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Overview of Online CME

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  • Caveat about the “number” of sites: I have somewhat artificially divided some of the larger sites into subsites, based on the fact that the subsites offer different instruction types, or geared towards different audiences, or focused on different disease. I will use 209 as the denominator for most of my calculations. If these divisions were removed, the “true” number of separate sites would be closer to 170.
    Beginning with this update, and in keeping with ACCME usage, I have replaced the words “course” and “courses” with “activity” and “activities.”
  • These numbers come from my own periodic review of the Internet using the search string, “online + continuing + medical +education”
  • With the June 2002 revision, I have changed the words “course” and ‘courses” to activity and “activities.”
  • I visited every site in May or early June 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. 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.
  • 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).
  • 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.
    ** Medscape provides figures for the total number of activities (350) and hours (500) available over one year, but not on any given day.
  • 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%
  • 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 percent has dropped (largely because of the appearance of emedicine and the disappearance of WebMD). $5 to $15 per hour is the overwhelming number in the fee-based instruction.
  • 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.
  • 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.
  • 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.
  • 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.
  • 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.
  • 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.
  • *
  • Transcript

    • 1. Overview of Online CME The Seventh Annual Meeting of the Global Alliance for Medical Education June 23-25, 2002 The McGill Faculty Club
    • 2. Online CME – An Update • Review of June 2002 • Bernard M. Sklar, M.D., M.S. • www.cmelist.com • bersklar@netcantina.com
    • 3. Plan of Talk • Results of Survey • Types of Instruction • Physician Use of CME and Online CME • Obstacles to Physician Use
    • 4. Master’s Thesis • This review is based on a recent update of the database that I created for my master’s thesis, The Current Status of Online Continuing Medical Education (June 2000). Find the thesis online at http://www.cmelist.com/mastersthesis • The thesis was based on a review of the CME literature and a survey of online CME done in February 2000.
    • 5. How Was the Survey Done? • Internet search of multiple search engines using search string “online + continuing + medical +education” • Following up leads from those searches • Information from ACCME • Email from viewers and CME providers
    • 6. Description of the List Each entry shows the name and URL of the site, when I last visited, how many credit hours are available, who awards the credit, the cost per unit, when the educational material was last updated, a description of the site and its contents and links to individual courses found at the site.
    • 7. Extensive Updates • I have been maintaining the list for about 5 years • The list was updated for my master’s thesis in February 2000, again in August and December 2000, in December 2001 and in June 2002.
    • 8. List of Online CME
    • 9. Database Created from List Based on examining each site, I created an Access database of the 207 sites actively offering CME in June 2002. The DB contains the number of activities, number of hours of instruction, types of instruction, specialty audiences, cost to users, sources of financial support and other parameters.
    • 10. Results of Study I • The number of sites and activities is rapidly increasing • April 1997 – 13 sites • December 1997 – 18 sites • August 1998 – 61 sites • May 1999 – 69 sites • December 1999 – 87 sites
    • 11. Results of Study II • February 2000 – 96 sites, 1874 activities, 3064 credit hours • August 2000 – 135 sites, 3659 activities, 5659 credit hours • December 2000 – 150 sites, 3510 activities, 6553 credit hours – Because of overlap, duplication, and miscounting , the “true number” of hours should have been about 5500.
