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Summary Slide Show of Online CME
 

Summary Slide Show of Online CME

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  • Explanation 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 use 284 as the denominator for most of my calculations. However, for the purpose of identifying the largest sites and for grouping sites by total hours, I have eliminated those divisions and use a denominator of xxx sites. Beginning with the June 2002 update, and in keeping with ACCME usage, I have replaced the words “course” and “courses” with “activity” and “activities.”
  • For the purpose of these calcualtions
  • The 34 largest sites (those with 100 hours or more) account for 80 hours (13% of sites, but 80% of hours). The 39 smallest sites (those with less than 5 hours) account for 112 hours (15% of sites, but <1% of hours). Beginning with the three previous revisions, and for the purpose of ranking sites by size, I have counted a “site” as the sum of all activities at a given site (therefore a denominator of 254 sites.)
  • Here are the 21 largest sites (according to the number of hours offered). The number 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 May 15 and July 15, 2003) = estimate or published number; the others were actually counted.
  • Here are the 21 largest sites (according to the number of hours offered). The number 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 May 15 and July 15, 2003) = estimate or published number; the others were actually counted.
  • Here are the 21 largest sites (according to the number of hours offered). The number 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 May 15 and July 15, 2003) = estimate or published number; the others were actually counted.
  • Here are the 21 largest sites (according to the number of hours offered). The number 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 May 15 and July 15, 2003) = estimate or published number; the others were actually counted.
  • 59% of sites offer free instruction. The bulk of the fee-instruction falls into the $5-15 per hour range. Using denominator of 286 sites.
  • 22% of the instruction hours are free. 75% of the fee hours cost $15 or less. The number of free hours has gone up by about 1700 hours since January 2004). $5 to $15 per hour remains the dominant charge for fee-based instruction (72%) Using denominator of 25075 hours.
  • 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 (pharmaceutical or surgical instrument) support 51% of sites. Universities and Medical Schools support 33% of sites. 22% of sites are supported by medical specialty associations. Many sites have multiple sources of support.
  • Primary Care (especially Family Practice and Internal Medicine) remain the predominant target audiences. More than half of sites have instruction for primary care doctors, with family practice and internal medicine the dominant groups. Denominator 300 sites.
  • Cardiology, Psychiatry, Infectious Disease/HIV and Oncology are relatively high target audiences. Denominator 300 sites.
  • Many sites have more than one type of instruction. The percentages of the various instruction types has changed very little. There may be a trend towards more slide-video lectures and streaming video (surgical procedures). Denominator 268 (includes some portal sites).
  • 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.
  • * 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.
  • *

Summary Slide Show of Online CME Summary Slide Show of Online CME Presentation Transcript

  • Online CME – An Update
    • Review of July 2009
    • Bernard M. Sklar, M.D., M.S.
    • www.cmelist.com/list.htm
    • [email_address]
  • Plan of Presentation
    • Results of Recent Surveys
    • Types of Instruction
    • Physician Use of CME and Online CME
    • Obstacles to Physician Use
    • Predictions
  • Master’s Thesis
    • This review is based on the July 2009 update of the database initially created for the master’s thesis, The Current Status of Online Continuing Medical Education (June 2000). Find the thesis online at http://www.cmelist.com/ mastersthesis
    • The June 2000 thesis was based on a review of the CME literature and a survey of online CME done in February 2000.
  • How Was the Survey Done?
    • The original survey was done by searching multiple search engines using the search string “online + continuing + medical +education”
    • Following up leads from those searches
    • Information from ACCME
    • Email from viewers and CME providers
  • Updating the Database
    • For the past several years, I have relied mostly on contacts from Online CME providers and users to add sites to my list
    • I add 3-4 new sites each month (and remove those sites that are no longer functioning)
    • This year I again searched the Internet for “online + continuing + medical + education”
  • Description of the List
    • Each entry shows the name and URL of the site, when it was last visited, how many credit hours are available, who awards the credit, the cost per unit, when the educational material was last updated, a statement about financial support, and a description of the site and its contents.
  • Thanks to Volunteers
    • Although I visit most of the sites myself, this last year a number of people volunteered to help keep the List current
    • You will find their names and titles in the “Reviewed by…” section of each review at http://www.cmelist.com/list.htm
    • Thanks to all!!
  • Extensive Updates
    • I have been maintaining the list for about twelve years, beginning in 1997. In 2008-2009 I had the assistance of volunteer reviewers
    • The database is continually updated .
    • From June 2008 through July 2009, we visited and updated the review of each site on the list.
  • Database Created from List
    • The database contains information about the 300 sites offering CME in July 2009. This information includes the number of activities, number of hours of instruction, types of instruction, target audiences, cost to users, the name of the accrediting organization and sources of financial support. The figures in this report are based on the 284 sites offering original CME.
