In Results, a sample entry from the list of online CME sites is shown; the results of the analysis of the online CME site database is presented; the growth in the number of online CME sites is illustrated; and the physician-usage survey results are given.

The List of Online CME Sites

Links to ninety-six web sites offering ACCME-accredited online CME were made. An alphabetical list by site name of the sites was created with descriptions of the offerings at that site. A single example from the February 2000 list is shown:

The list is found on the Internet at http://www.cmelist.com/list.htm.

Analysis of the Online CME Site Database

The Site Database was analyzed looking for answers to these questions:

(1) How many online CME sites exist, and how many courses and credit hours of CME do they offer?

(2) For which medical specialties is online CME available, and in what numbers and proportions?

(3) What are the dominant types of instruction found in online CME?

(4) What proportion of sites is affiliated with medical schools or universities?

(5) How much does online CME cost?

(6) Where do the sites find financial support?

(7) How do sites vary in size?

(8) How do the sites promote and advertise their offerings?

The results of these queries are shown:

(1) How Many Online CME Sites Exist, and How Many Courses and Credit Hours Of CME Do They Offer?

Ninety-six sites offering 1874 courses totaling 3064 credit hours of ACCME-accredited online CME were found. A course is a unit of instruction on a specific medical topic. Each course may offer from 0.5 hours to 65 hours of CME credit, but typical courses offer one to five credit hours. A list of numbers of courses and credit hours, by site, is shown in Table 6.

(2) Results by Medical Specialty:

Sixty-one (64%) of the sites offered instruction aimed at primary care physicians. Of the 96 sites, 57 (59%) offered instruction appropriate for Family Practice, 54(56%) for Internal Medicine, 16 (17%) for Pediatrics and 18 (19%) for Obstetrics/Gynecology). (These numbers total more than 96 and the percentages total more than 100% since the same course may be appropriate for many different specialties, and that one site may offer instruction aimed at different specialists). 

Seventy-three (76%) of the sites offered instruction aimed at specialists and subspecialists. 17/96 (18%) of sites offered instruction aimed at Neurologists, 17 (18%) had instructions for psychiatrists, 15 (16%) for Cardiology, and 10 (10%) for Oncology.

Seventeen (18%) of sites offered instruction that would be of interest to many or most specialties. These included sites with topics such as pain management, medical ethics, and domestic violence and practice management.  A complete listing of sites presented by medical specialty is shown in Table 7. 

(3) Types of Instruction: 

The numerical analysis of the forms of instruction is shown below:

 (4) University or Medical School Affiliation:

Forty-two of the ninety-six sites were produced and/or sponsored by universities or medical schools. In addition, many of the sites without specific university or medical school sponsorship indicated that university faculty members were engaged to create or review instruction.  

(5) Fees for Instruction:

Forty sites (42%) offered free instruction or instruction for less than $5 per credit hour. Thirty-two sites (34%) offered instruction for $5-15 per credit hour. Eighteen sites (19%) charged $15 or more per credit hour.  A complete tabulation of fees is shown in Table 8. 

(6) Sources of financial support: 

Online CME sites receive financial support from one or several sources: commercial sponsors (usually pharmaceutical companies), universities and medical schools, governmental agencies, medical associations or societies, foundations, insurance and managed care companies and user fees. In many cases, sites have received financial support from multiple sources. The sources of support are shown in the following table: 

 (7) The size of online CME sites:

Sites fall into several groups according to the number of courses and hours of credit offered. There are three sites offering greater than 100 hours of credit. These sites are HealthStream University (about 415 courses adding up to about 830 hours), Medscape (about 400 courses; most are one hour, totaling about 400 hours) and ArcMesa (about 54 courses totaling 207 hours). At the other end of the spectrum, there are 25 sites that offer 4 or fewer credit hours of instruction. The remainder of the sites fall in between these extremes as shown below.

(8) How many sites promote their instruction with email reminders? 

Eleven of the 96 sites offer email reminders of new courses to their registered users. These sites are: Current CME Reviews, Cyberounds, HealthGate, HealthStreamUniversity, MedConnect Emergency Medicine, MedConnect Family Practice, MedConnect Managed Care, MedConnect Neurology, Medscape CME Center, Primary and Virtual Lecture Hall.

