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The emergence of online CME is described as a convergence of several trends; these trends include developments in the theory and practice of distance education, new theories of how practicing physicians learn and developments in continuing medical education; several previous studies of online CME are discussed; similarities and differences between non-online CME and online CME are outlined; theories of effective online instruction are reviewed; multimedia, simulation and interactivity in online CME is discussed as is the newer tendency towards combinations of modalities in CME; the review of literature is concluded with a discussion of attempts to measure and enforce the quality of medical information presented on the Internet. Convergence
of trends The emergence of online CME results from the convergence of a number of trends in distance education, in theories of how practicing physicians learn, and in physicians' use of computer and Internet technology. Theory
and Practice in Distance Education Distance education has been practiced for at least 100 years. At first, it was called "home study" or "correspondence school." Text-based lessons and assignments were sent by surface mail and students returned their completed assignments in the same way. During the twentieth century, as more adults wanted to increase their work-related skills, the number of schools and the number of students increased. With development of technology such as audiotape, videotape, CD-ROMs, teleconferencing and email, distance education has become more sophisticated. Some of the developments in distance education in fields other than medicine and health care are presented. Most of the examples cited are concerned with education at the University undergraduate level or education aimed at helping working professionals upgrade their skills. A list of the Internet addresses mentioned in this and other sections is found in Table 1. The oldest of the large distance education organizations, the Open University of the United Kingdom, admitted its first students in 1971. It is the United Kingdom's largest university, with over 200,000 students and customers in 1997/98. The Open University represents 21% of all part-time higher education students in the United Kingdom. Courses are available
throughout Europe and, by means of partnership agreements with other
institutions, in many other parts of the world. Over 24,000 learners are
studying Open University courses outside the United Kingdom. University of Phoenix (URL updated December 2006) offers doctoral, graduate and undergraduate degree programs as well as certificate programs to working professionals around the world. Most of the programs are "live" at 85 campuses and learning centers located throughout the U.S., the Commonwealth of Puerto Rico, and Vancouver British Columbia. A
recent visit to the online area of the University of Phoenix web site
(URL updated December 2006) indicates the following online programs: Associate
of Arts in General Studies; Bachelor of Science in Business: Accounting,
Administration, Management, Project Management, Marketing, and
Information Systems; Bachelor of Science in Information Technology:
Database Management, Networks and Telecommunications, Programming
and Operating Systems, Systems Analysis, and Web Management; and
Bachelor of Science in Nursing. They also offer Master of Arts in
Education/ Curriculum and Technology; Organizational Management;
Business Administration; Accounting, Technology Management and Global
Management; Computer Information Systems; Nursing; and Doctor of
Management in Organizational Leadership. In the University of Phoenix Online Program communication is Many-to-many
rather than one-to-one. Each class shares its own group mailbox, which
serves as an “electronic classroom.” Each class uses a group forum
where students put their work and ideas before classmates for comment.
This upgrades the quality of most work before its more formal, academic
review by the instructor. The Online program is organized around the needs of working professionals. "Each online class lasts five or six weeks... Students devote an average of fifteen to twenty hours a week to their studies." The web site of the University of Phoenix Online Program site (URL updated December 2006) describes a typical course: Typically, on the first day of the week the instructor sends introductory information on the week's topic and confirms the assignments, such as reading from the textbook, completing a case study, or preparing a paper...The instructor also posts a short lecture or elaborates on the material, and provides discussion questions related to the topic. Throughout the week you work on your reading and assignments on your own... You use the computer conferencing system to participate in the class discussion and ask questions/receive feedback. When your assignments are due, you send them to your instructor online; s/he grades them and sends them back to you with comments. A more recent trend is that traditional and prestigious universities are now beginning distance education programs. Cardean University (URL updated December 2006) is a consortium of five universities: Columbia University, The University of Chicago, Stanford University, The London School of Economics and Political Science and Carnegie Mellon University, created to provide graduate business education online. In its statement of purpose, Cardean says, (we are) committed to advancing the way businesses and individuals learn. Developments in cognitive science and technology have created an unprecedented opportunity to shape an entirely new learning community. Unlike much distance learning, Cardean is a highly involving, highly motivating environment that features: Student-centered
design. Much traditional education is built around instructors' needs.
We've inverted that model and built Cardean to serve the needs of
learners. Students learn anytime and anyplace. Moreover, Cardean courses
are self-paced, allowing students to progress at their own speed.
