own, but offersalso has no CME of its own, but offers descriptions of over 900 activities (free and fee) with linksdescriptions of over 900 activities (free and fee) with links to those coursesto those courses
    46. 46. Five “Different” Sites IIFive “Different” Sites II •University of Wisconsin Professional Courses offer credit for courses on non-medical subjects which could be expected to improve your practice or your life. •Stanford SKOLAR offers credit for performing Internet literature searches on topics of your own interest
    47. 47. Sites I Could Not ViewSites I Could Not View There are a number of proprietary sites, e.g., staff model HMOs,There are a number of proprietary sites, e.g., staff model HMOs, like Kaiser-Permanente, where access to instruction is limitedlike Kaiser-Permanente, where access to instruction is limited to staff members of that organization. Those sites are notto staff members of that organization. Those sites are not reviewed in this report.reviewed in this report.
    48. 48. Email Reminders June 2002Email Reminders June 2002 About 25 sites send out regular email remindersAbout 25 sites send out regular email reminders about additions to their lists of activities onabout additions to their lists of activities on request by users:request by users: American College of Cardiology, Boston University, Cancer Education, CME Reviews, Cyberounds, Doctor's Guide Webcasts, Ecornell, EMedHome, EMedicine, cmecourses (HealthStream), Journal of Clinical Psychiatry, Medscape, Medinfosource, Medsite, MMWR, mypatient.com, Natal U, PDR.net, Pedsref.org, psychLINK, Psychiatrist.com (NetSociety), Serono, University of Wisconsin, Virtual Lecture Hall, and World Medical Leaders
    49. 49. Email Reminders December 2002Email Reminders December 2002 About 24 sites send out regular email remindersAbout 24 sites send out regular email reminders about additions to their lists of activities onabout additions to their lists of activities on request by users: Audio Digest, Bostonrequest by users: Audio Digest, Boston University, cmecorner, cmecourses,University, cmecorner, cmecourses, CMEcybersessions, Cyberounds, Doctor’s Guide,CMEcybersessions, Cyberounds, Doctor’s Guide, eMedHome.com, eMedicine, GAMA Longevity,eMedHome.com, eMedicine, GAMA Longevity, Medsite, Journal of Clinical Psychiatry,Medsite, Journal of Clinical Psychiatry, Medinfosource, Medscape, Meniscus, MMWR,Medinfosource, Medscape, Meniscus, MMWR, mypatient.com, Natal U, pedsref, psychLINK,mypatient.com, Natal U, pedsref, psychLINK, Serono, University of Wisconsin, Virtual LectureSerono, University of Wisconsin, Virtual Lecture Hall, World Medical LeadersHall, World Medical Leaders
    50. 50. Types of Instruction-DefinitionsTypes of Instruction-Definitions Text-OnlyText-Only Text-and-GraphicsText-and-Graphics Slides-Only (or Slides and Text)Slides-Only (or Slides and Text) Slide-AudioSlide-Audio Slide-VideoSlide-Video Question-and-AnswerQuestion-and-Answer Case-Based InteractiveCase-Based Interactive Guideline or Consensus (usually text only)Guideline or Consensus (usually text only) CorrespondenceCorrespondence GamesGames Journal with Multiple TopicsJournal with Multiple Topics
    51. 51. Types of Instruction – Dec 2000Types of Instruction – Dec 2000 Text only -- 37 sites; 25%Text only -- 37 sites; 25% Text-and-graphics – 45 sites; 30 %Text-and-graphics – 45 sites; 30 % Slide-audio – 45 sites; 30 %Slide-audio – 45 sites; 30 % Slide-video – 21 sites; 14 %Slide-video – 21 sites; 14 % Guidelines – 5 sites; 3 %Guidelines – 5 sites; 3 % Question-and-answer – 6 sites; 4 %Question-and-answer – 6 sites; 4 % Case-based Interactive – 27 sites; 18 %Case-based Interactive – 27 sites; 18 % Many sites have more than one type of instructionMany sites have more than one type of instruction
    52. 52. Types of Instruction – Dec 2001Types of Instruction – Dec 2001 Text only -- 47 sites; 24%Text only -- 47 sites; 24% Text-and-graphics – 59 sites; 30 %Text-and-graphics – 59 sites; 30 % Slide-audio – 57 sites; 29 %Slide-audio – 57 sites; 29 % Slide-video – 21 sites; 11%Slide-video – 21 sites; 11% Guidelines – 5 sites; 3 %Guidelines – 5 sites; 3 % Question-and-answer – 9 sites; 5 %Question-and-answer – 9 sites; 5 % Case-Based-Interactive – 26 sites; 13 %Case-Based-Interactive – 26 sites; 13 % Correspondence – 3 sites; 2 %Correspondence – 3 sites; 2 % Games – 2 sites; 1 %Games – 2 sites; 1 % Slides-Only – 4 sites; 2 %Slides-Only – 4 sites; 2 % Many sites have more than one type of instructionMany sites have more than one type of instruction