    • 12. Results of Study III • December 2001 • 197 sites • 12026 activities • 17523 hours
    • 13. Results of Study IV • June 2002 • 209 sites • 10952 activities • 18266 hours
    • 14. Size of Sites – December 2000 No. of Credit- Hours Number of Sites Number of Hours % of Sites % 0f Hours Greater than 100 6 4082 4 62 50-99 12 779 8 12 25-49 21 717 14 11 10-24 41 681 27 10 5-9 29 193 19 3 < 5 41 100 27 2 Total 150 6553 100 100
    • 15. Size of Sites – December 2001 No. of Credit- Hours Number of Sites Number of Hours % of Sites % 0f Hours Greater than 100 14 14587 7 83 50-99 9 596 5 3 25-49 29 1046 15 6 10-24 56 918 28 5 5-9 38 271 19 2 < 5 51 103 26 1 Total 197 18266 100 100
    • 16. Size of Sites – June 2002 No. of Credit- Hours Number of Sites Number of Hours % of Sites % 0f Hours Greater than 100 12 14615 5 80 50-99 16 1119 8 6 25-49 31 1137 15 6 10-24 62 1036 30 6 5-9 33 227 16 1 < 5 54 129 26 <1 Total 209 18263 100 100
    • 17. The Largest Sites December 2000 Name of Site No. of Activities No. of Hours HealthStream* 907 1360 Challenger 7 901 CMEWeb 507 759 Medscape** 539 726 ArcMesa 63 232 Milliman/Robertson** * 6 104
    • 18. The Largest Sites December 2001 Name of Site No. of Activities No. of Hours eMedicine CME 6500 10000 CMEWeb 976 1400 Challenger 10 897 cmecourses (HS) 300 500 WEBMD Just in Time 1400 350 Medscape CME 200 300 ArcMesa 80 293
    • 19. The Largest Sites June 2002 Name of Site No. of Activities No. of Hours eMedicine CME* 6500 10000 CMEWeb* 976 1400 Challenger 14 964 TheAnswer.com* 5 300 cmecourses (HS)* 300 500 JournalBytes (All Spec) 108 372 Medscape CME** 200 300 ArcMesa 80 293 Radcourses (HS) 28 128 RSNA Education Exhibits 127 127 Natal U 83 122 Mypatient.com 109 109
    • 20. Fee Structure by Site Dec 2000 Dominant or Average Fee Number of Sites % of Sites Free 74 49 <$5 per hour 2 1 $5 per hour 6 4 $6-9 per hour 16 11 $10 per hour 14 9 $11-14 per hour 6 4 $15 per hour 10 7 $16-19 per hour 5 3 $20 per hour 6 4 $21-24 per hour 2 1 $25 per hour 5 3 >$25 per hour 4 3
    • 21. Fee Structure by Site Dec 2001 Dominant or Average Fee Number of Sites % of Sites Free 98 50 <$5 per hour 6 3 $5 per hour 6 4 $6-9 per hour 13 7 $10 per hour 22 11 $11-14 per hour 9 5 $15 per hour 19 10 $16-19 per hour 3 2 $20 per hour 5 3 $21-24 per hour 2 1 $25 per hour 10 5 >$25 per hour 4 2
    • 22. Fee Structure by Site June 2002 Dominant or Average Fee Number of Sites % of Sites Free 105 50 <$5 per hour 5 2 $5 per hour 6 3 $6-9 per hour 13 5 $10 per hour 24 11 $11-14 per hour 8 4 $15 per hour 25 12 $16-19 per hour 4 1 $20 per hour 3 1 $21-24 per hour 1 <1 $25 per hour 10 4 >$25 per hour 5 2
    • 23. Hourly Fee Structure Dec 2000 Dominant or Average Fee No of Hours % of Hours Free 1587 24 <$5 per hour 103 2 $5 per hour 223 3 $6-9 per hour 1183 18 $10 per hour 1050 16 $11-14 per hour 524 8 $15 per hour 1505 23 $16-19 per hour 170 3 $20 per hour 51 1 $21-24 per hour 18 0 $25 per hour 61 1 >$25 per hour 79 1
    • 24. Hourly Fee Structure Dec 2001 Dominant or Average Fee No of Hours % of Hours Free 1978 11 <$5 per hour 365 8 $5 per hour 10285 59 $6-9 per hour 1712 10 $10 per hour 1447 8 $11-14 per hour 470 3 $15 per hour 845 5 $16-19 per hour 55 <1 $20 per hour 87 <1 $21-24 per hour 9 <1 $25 per hour 114 1 >$25 per hour 155 1
    • 25. Hourly Fee Structure June 2002 Dominant or Average Fee No of Hours % of Hours Free 1763 10 <$5 per hour 566 3 $5 per hour 10203 56 $6-9 per hour 2153 12 $10 per hour 1643 9 $11-14 per hour 434 2 $15 per hour 1009 5 $16-19 per hour 137 1 $20 per hour 57 <1 $21-24 per hour 7 <1 $25 per hour 115 <1 >$25 per hour 177 1
    • 26. Financial Support Dec 2000 Source of Support No. of Sites % of Sites Commercial Companies 43 32 University/Medical School 54 40 Government 7 5 Medical/Specialty Association 13 10 Foundation 7 5 Insurance or Managed Care 4 3 User Fees/Partial or Complete 76 51