The Growth of Online CME Sites

Review of an article from April 1997 (Sklar, 1997) showed 13 sites offering online CME. In December 1997, 18 online CME sites were found using the search described in "Methods." Using the same search parameters, 37 sites were found in March 1998; in August 1998, 61 sites; in April and May 1999, 69 sites; in August 1999, 76 sites; in early December 1999, 87 sites and in February 2000, 96 sites.

The Usage Survey:

The usage survey was created looking for answers to these questions:

(1) How many physicians visit online CME courses?

(2) How many physicians are using the Internet to earn CME credits?

(3) How many credits are they earning?

(4) What are the trends in usage?

Twenty-three sites responded to the survey with some kind of usable information. Eleven sites did not respond or email was returned as being sent to an incorrect address. Three sites responded, but had no usable information. Two sites refused to share information. Five sites promised to share information, but eventually did not send anything after a second request. Three sites requested that information identifying the site be disguised because of proprietary considerations. A tabulation of the various responses to the Survey is shown in Table 9.

The statements in this section are direct quotes or paraphrases of information given by the site owners either in email messages or in telephone conversations. In one case (Virtual Hospital), the figures are taken from a published medical paper. The responses of the site owners are presented in order of the approximate number of credit hours awarded by each site. 

Medical Directions, Inc. operates the Virtual Lecture Hall. This site has been active since May 1998 and currently offers sixteen courses totaling sixty-three hours. Their instruction is aimed primarily to primary care physicians. The instruction type is either interactive or question/answer. 

The owner of Medical Directions, Inc. stated on November 26, 1999,

In the first 6 months (5/98 to 11/98) we dispensed 1,500 hours of CME. In the second 6 months we provided 4,500 hours of CME. In the third 6 months we provided 9,000 hours of CME. In the first 6 months we had 1993 new registrants (almost all MDs/DOs). In the second 6 months we had 2788 new registrants. In the third 6 months we had 2183 new registrants. So, our registrants base is growing at a rather consistent clip of around 100/week. I would note, however, that during the last 12 weeks our registration rate has increased to 140/week, so we may be seeing an upsurge.  

A visit to the Virtual Lecture Hall site on January 24, 2000 showed the message, "Physicians have received over 18,075 hours of AMA Category 1 CME credit from the VLH since May 1998." A second visit on February 14, 2000 showed the message, "Physicians have received over 19,723 hours of AMA Category 1 CME credit from the VLH since May 1998." And a third visit on March 25, 2000 showed the message, "20,801 CME hours issued since May 1998." This would suggest that Virtual lecture Hall is presently awarding about 1000 credit hours per month. 

Virtual Lecture Hall keeps in frequent touch with its subscribers by email and offers a free service of keeping track of the users' CME hours. 

Another large site, which asked not to be named, started in late 1998 or early 1999. Their instruction is of the question/answer type. The site manager offered this data: In 1999, they had between 2096 and 5341 courses per month "accessed but not necessarily completed." During that same period, the number of courses completed (quiz completed) ranged from 236 to 505 per month. This site also uses email reminders to registered users.

Medscape declined to participate in the survey for "proprietary reasons." However, George Lundberg, medical director of Medscape, stated in an Internet audio broadcast on February 8, 2000, "last week we gave out 6000 CME certificates." (Lundberg, 2000)

ArcMesa presently offers over 200 hours of credit and has been rapidly increasing its numbers of users. The site became operational in October 1997. They reported 13 courses taken in 1997, 241 courses taken in 1998, 542 courses in 1999 and 312 in the first month of January 2000. 

Cyberounds offers a new course each week and sends an email reminder about that course. The owner of Cyberounds explained that there are two types of registration. In one type, where doctors pay $125 for the year or $125 for 50 hours, and where the instruction type is text-only, Cyberounds has "about 400" subscribers. In the other type of registration, where doctors pay one course at a time, and where the questions are embedded in the text, they are getting "300-600 responses per program." 

The Director and Moderator of the Johns Hopkins Saturday Morning Program (no longer available) said, "there were about 350 logons weekly with just a handful of subscribers for CME credit." 

The editor of the Cancer Control Journal of the Moffitt Cancer Center wrote, "we have 121 registered physicians. They have taken (approximately) 319 tests since March 1999 for a total of 1,066 CME credits." She also wrote that that the site was getting 2100 to 3600 "hits" per month.

