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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.
  • 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.
  • I would guess that this practice improves usership, but I have no proof.,
  • 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.
  • *
  • slide show

    1. 1. Online CME – An Update <ul><li>Review of December 2006 </li></ul><ul><li>(amended 8/30/2008 to show new ACCME participation numbers) </li></ul><ul><li>Bernard M. Sklar, M.D., M.S. </li></ul><ul><li> </li></ul><ul><li>[email_address] </li></ul>
    2. 2. Important Note!! 8/30/08 <ul><li>My own figures are getting sadly out of date; my last complete set of visits to all sites was in December 2006. </li></ul><ul><li>However, the Annotated List of Online CME is much more current. </li></ul><ul><li>And, most importantly, the ACCME Annual Report for 2007 is now online and shows another substantial increase in Online CME use </li></ul>
    3. 3. Plan of Presentation <ul><li>Results of Recent Surveys </li></ul><ul><li>Types of Instruction </li></ul><ul><li>Physician Use of CME and Online CME </li></ul><ul><li>Obstacles to Physician Use </li></ul><ul><li>Predictions </li></ul>
    4. 4. Master’s Thesis <ul><li>This review is based on the December 2006 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 mastersthesis </li></ul><ul><li>The June 2000 thesis was based on a review of the CME literature and a survey of online CME done in February 2000. </li></ul>
    5. 5. How Was the Survey Done? <ul><li>The original survey was done by searching multiple search engines using the search string “online + continuing + medical +education” </li></ul><ul><li>Following up leads from those searches </li></ul><ul><li>Information from ACCME </li></ul><ul><li>Email from viewers and CME providers </li></ul>
    6. 6. Updating the Database <ul><li>For the past several years, I have relied on contacts from Online CME providers and users to add sites to my list </li></ul><ul><li>I add 3-4 new sites each month (and remove those sites that go offline </li></ul><ul><li>This year I also searched the Internet again for “online + continuing + medical + education” </li></ul>
    7. 7. Description of the List <ul><li>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 statement about financial support, a description of the site and its contents and links to individual courses found at the site. </li></ul>
    8. 8. Extensive Updates <ul><li>I have been maintaining the list for about nine years, beginning in 1997 </li></ul><ul><li>The database was updated for my master’s thesis in February 2000, and every six months since. </li></ul><ul><li>From March through December 2006, I visited and updated the review of each site on the list. </li></ul>
    9. 9. Database Created from List <ul><li>The database contains information about the 300 sites offering CME in early December 2006. 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. </li></ul>
    10. 10. 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
    11. 11. Growth of Sites, Activities and Hours II 25075 14963 283 June 2005 26287 15744 300 December 2006 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
    12. 12. Explanation of calculations on next several slides <ul><li>Although the number of sites is now estimated at 300, the number used for the following calculations is 286 </li></ul><ul><li>This method counts only those sites which offer original content and not 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) </li></ul>
    13. 13. Growth of large sites (offering more than 100 Credit Hours) 80 13 20456 34 June 2005 81 11 17549 25 January 2004 79 14 20884 40 December 2006 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
    14. 14. Size of Sites – December 2006 100 100 26287 286 Total 1 17 123 48 < 5 1 14 273 39 5-9 5 28 1201 80 10-24 6 16 1643 46 25-49 8 12 2163 33 50-99 79 14 20884 40 Greater than 100 % 0f Hours % of Sites Number of Hours Number of Sites No. of Credit-Hours
    15. 15. The Largest Sites Dec 2006 - I 300 300 Rad Soc North America 300 5 TheAnswerPage 350 97 ArcMesa Educators 318 318 Oncologist (The) 346 108 JournalBytes (All Specialties) 220 173 PriMed Online 250 32 NetCE 300 300 Clinical Directors Network 300 179 FreeCME 346 346 McGill Cont Medical Education 231 10 CardioVillage 205 205 Ohio State University 9586 6391 eMedicine CME 1284 856 CMEWeb 2800 40 Challenger No. of Hours No. of Activities Name of Site