  • Growth of Sites, Activities and Hours I 5500 3510 150 December 2000 18266 10952 209 June 2002 17523 12026 197 December 2001 5659 3659 135 August 2000 3064 1874 96 February 2000 Not counted Not counted 87 December 1999 Not counted Not counted 68 May 1999 Not counted Not counted 61 August 1998 Not counted Not counted 18 December 1997 Not counted Not counted 13 April 1997 Number of Credit Hours Number of Activities Number of Sites Date Searched
  • Growth of Sites, Activities and Hours II 26287 15744 300 December 2006 20666 12968 300 July 2009 25075 14963 283 June 2005 21700 12395 271 January 2004 20299 11346 253 July 2003 19105 11485 229 December 2002 Number of Credit Hours Number of Activities Number of Sites Date Searched
  • Explanation of calculations on next several slides
    • Although the number of sites is now estimated at 300, the number used for the following calculations is 284.
    • This method counts only those sites which offer original content and not the approximately 16 those sites which only link to or re-package content offered elsewhere (Nothing wrong with doing that, but I don’t want to count the same activity twice).
  • Growth of large sites (offering more than 100 Credit Hours) 79 14 20884 40 December 2006 75 15 15534 44 July 2009 80 13 20456 34 June 2005 81 11 17549 25 January 2004 80 10 16388 21 July 2003 81 8 15404 16 December 2002 83 7 14587 14 December 2001 % of hours % of Sites Number of Hours Number of Sites Date Searched
  • Size of Sites – July 2009 100 100 26287 284 Total <1 15 100 43 < 5 1 16 337 45 5-9 5 27 1236 76 10-24 7 14 1445 40 25-49 10 11 2012 31 50-99 75 15 14587 44 Greater than 100 % 0f Hours % of Sites Number of Hours Number of Sites No. of Credit-Hours
  • The Largest Sites July 2009 - I 1221 814 CMEWeb 300 300 RSNA (Radiological Soc North America) 300 5 TheAnswerPage 850 850 Medscape CME Center 450 300 Pri-Med Online 502 28 Virtual Lecture Hall 264 88 Practical Reviews Online (was JournalBytes) 425 55 NetCE Continuing Education on the Internet 332 259 American Society for Clinical Pathology 469 469 Clinical Directors Network (CDN) 250 10 CardioVillage 2325 1328 Contemporary Forums-Online CE Library 1560 54 Challenger Online Lecture Hall 1980 990 Audio Digest # of Hours # of Activities Name of Site
  • The Largest Sites July 2009 - II 195 130 CMELectures.org 150 100 Neurology (J American Acad Neurology) 147 149 Washington University (St Louis) 195 195 Oncologist (The) 169 36 MedRisk Online 181 43 Harvard Online CME 143 143 Childrens of Minnesota Grand Rounds 166 100 Johns Hopkins Advanced Studies Courses 156 3 American Acad Ped PREP Self-Ass Online 172 115 Drexel MCP Hahnemann Virt Grand Rounds 140 67 FreeCME 216 98 Sullivan Group (The) 200 200 CME Institute 210 210 theheart.org # of Hours # of Activities Name of Site
  • The Largest Sites July 2009 - III 129 129 Ohio State University Center for CME 111 111 McGill CME 105 69 American Psychiatric Association 120 1 ACP Medicine Online Version 118 92 Texas Heart Institute 120 120 CMEDownload 105 165 PedsEducation.org 115 68 American Acad Allergy Asthma Immunology 112 134 Cleveland Clinic 120 120 Epocrates Mobile CME 103 103 PeerView Press Online CME 140 140 NEJM Weekly CME Program 130 130 JAMA & Archives 137 66 American Acad of Orthopaedic Surgery OKO # of Hours # of Activities Name of Site
  • The Largest Sites July 2009 - IV 100 37 American Academy Ped Online Courses 100 50 CE Central # of Hours # of Activities Name of Site
  • Fee Structure – Free Sites
    • There has been a modest increase in the number of sites offering free CME – from 168 sites (59%)in December 2006 to 180 sites (63%) in July 2009.
    • There has been a larger increase in the number of free credit-hours – from 5740 (21%) in December 2006 to 7066 (34%) in July 2009.