    • 27. Financial Support Dec 2001 Source of Support No. of Sites % of Sites Commercial Companies 99 50 University/Medical School 83 42 Government 11 6 Medical/Specialty Association 47 24 Foundation 17 9 Insurance or Managed Care 5 3 User Fees/Partial or Complete 99 50
    • 28. Financial Support June 2002 Source of Support No. of Sites % of Sites Commercial Companies 113 54 University/Medical School 86 41 Government 15 7 Medical/Specialty Association 58 28 Foundation 15 7 User Fees/Partial or Complete 104 50
    • 29. Sites by Specialty – Primary Care Dec 2000 No. of Sites % of Sites Primary Care Sites 93 62 including: Family Practice 83 55 Internal Medicine 80 53 Pediatrics 22 15 Obstetrics/Gynecology 22 15
    • 30. Sites by Specialty – Primary Care Dec 2001 No. of Sites % of Sites Primary Care Sites 114 58 including: Family Practice 95 48 Internal Medicine 86 44 Pediatrics 29 15 Obstetrics/Gynecology 25 13 Multiple Specialties 6 3
    • 31. Sites by Specialty – Primary Care June 2002 No. of Sites % of Sites Primary Care Sites 123 59 including: Family Practice 98 47 Internal Medicine 91 44 Pediatrics 37 18 Obstetrics/Gynecology 29 14 Multiple Specialties (>6) 10 5
    • 32. Sites by Specialty – Subspecialties Dec 2000 Subspecialty sites Number of Sites % of Sites including: 113 75 Neurology 21 14 Psychiatry 23 15 Cardiology 20 13 Oncology 13 9 Infectious Disease 13 9 Radiology* 10 7 Dermatology 7 5 Gastroenterology 7 5 Pulmonary 9 6 Surgery 7 5 General Interest 26 17
    • 33. Sites by Specialty – Subspecialties Dec 2001 Subspecialty sites Number of Sites % of Sites including: 140 71 Neurology 14 7 Psychiatry 21 11 Cardiology 19 10 Oncology 10 5 Infectious Disease 14 6 Radiology 12 6 Geriatrics 12 6 Pulmonary 9 5 Surgery 6 5 General Interest 26 17
    • 34. Sites by Specialty – Subspecialties June 2002 Subspecialty sites Number of Sites % of Sites 123 59 including: Cardiology 23 11 Psychiatry 20 10 Oncology 17 8 Neurology 15 7 Radiology 14 7 Infectious Disease 13 6 Urology 11 5 Endocrine 10 5 Pulmonary 10 5 Geriatrics 9 4 Surgery 9 4
    • 35. Sites by Specialty-2001- Other • 26 sites (13%) offer subjects of interest to many different specialties; for example, ethics, legal, practice management, genetics, and basic science • Many other specialties were included at 5 or fewer sites
    • 36. Sites by Specialty-June 2002- Other • 33 sites (16%) offer subjects of interest to many different specialties: for example, ethics, legal, practice management, risk management, tobacco cessation, genetics, basic science • Many other specialties are included at 5 or fewer sites
    • 37. Five “Different” Sites I • CE Medicus has no CME of its own, but offers access without fee to about 600 activities at five sites (apparently by special arrangement) • Digiscript contains many hundreds of audio and video slide lectures recorded at medical meetings. The yearly charge is $400. Some activities offer CME and some do not. The site is searchable by medical topic and by sponsoring organization. You may have to pay an additional fee for CME credit by any given sponsor. • Doctor’s Guide also has no CME of its own, but offers descriptions of over 600 activities (free and fee) with links to those courses
    • 38. Five “Different” Sites II •Stanford SKOLAR offers credit for performing Internet literature searches on topics of your own interest •University of Wisconsin Professional Courses offer credit for courses on non-medical subjects which could be expected to improve your practice or your life.
    • 39. Sites I Could Not View • There may be a number of proprietary sites, e.g., staff model HMOs, like Kaiser- Permanente, where access to instruction is limited to staff members of that organization. Those sites are not reviewed in this report.
    • 40. Email Reminders June 2002 About 25 sites send out regular email reminders about additions to their lists of activities on 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.