    16. 16. The Largest Sites Dec 2006 - 2 126 62 University of Wisconsin 127 27 MedRisk Online 120 3 Amer Acad Ped Self Assessment 120 1 ACP Medicine Online Version 130 130 JAMA & Archives 120 120 Epocrates Mobile CME 165 110 Pediatrix University 145 145 Amer Soc Clin Path Check Sample 146 73 Audio Digest 135 271 BioCritique 140 140 NEJM Weekly CME Program 200 200 CME Institute (Psychiatry) 165 110 166 100 Johns Hopkins Adv Study courses No. of Hours No. of Activities Name of Site
    17. 17. The Largest Sites Dec 2006 - 3 100 100 The 110 110 Children’s Minnesota Grand Rounds 106 6 Anesoft Medical Simulation 110 106 Washington Univ St Louis 103 99 105 3 EMed Home Concert program 117 36 Johns Hopkins Adv Study Journal 114 14 Amer Acad Peds Other Courses 116 17 American Psychiatric Association No. of Hours No. of Activities Name of Site
    18. 18. Fee Structure – Free Sites <ul><li>There has been a leveling off in the number of sites offering free CME – from 177 sites (70%) to 168 sites (59%) in December 2006. </li></ul><ul><li>There has been a similar leveling off in the number of free credit-hours – from 5075 hours (20%) in June 2005 to 5740 (21%) in December 2006. </li></ul>
    19. 19. Fee Structure – Pay for Credit Sites <ul><li>There has been very little change in the median fee for a credit hour. The bulk of the fee instruction (70-80%) continues to cost $5 to $15 per credit hour </li></ul>
    20. 20. Fee Structure by Site Dec 2006 1 4 $11-14 per hour % of Sites Number of Sites Dominant or Average Fee 3 10 >$25 per hour 2 6 $25 per hour 1 4 $21-24 per hour 3 10 $20 per hour 1 3 $16-19 per hour 10 28 $15 per hour 6 16 $10 per hour 5 14 $6-9 per hour 3 8 $5 per hour 5 15 <$5 per hour 59 168 Free
    21. 21. Hourly Fee Structure Dec 2006 38 10042 $5 per hour 1 78 $11-14 per hour % of Hours No of Hours Dominant or Average Fee 1 230 >$25 per hour 1 199 $25 per hour 1 272 $21-24 per hour 2 407 $20 per hour 1 304 $16-19 per hour 17 4384 $15 per hour 3 904 $10 per hour 9 2448 $6-9 per hour 5 1203 <$5 per hour 22 5740 Free
    22. 22. Financial Support Summary: There has been very little change in relative percentages of financial support since December, 2001. As the number of free sites increases, the number of fee sites decreases
    23. 23. Financial Support Dec 2006 41 118 (approximate) User Fees/Partial or Complete 4 13 Foundation 22 66 Medical/Specialty Association 11 33 Government 33 98 University/Medical School 51 152 Commercial Companies % of Sites No. of Sites Source of Support
    24. 24. Primary Care and Specialty Sites <ul><li>Family Practice and Internal Medicine content continues to dominate the Primary Care sites (about 40% of sites). </li></ul><ul><li>Cardiology, Psychiatry, Infectious Disease/HIV, and Oncology content appear most frequently (about 20% of sites for each specialty). </li></ul><ul><li>Many sites offer instruction for more than one specialty group </li></ul>
    25. 25. Specialty – Primary Care Dec 2006 9 28 Obstetrics/Gynecology including: 12 35 Multiple Specialties (>6) 12 37 Pediatrics 32 97 Internal Medicine 36 108 Family Practice Primary Care Sites % of Sites No. of Sites
    26. 26. Subspecialties Dec 2006 4 13 Surgery 5 16 Endocrine 8 24 Infectious Disease/HIV 3 8 Geriatrics 7 20 Radiology 7 20 Oncology 9 27 Cardiology 3 8 Urology % of Sites Number of Sites Subspecialty sites 3 10 Pulmonary-Critical Care 4 12 Neurology 7 20 Psychiatry including:
    27. 27. Sites by Specialty-Dec 2006- Other <ul><li>36 sites (12%) offer subjects of interest to many specialists: ethics, legal, practice management, risk management, tobacco cessation, addiction, alcoholism, genetics, basic science </li></ul><ul><li>Many other specialties are included at 5 or fewer sites </li></ul>
    28. 28. Five “Different” Sites Dec 2006- I <ul><li>CE Medicus has no CME of its own, but offers access without fee to about 6100 activities (about 9000 hours) produced by 20 content providers. Instruction is free. </li></ul><ul><li>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 </li></ul><ul><li>Digiscript contains many hundreds of audio and video slide lectures recorded at medical meetings. The yearly charge is $400. Some activities offer CME and others 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. </li></ul>
    29. 29. Five “Different” Sites Dec 2006- II <ul><li>Challenger now requires subscribers to buy a CDROM for each course. Once you purchase that CD, you have unlimited access to the website corresponding to that course. Thus, it is no longer “pure” online CME; I have included the number of Challenger’s courses and hours in this report for sake of consistency. </li></ul><ul><li>American College of Cardiology Self-Selected CME allows subscribers to earn credits for reading parts of articles of interest. </li></ul>