  • Fee Structure – Pay for Credit Sites
    • There has been very little change in the median fee for a paid credit hour. The bulk of the fee instruction (about 62%) continues to cost $5 to $15 per credit hour
  • Fee Structure by Site July 2009 1 3 $11-14 per hour % of Sites Number of Sites Dominant or Average Fee 3 7 >$25 per hour 2 5 $25 per hour 1 3 $21-24 per hour 4 11 $20 per hour 1 3 $16-19 per hour 9 25 $15 per hour 4 12 $10 per hour 4 11 $6-9 per hour 2 6 $5 per hour 4 12 <$5 per hour 63 180 Free
  • Hourly Fee Structure July 2009 4 628 $5 per hour 1 90 $11-14 per hour % of Hours No of Hours Dominant or Average Fee 1 142 >$25 per hour 2 452 $25 per hour 2 412 $21-24 per hour 6 1184 $20 per hour 2 354 $16-19 per hour 17 3541 $15 per hour 11 2295 $10 per hour 9 1875 $6-9 per hour 13 2624 <$5 per hour 34 7066 Free
  • Financial Support Summary: There has been very little change in relative percentages of financial support since December, 2001. As the number of free sites and activities increases, the number of fee sites and activities decreases
  • Financial Support July 2009 37 104 User Fees/Partial or Complete 8 22 Foundation 21 61 Medical/Specialty Association 12 33 Government 30 86 University/Medical School 51 146 Commercial Companies % of Sites No. of Sites Source of Support
  • Primary Care and Specialty Sites
    • Family Practice and Internal Medicine content continues to dominate the Primary Care sites (about 40% of all sites).
    • Among the Specialty Sites, Cardiology, Psychiatry, Infectious Disease/HIV, and Oncology content appear most frequently (about 20% of sites for each specialty).
    • Many sites offer instruction for more than one specialty group
  • Specialty – Primary Care July 2009 10 27 Obstetrics/Gynecology including: 12 33 Multiple Specialties (>6) 15 42 Pediatrics 33 93 Internal Medicine 38 108 Family Practice 76 217 Primary Care Sites % of All Sites No. of Sites
  • Subspecialties July 2009 4 10 Rheumatology 7 19 Surgery 5 13 Anesthes/Pain Management 11 30 Oncology 4 12 Endocrine 5 14 Neurology 8 24 Infectious Disease/HIV 6 16 Radiology 6 18 Gastroenterology 10 28 Cardiology % of Sites Number of Sites Subspecialty sites 7 19 Psychiatry
  • Sites by Specialty-July 2009- Other
    • 36 sites (12%) offer subjects of interest to many specialists: ethics, legal, practice management, risk management, tobacco cessation, addiction, alcoholism, genetics, basic science
    • Many other specialties are included at 8 or fewer sites
  • “ Portal” Sites July 2009
    • These two sites offer no original CME activities, but do offer convenient starting places for a large number of activities:
    • CE Medicus offers access without fee to about 3000 activities (probably about 4000 hours) produced by about 11 content providers. Instruction is free.
    • Doctor’s Guide also has no CME of its own, but offers descriptions of over 2000 activities (free and fee) with links to those courses
  • Large Sites where Hours cannot be counted
    • American College of Cardiology - CME content is interspersed through the Cardiosource site and cannot readily be counted; but there are probably several hundred hours.
    • Medical Rounds is a Canadian site which does not offer US CME credit. However, many Canadian medical schools have contributed to several hundreds of lectures to this series. All talks were originally presented at grand rounds of quality educational institutions or at accredited medical meetings.
    • MedPage Today - Each day, important medical events and studies are summarized and presented in the form of news stories as brief (0.25 hours) CME activities. In addition there are links to about 38 longer CME activities in a variety of specialty areas. Each of these longer activities offers 1.0-2.5 credits.
  • Types of Instruction
    • The one major change in types of instruction is the rapid increase of podcasting (up from 5 sites in December 2006 to 23 sites in July 2009.
    • Text (with or without graphics) remains the dominant mode, followed by slide-audio or slide-video lectures, case-based interactive and question-and-answer instruction.
    • For definitions of these and other types of online instruction, see Types of Online CME Instruction Defined
  • Types of Instruction July 2009 I 4 10 Question-and-answer 1 3 Guidelines 31 89 Text only 30 86 Slide-audio Lecture % of Sites Number of Sites Instruction Type 17 48 Case-Based-Interactive 24 69 Slide-video Lecture 20 57 Text-and-graphics
  • Types of Instruction July 2009 II % of Sites Number of Sites Instruction Type 0 0 Correspondence 3 8 Games 7 20 Journal 5 15 Journal with multiple subjects 2 6 Board Review/Self-Assessment 4 12 Streaming Video <1 1 Self-Directed Search (POS) 5 13 Text-Audio 8 23 Podcast (Audio and/or Video)
  • Sites I Could Not View
    • There are 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.
  • Point of Care/Self Study
    • I count only one site currently offering “Point of Care” CME (also called “self-directed study”); this is the College of Family Physicians of Canada
    • The several other sites seem to have abandoned the effort
  • Sites that have closed I
    • About 110 sites disappeared between December 2008 and July 2009, either because credit expired or without with an explanation
  • Sites that have closed II
    • The most significant closure, numerically, is eMedicine , whose CME has been folded into Medscape. I had been attributing 6391 activities and 9586 hours to eMedicine .
