Overview of Online CME
The Seventh Annual Meeting
of the
Global Alliance for Medical Education
June 23-25, 2002
The McGill Faculty Club
Online CME – An Update
• Review of June 2002
• Bernard M. Sklar, M.D., M.S.
• www.cmelist.com
Plan of Talk
• Results of Survey
• Types of Instruction
• Physician Use of CME and Online CME
• Obstacles to Physician Use
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.
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
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.
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.
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.
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
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.
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
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
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
The Largest Sites December 2000Name of Site No. of
ActivitiesNo. of Hours
HealthStream* 907 1360
Challenger 7 901
CMEWeb 507 759
Medscape** 539 726
ArcMesa 63 232
Milliman/Robertson***
6 104
The Largest Sites December 2001Name of Site No. of Activities No. of Hours
eMedicine CME 6500 10000
CMEWeb 976 1400
Challenger 10 897
cmecourses (HS) 300 500WEBMD Just in Time 1400 350
Medscape CME 200 300
ArcMesa 80 293
The Largest Sites June 2002Name 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
Fee Structure by Site Dec 2000Dominant 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
Fee Structure by Site Dec 2001Dominant 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
Fee Structure by Site June 2002Dominant 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
Hourly Fee Structure Dec 2000Dominant 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
Hourly Fee Structure Dec 2001Dominant 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
Hourly Fee Structure June 2002Dominant 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
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
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
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
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
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
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
Sites by Specialty – Subspecialties Dec 2000Subspecialty 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
Sites by Specialty – Subspecialties Dec 2001Subspecialty 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
Sites by Specialty – Subspecialties June 2002Subspecialty 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
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
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
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
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.
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.
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.
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
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
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
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
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 %)
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
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%)
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
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
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
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
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. There is grant money available for research into effective CME.
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
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
Conclusions III
• The future lies in the integration of medical practice, quality assessment and user-specific CME
• The challenges and opportunities are great
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