    30. 30. Email Reminders Dec 2006 <ul><li>It is becoming increasingly common for the larger sites to send email reminders on request of the users about their new courses. At least 55 sites are doing this regularly </li></ul>
    31. 31. Types of Instruction <ul><li>There has been little recent change in the proportion of instruction types. (But see my comments about podcasts and point-of-service models below.) </li></ul><ul><li>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. </li></ul><ul><li>For definitions of these and other types of online instruction, see Types of Online CME Instruction Defined </li></ul>
    32. 32. Types of Instruction Dec 2006-I 3 10 Question-and-answer 2 5 Guidelines 29 86 Text only 22 67 Slide-audio % of Sites Number of Sites Instruction Type 19 57 Case-Based-Interactive 19 56 Slide-video 22 65 Text-and-graphics
    33. 33. Types of Instruction Dec 2006-II % of Sites Number of Sites Instruction Type 1 4 Correspondence 1 4 Games 6 18 Journal 4 12 Journal with multiple subjects 2 5 Board Review/Self-Assessment 5 14 Streaming Video 1 3 Self-Directed Search (POS) 2 5 Text-Audio 2 5 Pod cast
    34. 34. More about Question & Answer Instruction <ul><li>Only 10 sites (3%) feature Q&A, BUT the number of hours is relatively large (3545) </li></ul><ul><li>Challenger - 2800 hours </li></ul><ul><li>TheAnswerPage – 300 hours </li></ul><ul><li>Am Acad Pediatrics Self-Assessment – 120 hours </li></ul><ul><li>EMedHome Concert – 105 hours </li></ul><ul><li>Am Acad Orthopedic Self-Assessment – 75 hours </li></ul><ul><li>Orthopedics Hyperguide – 50 hours </li></ul><ul><li>Ecore Family Practice – 40 hours </li></ul><ul><li>Medical Letter – 26 hours </li></ul><ul><li>Medical Education Opportunities – 20 hours </li></ul><ul><li>Interactive Testing in Psychiatry – 7 hours </li></ul><ul><li>Total about 3545 hours (13 % of all CME hours) </li></ul>
    35. 35. Sites I Could Not View <ul><li>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. </li></ul>
    36. 36. Podcasts <ul><li>I only counted five sites offering podcasts, but I may have missed some sites that added podcasts after my visit </li></ul><ul><li>I believe that podcasting will catch on quickly because the technology is easy to apply and because most younger doctors and many older ones have I-Pods or other portable players </li></ul>
    37. 37. Point of Care/Self Study <ul><li>I counted only three sites offering “Point of Care” CME, but I believe some have been added since my count. </li></ul><ul><li>I know that some providers (Skolar, MerckMedicus) have given up the effort </li></ul><ul><li>Time will tell; it’s a great idea, but may be too awkward to use in practice </li></ul>
    38. 38. Sites that have closed <ul><li>About 44 sites offering about 800 credit hours disappeared between July 2005 and November 2006 </li></ul><ul><li>In about half the cases, this was planned because credit expired </li></ul><ul><li>In the other half, the site disappeared, sometimes with an explanation and sometimes without </li></ul>
    39. 39. CME Participation by Location Based on ACCME Figures for 2007 <ul><li>Live meetings and conferences accounted for 45% of “physician-registrants” </li></ul><ul><li>Home study CME (“enduring materials”) and journals accounted for 22.3% of physician-registrants </li></ul><ul><li>Online CME accounted for about 30.7% of physician-registrants </li></ul>
    40. 40. Physician Usage of Online CME <ul><li>Physician usage of online CME is increasing, and now accounts for almost 31% of all CME </li></ul><ul><li>According to ACCME: </li></ul><ul><li>1997: 13,115 physician-registrants (0.34%) </li></ul><ul><li>1998: 37,879 physician-registrants (1.03%) </li></ul><ul><li>1999: 79,536 physician-registrants (1.79%) </li></ul><ul><li>2000: 181,922 physician-registrants (3.57%) </li></ul><ul><li>2001: 230,055 physician-registrants (4.44%) </li></ul><ul><li>2002: 329,110 physician-registrants (6.08%) </li></ul><ul><li>2004: 895,120 physician-registrants (14%) </li></ul><ul><li>2005: 1,368,335 physician-registrants (18%) </li></ul><ul><li>2006: 2,184,460 physician-registrants (26%) </li></ul><ul><li>2007: 2,673455 physician-registrants (30.7%) </li></ul>
    41. 41. Changes and Trends I <ul><li>There is a gradual upward trend in the numbers of sites, courses and hours (about 5% increase over the past 18 months) </li></ul><ul><li>Some of that upward trend is “new”; some is accounted for by counting sites not previously found; about 44 sites offering about 800 hours have discontinued operation </li></ul><ul><li>There has been a small increase in the number of free CME hours (5740 vs. 5074) over the 18 months. There has been little change in the specialty groups targeted, types of instruction or the sources of financial support. </li></ul>