    • The closure of eMedicine has led to a major decline in the overall number of activities and hours and likewise to a major decline in the number of activities in the “$5 to 10 per hour” fee bracket
  • CME Participation by Location Based on ACCME Figures for 2008
    • Live meetings and conferences accounted for 40% of “physician-participants”
    • Home study CME (“enduring materials”) and journals accounted for 20.4% of physician-participants
    • Online CME accounted for almost 41% of physician-participants
  • Physician Usage of Online CME
    • Physician usage of online CME is increasing, and now accounts for almost 41% of all CME
    • According to ACCME:
    • 1997: 13,115 physician- participants (0.34%)
    • 1998: 37,879 physician- participants (1.03%)
    • 1999: 79,536 physician- participants (1.79%)
    • 2000: 181,922 physician- participants (3.57%)
    • 2001: 230,055 physician- participants (4.44%)
    • 2002: 329,110 physician- participants (6.08%)
    • 2004: 895,120 physician- participants (14%)
    • 2005: 1,368,335 physician- participants (18%)
    • 2006: 2,184,460 physician- participants (26%)
    • 2007: 2,673455 physician- participants (30.7%)
    • 2008: 4,365,013 physician- participants (40.9%)
  • Some important caveats about the numbers
    • The numbers I have quoted in this and all previous reports are quoted in “physician-participants.” This term is not explained at the ACCME site, but it is certainly not the same as “credit-hours” earned.
    • The numbers I have quoted in this and all previous reports are based on the reports of the 725 providers certified directly by the ACCME and NOT on the reports of the 1600 providers accredited by the State Medical Societies (those 1600 providers provide a very small amount of online CME)
  • Changes and Trends I
    • For the first time since 1997, there has been a reduction in the number of online CME activities and hours available. This is mostly explained by the disappearance of the 9586 hours formerly provided by eMedicine .
    • About 100 sites have vanished since December 2006, and about 100 new sites have appeared during that
    • There has been a significant increase in the number of free CME hours (7066 vs. 5740) over the past 2 ½ years. There has been little change in the specialty groups targeted. There are considerably more slide-audio and slide-video lectures and a large increase in podcasts.
  • Changes and Trends II
    • The number of physician-participants for online CME went up from 181,922 (3.57%) in 2000 to 230,055 (4.44%) in 2001 to 329,110 (6.08%) in 2002 to 899,390 (14%) in 2004 to 1,368,335 (18%) in 2005 to 2,184,460 (26%) in 2006 to 2,673,455 (30.7%) in 2007 and to 4,365,013 (40.9%)
    • The number of physicians registering for online CME has quintupled in the past seven years.
    • Return to beginning of the Sklar Report , if desired, or just keep going down
  • Why is Online CME use Still Low? I
    • I think we can soon retire this section. The 2008 ACCME figures show that online CME accounts for 40% of “physician-participants.” Other ways of calculation this ratio are somewhat less glowing, but still, the trend is obviously upwards
    • My points about the “low” use of Online CME are still pertinent, BUT much less so than just a few years ago:
    • Some physicians remain uneasy with computers and the Internet
    • Some physicians are still 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
    • Many doctors still find attending their yearly specialty meeting satisfying and sufficient
  • Why is Online CME Use Still Low? II
    • These observations remain true, BUT, again, to a lesser extent tan in past years:
    • 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
  • Why Choose One Online CME Site Over Another?
    • “ Look and Feel”
    • Your specialty’s “official” site
    • Price (lower is better; free is best)
    • Preference for Type of Instruction
    • Email reminders (the more frequent the better)
    • The CME is part of a larger medical site which offers additional services for doctors (“one-stop-shopping”)
    • Help with CME reporting
    • Recommendation by colleagues, medical group
    • Special arrangements with physician group
  • What do Physicians Want?
    • Do physicians really want online CME?
    • (I believe that, with usage now at 40%, the answer is YES)
    • What do they like and dislike?
    • (According to most studies, lectures are still the preferred mode of instruction)
  • A Long Term Solution
    • I believe that:
    • Eventually, CME will be 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
  • 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.
  • 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.
  • Conclusions I
    • The number of online CME activities and credits has leveled off. Online CME continues to become nicer to look at, with more graphics, lots more audio and video, and a bit more interactive programming. Podcasts are growing rapidly in popularity.
  • Conclusions II
    • The percentage of “physician-participants” for online CME about 40%
    • Barriers to usage are coming down
    • There is very little 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
    • Results of most studies indicate that a coordinated set of educational interventions will be needed to accomplish behavior change
  • Conclusions III
    • The future lies in the integration of medical practice, quality assessment and user-specific CME
    • The challenges and opportunities are great
  • 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
    • ACCME Annual Report 2008
  • Questions or Comments?
    • Send email to [email_address]