    53. 53. Types of Instruction – June 2002Types of Instruction – June 2002 Text only -- 57 sites; 27%Text only -- 57 sites; 27% Text-and-graphics – 71 sites; 34 %Text-and-graphics – 71 sites; 34 % Slide-audio – 60 sites; 29 %Slide-audio – 60 sites; 29 % Slide-video – 23 sites; 11%Slide-video – 23 sites; 11% Guidelines – 8 sites; 3 %Guidelines – 8 sites; 3 % Question-and-answer – 6 sites; 3 %Question-and-answer – 6 sites; 3 % Case-Based-Interactive – 31 sites; 15 %Case-Based-Interactive – 31 sites; 15 % Correspondence – 2 sites; 2 %Correspondence – 2 sites; 2 % Games – 2 sites; 1 %Games – 2 sites; 1 % Slides-Only – 4 sites; 2 %Slides-Only – 4 sites; 2 % Slides-and-Text – 4 sites; 2 %Slides-and-Text – 4 sites; 2 % Many sites have more than one type of instructionMany sites have more than one type of instruction
    54. 54. Types of Instruction – December 2002Types of Instruction – December 2002 Text only -- 62 sites; 27%Text only -- 62 sites; 27% Text-and-graphics – 70 sites; 31 %Text-and-graphics – 70 sites; 31 % Slide-audio – 66 sites; 29 %Slide-audio – 66 sites; 29 % Slide-video – 27 sites; 12%Slide-video – 27 sites; 12% Guidelines – 8 sites; 3 %Guidelines – 8 sites; 3 % Question-and-answer – 7 sites; 3 %Question-and-answer – 7 sites; 3 % Case-Based-Interactive – 41 sites; 18 %Case-Based-Interactive – 41 sites; 18 % Correspondence – 5 sites; 2 %Correspondence – 5 sites; 2 % Games – 2 sites; 1 %Games – 2 sites; 1 % Slides-Only – 5 sites; 2 %Slides-Only – 5 sites; 2 % Slides-and-Text – 6 sites; 3 %Slides-and-Text – 6 sites; 3 % Journal with Multiple Subjects – 19 sites; 8%Journal with Multiple Subjects – 19 sites; 8% Many sites have more than one type of instructionMany sites have more than one type of instruction
    55. 55. More about Question & Answer InstructionMore about Question & Answer Instruction Only 6 sites (3%) feature Q&A, BUT the number ofOnly 6 sites (3%) feature Q&A, BUT the number of hours is relatively largehours is relatively large Challenger - 1000 hoursChallenger - 1000 hours TheAnswerPage – 300 hoursTheAnswerPage – 300 hours Ecore – 36 hoursEcore – 36 hours Familypractice.com - 27 hoursFamilypractice.com - 27 hours Interactive Testing in Psychiatry – 7 hoursInteractive Testing in Psychiatry – 7 hours Family Practice Image Quiz – 3hoursFamily Practice Image Quiz – 3hours Total about 1373 hours (7 % of all CME hours)Total about 1373 hours (7 % of all CME hours)
    56. 56. CME Participation by Location Based onCME Participation by Location Based on ACCME Figures for 2001ACCME Figures for 2001 Live meetings and conferences account for 76% ofLive meetings and conferences account for 76% of “physician-registrants”“physician-registrants” Home study CME (“enduring materials”) andHome study CME (“enduring materials”) and journals account for 19.6% of physician-registrantsjournals account for 19.6% of physician-registrants Online CME accounts for only 4.4% of physician-Online CME accounts for only 4.4% of physician- registrantsregistrants
    57. 57. Physician Usage of Online CMEPhysician Usage of Online CME Physician usage of online CME is increasing, butPhysician usage of online CME is increasing, but still accounts for less than 5% of all CMEstill accounts for less than 5% of all CME According to ACCME:According to ACCME: 1997:1997: 13,115 physician-registrants (0.34%)13,115 physician-registrants (0.34%) 1998: 37,879 physician-registrants (1.03%)1998: 37,879 physician-registrants (1.03%) 1999: 79,536 physician-registrants (1.79%)1999: 79,536 physician-registrants (1.79%) 2000: 181,922 physician-registrants (3.57%)2000: 181,922 physician-registrants (3.57%) 2001: 230,055 physician-registrants (4.44%)2001: 230,055 physician-registrants (4.44%)
    58. 58. Changes and Trends IChanges and Trends I There is a gradual upward trend in the numbersThere is a gradual upward trend in the numbers of sites, courses and hours (about 9% over theof sites, courses and hours (about 9% over the past year)past year) Some of that upward trend is “new”; some isSome of that upward trend is “new”; some is accounted for by counting sites not previouslyaccounted for by counting sites not previously foundfound There has been very little change in the pricing ofThere has been very little change in the pricing of credits, the specialty groups targeted, types ofcredits, the specialty groups targeted, types of instruction or the sources of financial support.instruction or the sources of financial support.