    42. 42. Changes and Trends II <ul><li>Number of physician-registrants 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. </li></ul><ul><li>The number of physicians registering for online CME has quintupled in the past six years. </li></ul><ul><li>Return to beginning of the Sklar Report , if desired, or just keep going down </li></ul>
    43. 43. Why is Online CME use Still So Low? I <ul><li>Pretty soon I hope to eliminate the ”Why is Online CME Use so low?” portion of this report. </li></ul><ul><li>My points about the “low” use of Online CME are still pertinent, BUT much less so than just a few years ago: </li></ul><ul><li>Some physicians are still uneasy with computers and the Internet </li></ul><ul><li>Some physicians are unaware of online CME or don’t know how to find it </li></ul><ul><li>Much live CME, especially at the hospital, is convenient, free and offers collegial interaction </li></ul><ul><li>Many doctors still find attending their yearly specialty meeting satisfying and sufficient </li></ul>
    44. 44. Why is Online CME Use Still So Low? II <ul><li>These observations remain true, BUT, again, to a lesser extent tan in past years: </li></ul><ul><li>A series of “gates” for the user to pass through </li></ul><ul><li>Navigation: Download and install plug-ins </li></ul><ul><li>Registration hassle </li></ul><ul><li>Fear of giving out license, DEA, credit card </li></ul><ul><li>Paying in advance for content you can’t view </li></ul><ul><li>Get content free, leave without paying </li></ul><ul><li>Each site has a different procedure and password </li></ul>
    45. 45. Why Choose One Online CME Site Over Another? <ul><li>“ Look and Feel” </li></ul><ul><li>Your specialty’s “official” site </li></ul><ul><li>Price (lower is better; free is best) </li></ul><ul><li>Preference for Type of Instruction </li></ul><ul><li>Email reminders (the more frequent the better) </li></ul><ul><li>The CME is part of a larger medical site which offers additional services for doctors (“one-stop-shopping”) </li></ul><ul><li>Help with CME reporting </li></ul><ul><li>Recommendation by colleagues, medical group </li></ul><ul><li>Special arrangements with physician group </li></ul>
    46. 46. What do Physicians Want? <ul><li>Do physicians really want online CME? </li></ul><ul><li>(I believe that, with usage now at 31%, the answer is YES) </li></ul><ul><li>What do they like and dislike? </li></ul><ul><li>(According to most studies, lectures are still the preferred mode of instruction) </li></ul>
    47. 47. A Long Term Solution <ul><li>I believe that: </li></ul><ul><li>Eventually, CME will be integrated with the physician’s daily practice life </li></ul><ul><li>Systems will be developed which allow a computer program to “know” when a physician is making a mistake or needs additional information </li></ul><ul><li>The system will present instruction on the spot to help the physician do the right thing </li></ul>
    48. 48. Other Problems to Solve <ul><li>Another problem will be to prove that a given CME activity actually improves physician performance. </li></ul><ul><li>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. </li></ul>
    49. 49. Opportunities for Research <ul><li>More sophisticated (and expensive) methods of evaluation exist, such as reviewing physician charts or interviewing patients </li></ul><ul><li>This is a great opportunity for research. </li></ul>
    50. 50. Conclusions I <ul><li>The number of online CME activities and credits is growing rapidly. Online CME is becoming nicer to look at, with more graphics, lots more audio and video, and a bit more interactive programming </li></ul>
    51. 51. Conclusions II <ul><li>The percentage of CME hours earned online has risen to about 31% </li></ul><ul><li>Barriers to usage are coming down </li></ul><ul><li>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 </li></ul><ul><li>Results of most studies indicate that a coordinated set of educational interventions will be needed to accomplish behavior change </li></ul>
    52. 52. Conclusions III <ul><li>The future lies in the integration of medical practice, quality assessment and user-specific CME </li></ul><ul><li>The challenges and opportunities are great </li></ul>
    53. 53. Important URLs <ul><li>Master’s thesis: </li></ul><ul><li>My home page: </li></ul><ul><li>Online CME list: </li></ul><ul><li>Definitions of types of online CME instruction: </li></ul><ul><li>ACCME Annual Report 2007 </li></ul>
    54. 54. Questions or Comments? <ul><li>Send email to [email_address] </li></ul>