The editor of Pain.com, a free site, wrote, "we do not have definite numbers for physicians visiting Pain.com, but for November 1999 we had 346,252 page views from 56,911 visitors and awarded 248 hours of online CME credit." 

One university-sponsored specialty-oriented site which asked not to be identified reported, "from February 1999 through December 1999, (we had) 552 clients registered; 369 clients were MDs; we issued 252 certificates." 

One medium-sized site said that about 10% of their doctor-visitors were regular users of their site and that 90% visited "occasionally." They also noted "most doctors do their accreditation in one sitting and take on average 2 courses per sitting." And they stated, "from July 1, 1998 to June 30, 1999, we awarded 127.5 CME credit hours for 18 courses." 

CMEWeb specializes in question-answer instruction. They reported that, in the past three years, 4,000 doctors took tests at their site. These doctors took over 20,000 tests, worth over 30,000 credit hours. 

The editor of Radiological Society of North America Electronic Journal (URL updated December 4, 2006) said, "The total number of RSNA EJ CME tests taken is approximately 2600. The RadioGraphics CME tests taken average about 800 per month." 

Morbidity and Mortality Weekly Report (MMWR) (URL updated December 4, 2006), a free federal government-sponsored site devoted to infectious disease, has ten different courses offering one to three hours of credit each. Over the most recent reporting year, they awarded from 187 to 4236 credit hours with a total of 9201 credit hours. On the most popular course, Hepatitis C, 2118 users earned 4236 credit hours. 

NIH Consensus Development Program, another free federal government-sponsored program, has been offering free CME credit for reading and answering questions about their online Consensus Statements since mid-1995.  The director of the NIH program stated that from mid-1995 through the end of 1999, about 2870 physicians earned about 4007 credits using the online version of the service. These credits were earned on a total of 12 different courses. He stated that this had occurred in the absence of any promotion. 

During the same period, each of the 12 NIH Consensus Statements courses was promoted to about 60,000 physicians by sending the printed version of the Consensus Statements along with the quiz form. This resulted in about 4160 physicians earning about 5767 credits through the mail version of the service. 

The owner of Pediatric Grand Rounds reported that he had 255 physicians registered. He also stated that for 1998 (8/98 to 12/98): 27 hours of CME were used. He stated, "most of our users log on and watch but either don't register or don't register for CME. For 1999 so far, only 40 hours have been awarded." 

The University of Washington online CME site, a new generalist-oriented site, stated, "we currently have 15 (apparently all doctors) signed up for our courses, and as of last week, they had earned a total of 34 hours of CME credits." 

The editor of Current CME Reviews, a psychiatric CME site, stated, "we have about 500 registered users that visit our site regularly to take tests." 

The project director of The AAPM&R (American Academy of Physical Medicine and Rehabilitation) EMG Case-of-the-Month Series reported, "from our 1998 ACCME report, we have a total  of 220 participants and up to 36 hours of instruction." 

The Virtual Hospital at the University Iowa (no longer available December 4, 2006) produces CME primarily for critical care and pulmonary physicians. They responded to the email request for information by referring to a published article (Peterson, M., Galvin, J., Dayton, C. and D'Alessandro, M. (1999)) in which they

determined the number of users who registered and submitted examinations with a score of greater than or equal to 70%. Between August 1996 and January 1998, registered users submitted 169 completed CME examinations. Of the users who submitted these examinations, 15 paid CME fees and received 52 h of AMA category 1 CME credit. The physicians who successfully completed the remaining 117 modules elected not to pay for formal CME credit.

MedRisk Online offers eight text-only programs on reducing malpractice risk in various practice settings. The director reported, "We have provided online versions since 1997. To date, fewer than 100 physicians have completed online courses, though more have registered and not yet completed their courses." 

One site offering a medical ethics program reported, "34 physicians had subscribed for 15 credit hours each."  A site offered a course in immunology had not yet had any subscribers.

Alcohol Problems: Psychosocial Issues (no longer available December 4, 2006), from Dalhousie University, is organized more like a traditional distance education course, in which students read material, answer questions, get personal online responses from the instructor and can interact with other students. The instructor reported, "the current course has been very successful with 11 participants from Western Canada, Eastern Canada, Martinique and Brazil, a very active enthusiastic group." 

The director of the Stanford Medical Informatics online "Short Course" said, "about 15 people have taken the course over the last year."