    59. 59. Changes and Trends IIChanges and Trends II Number of physician-registrants for online CMENumber of physician-registrants for online CME went up fromwent up from 181,922 (3.57%) to 230,055 (4.44%)181,922 (3.57%) to 230,055 (4.44%) Glass half full or half empty?Glass half full or half empty?
    60. 60. Why is Online CME use So Low? IWhy is Online CME use So Low? I Some physicians are still uneasy with computersSome physicians are still uneasy with computers and the Internet (but rapidly improving)*and the Internet (but rapidly improving)* Many physicians are unaware of online CME or don’tMany physicians are unaware of online CME or don’t know how to find itknow how to find it Much live CME, especially at the hospital, isMuch live CME, especially at the hospital, is convenient, free and offers collegial interactionconvenient, free and offers collegial interaction
    61. 61. Why is Online CME Use So Low? IIWhy is Online CME Use So Low? II A series of “gates” for the user to pass throughA series of “gates” for the user to pass through Navigation; Download and install plug-insNavigation; Download and install plug-ins Registration hassleRegistration hassle Fear of giving out license, DEA, credit cardFear of giving out license, DEA, credit card Paying in advance for content you can’t viewPaying in advance for content you can’t view Get content free, leave without payingGet content free, leave without paying Each site has a different procedure and passwordEach site has a different procedure and password
    62. 62. Why Choose One Online CME Site OverWhy Choose One Online CME Site Over Another?Another? PricePrice Preference for Type of InstructionPreference for Type of Instruction Email remindersEmail reminders Part of larger medical sitePart of larger medical site Help with CME reportingHelp with CME reporting Recommendation by colleagues, medical groupRecommendation by colleagues, medical group Special arrangements with physician groupSpecial arrangements with physician group
    63. 63. A Long Term SolutionA Long Term Solution Eventually, CME will be totally integrated with theEventually, CME will be totally integrated with the physician’s daily practice lifephysician’s daily practice life Systems will be developed which allow a computerSystems will be developed which allow a computer program to “know” when a physician is making aprogram to “know” when a physician is making a mistake or needs additional informationmistake or needs additional information The system will present instruction on the spot toThe system will present instruction on the spot to help the physician do the right thinghelp the physician do the right thing
    64. 64. Other Problems to SolveOther Problems to Solve Another problem will be to prove that a given CMEAnother problem will be to prove that a given CME activity actually improves physician performance.activity actually improves physician performance. For now, CME providers and evaluating groups willFor now, CME providers and evaluating groups will need to settle for some lesser measure, such as theneed to settle for some lesser measure, such as the difference in scores between pre-tests and post-difference in scores between pre-tests and post- tests, or statements by “experts” that the course willtests, or statements by “experts” that the course will correct the deficiency.correct the deficiency.
    65. 65. Opportunities for ResearchOpportunities for Research More sophisticated (and expensive) methods ofMore sophisticated (and expensive) methods of evaluation exist, such as reviewing physician chartsevaluation exist, such as reviewing physician charts or interviewing patientsor interviewing patients This is a great opportunity for research. There isThis is a great opportunity for research. There is grant money available for research into effectivegrant money available for research into effective CME.CME.
    66. 66. Conclusions IConclusions I The number of online CME activities and credits isThe number of online CME activities and credits is growing rapidly (but not so rapidly as in the previousgrowing rapidly (but not so rapidly as in the previous periods)periods) Online CME is becoming nicer to look at, with moreOnline CME is becoming nicer to look at, with more graphics, lots more audio and video, and a bit moregraphics, lots more audio and video, and a bit more interactive programminginteractive programming
    67. 67. Conclusions IIConclusions II The percentage of CME hours earned online is still onlyThe percentage of CME hours earned online is still only about 4.4%about 4.4% Barriers to usage are still majorBarriers to usage are still major Almost no proof that any kind of standalone CME,Almost no proof that any kind of standalone CME, whether live, home study or online, and regardless ofwhether live, home study or online, and regardless of mode of instruction, is useful in changing physicianmode of instruction, is useful in changing physician practicepractice
    68. 68. Conclusions IIIConclusions III The future lies in the integration of medical practice,The future lies in the integration of medical practice, quality assessment and user-specific CMEquality assessment and user-specific CME The challenges and opportunities are greatThe challenges and opportunities are great
    69. 69. Important URLsImportant URLs Master’s thesis:Master’s thesis: www.cmelist.com/mastersthesiswww.cmelist.com/mastersthesis// My home page:My home page: www.cmelist.comwww.cmelist.com Online CME list:Online CME list: www.cmelist.com/list.htmwww.cmelist.com/list.htm Definitions of types of online CME instruction:Definitions of types of online CME instruction: www.cmelist.com/Instruction_Types_defined.htmwww.cmelist.com/Instruction_Types_defined.htm

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