    • 41. Types of Instruction-Definitions • Text-Only • Text-and-Graphics • Slides-Only (or Slides and Text) • Slide-Audio • Slide-Video • Question-and-Answer • Case-Based Interactive • Guideline or Consensus (usually text only) • Correspondence • Games
    • 42. Types of Instruction – Dec 2000 • Text only -- 37 sites; 25% • Text-and-graphics – 45 sites; 30 % • Slide-audio – 45 sites; 30 % • Slide-video – 21 sites; 14 % • Guidelines – 5 sites; 3 % • Question-and-answer – 6 sites; 4 % • Case-based Interactive – 27 sites; 18 % • Many sites have more than one type of instruction
    • 43. Types of Instruction – Dec 2001 • Text only -- 47 sites; 24% • Text-and-graphics – 59 sites; 30 % • Slide-audio – 57 sites; 29 % • Slide-video – 21 sites; 11% • Guidelines – 5 sites; 3 % • Question-and-answer – 9 sites; 5 % • Case-Based-Interactive – 26 sites; 13 % • Correspondence – 3 sites; 2 % • Games – 2 sites; 1 % • Slides-Only – 4 sites; 2 % Many sites have more than one type of instruction
    • 44. Types of Instruction – June 2002 • Text only -- 57 sites; 27% • Text-and-graphics – 71 sites; 34 % • Slide-audio – 60 sites; 29 % • Slide-video – 23 sites; 11% • Guidelines – 8 sites; 3 % • Question-and-answer – 6 sites; 3 % • Case-Based-Interactive – 31 sites; 15 % • Correspondence – 2 sites; 2 % • Games – 2 sites; 1 % • Slides-Only – 4 sites; 2 % • Slides-and-Text – 4 sites; 2 % Many sites have more than one type of instruction
    • 45. More about Q&A Instruction • Only 6 sites (2%) feature Q&A, BUT the number of hours is relatively large • Challenger - 964 hours • TheAnswerPage – 300 hours • E-core – 27 hours • Familypractice.com - 25 hours Total about 1316 hours (7 %)
    • 46. CME Participation by Location Based on ACCME Figures for 2001 • Live meetings and conferences account for 76 % of “physician-registrants” • Home study CME (“enduring materials”) and journals account for 19.6 % of physician-registrants • Online CME accounts for only 4.4 % of physician-registrants
    • 47. Physician Usage of Online CME • Physician usage of online CME is increasing, but still accounts for less than 5% of all CME • According to ACCME: • 1997: 13,115 physician-registrants (0.34%) • 1998: 37,879 physician-registrants (1.03%) • 1999: 79,536 physician-registrants (1.79%) • 2000: 181,922 physician-registrants (3.57%) • 2001: 230,055 physician-registrants (4.44%)
    • 48. Why is Online CME Use So Low? I • Many physicians still uneasy with computers and Internet* • Many physicians unaware of online CME or don’t know how to find it • Much live CME, especially at the hospital, is convenient, free and offers collegial interaction
    • 49. Why is Online CME Use So Low? II • A series of “gates” for the user to pass through • Navigation; Download and install plug-ins • Registration hassle • Fear of giving out license, DEA, credit card • Paying in advance for content you can’t view • Get content free, leave without paying • Each site has a different procedure and password
    • 50. Why Choose One Online CME Site Over Another? • Price • Preference for Type of Instruction • Email reminders • Part of larger medical site • Help with CME reporting • Recommendation by colleagues, medical group • Special arrangements with physician group
    • 51. A Long Term Solution • Eventually, CME will be totally integrated with the physician’s daily practice life • Systems will be developed which allow a computer program to “know” when a physician is making a mistake or needs additional information • The system will present instruction on the spot to help the physician do the right thing
    • 52. Other Problems to Solve • Another problem will be to prove that a given CME activity actually improves physician performance. • For now, CME providers and evaluating groups will need to settle for some lesser measure, such as the difference in scores between pre-tests and post-tests, or statements by “experts” that the course will correct the deficiency.
    • 53. Opportunities for Research • More sophisticated (and expensive) methods of evaluation exist, such as reviewing physician charts or interviewing patients • This is a great opportunity for research. There is grant money available for research into effective CME.
    • 54. Conclusions I • The number of online CME activities and credits is growing rapidly (but not so rapidly as in the previous periods) • Online CME is becoming nicer to look at, with more graphics, lots more audio and video, and a bit more interactive programming
    • 55. Conclusions II • The percentage of CME hours earned online is still only about 4.4% • Barriers to usage are still major • Almost no proof that any kind of standalone CME, whether live, home study or online, and regardless of mode of instruction, is useful in changing physician practice
    • 56. Conclusions III • The future lies in the integration of medical practice, quality assessment and user- specific CME • The challenges and opportunities are great
    • 57. Important URLs • Master’s thesis: www.cmelist.com/mastersthesis/ • My home page: www.cmelist.com • Online CME list: www.cmelist.com/list.htm • Definitions of types of online CME instruction: www.cmelist.com/Instruction_Types_defined.htm

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