Students' individual styles, interests, and schedules will shape their
own personalized paths to learning Real-world
relevance. In the real world, learning occurs when you set out to solve
a problem. Cardean courses emulate this approach to learning. For the
most part, they are structured around real-world business projects. This
model is not only inherently motivating; it also ensures that Cardean
knowledge is highly relevant in the workplace. Collaboration. Cardean learning stimulates interaction. Using collaborative tools such as threaded discussions, chat, and e-mail, students can interact with faculty and other students as often as they want. This not only provides them with a learning support network, it also furnishes them with a wide variety of perspectives and a strong sense of underlying community— hallmarks of most successful business environments. There are several journals devoted to distance education. The American Journal of Distance Education publishes a monthly print journal that "acts as a forum for criticism and debate about research in and the practice of distance education in the Americas." The Virtual Education Gazette (renamed geteducated.com), an online newsletter, is published by Distance Learning Consultants & Industry Analysts; it offers a monthly review of new developments and distance education courses. Distance education is not without critics: Phipps and Merisotis (1999), in their review of studies of distance education, conclude, "Existing research is inadequate to draw conclusions on the effectiveness of distance education." Teaching at an Internet Distance (1999) is the product of a series of meetings held at the University of Illinois in 1998 and 1999 to "study the pedagogy of online learning, to examine what (makes) good teaching, whether in the classroom or online, and to suggest how online teaching and learning can be done with high quality." The seminar focused almost entirely on pedagogy, and sought to "identify what made teaching to be good teaching, whether in the classroom or online." The seminar concluded that Online teaching and learning can be done with high quality if new approaches are employed which compensate for the limitations of technology, and if professors make the effort to create and maintain the human touch of attentiveness to their students.... Online courses... can be used in undergraduate education, continuing education, and in advanced degree programs.... Participants concluded that the "ongoing physical and even emotional interaction between teacher and students, and among students themselves, was an integral part of a university education. Moore (1999) compares the
business strategies of distance education providers to the retail
service industry. He states Using the retailing model, we may perceive suppliers of distance education as choosing among the following strategies: 1) the distance education superstore; 2) the distance education chain store; 3) the distance education boutique; 4) the distance education cooperative; 5) corporate alliances: and 6) the distance education consultancy Moore (1999) says, "In considering which business strategy to adopt, distance education institutions and their faculties must ask themselves"
New Theories Of How Practicing
Physicians Learn There has been a marked movement away from the "teacher-centered" model of how adults learn best to a "learner-centered" model. This movement has been felt in continuing medical education as well. Merriam (1996), in a review of adult learning theories, finds "a number of implications for the education of health professionals. The first is to develop
self-directed learners. No amount of academic preparation, undergraduate
or graduate, or CPE will be able to keep pace with changes in the health
field. Professionals must take it upon themselves to be lifelong
learners, to engage in learning projects to stay current. A second major implication is that, "the more significant learning is that which is situated in the context of adult life, in 'authentic' activity." Some of these activities are "apprenticeships, reflective practicums, internships, mentorships and case study instructional methodologies." Fox and Bennett (1998) identify two models of physicians' practice-based learning. The first model, which they call "self-directed learning," consists of 3 stages:
Fox and Bennett (1998) go on to say In each of the three stages (of self-directed learning), the learner identifies and utilises resources drawn from three broad categories: human resources, especially colleagues and coworkers; material resources, especially journals and other sources of information; and formal continuing education programmes, such as national specialty society programmes. Because the selection and use of resources is under the control of the learner, the "curriculum" is self-directed - it is developed and managed by the learner. The
second model is called "organisational learning."
Fox and Bennett (1998) note that doctors also learn from their work with patients, on teams with other healthcare professionals, and in consultation with colleagues. Within the culture of health care, each setting from primary care to tertiary referral units represents a unique organisation with a personality shaped by beliefs, norms, and ways of thinking, learning, and adjusting behaviour to changes in the environment. Fox and Bennett (1998) conclude that, in the future, CME providers (will) · Facilitate self directed learning by providing for self assessment, the acquisition of knowledge and skills, and the opportunity to reflect on clinical performance · Offer high quality individual and group education that provides authoritative information, knowledge, and skills based on expertise and evidence, (and) · Assist healthcare delivery systems to develop and practise organisational learning Trends in Continuing Medical Education Physicians have been confronted with the need to keep their knowledge current for many hundreds of years. Ell (1992) describes a CME system practiced in Venice from 1300 to 1800. Practitioners were required to attend a yearly refresher course in anatomy in order to renew their licenses. Uhl (1992) reports the "expanding interest in CME during this century" and divides that interest into four stages:
In the United States, no formal attempts at requiring CME were documented until 1932, when the American Association of Medical Colleges first proposed mandatory CME. After several decades of discussion and debate, in 1947 the American Academy of General Practice began to require 150 hours of CME every 3 years as a condition for membership. The American Medical Association (AMA) began the Physician's Recognition Award (PRA) in 1969 (AMA, 1999). New Mexico became the first state to pass a bill authorizing its Board of Medical Examiners to require CME for license renewal in 1971. In 1975, the Accreditation Council for Continuing Medical Education (ACCME) was formed as a consortium of seven organizations which all have interests in CME (ACCME, 1999). Since that time, the AMA and the ACCME have played major roles in the development and accreditation of CME. In the 1960's, as CME was developing, physician participation in these educational activities was encouraged but not required. Over the past four decades, there has been a major movement in the direction of making proof of obtaining CME credits a requirement for physicians. Increasingly, proof of CME is required for state licensure, specialty board certification and recertification, specialty society membership, hospital privileges, and payment for services by insurance companies and other payors. In a 1995 survey, the AMA found that thirty-one states required proof of CME for relicensure; by 1997, twenty-four specialty boards had made CME a requirement for certification or recertification (AMA, 1999b) Formal CME has burgeoned along with these requirements. In 1997 (ACCME, 1998), providers produced 49,563 ACCME-accredited activities totaling 544,366 credit hours. There were 3,842,236 MD registrants for these activities. In 1998 (ACCME, 1997), providers produced 61,929 ACCME-accredited activities totaling 590,301 credit hours. There were 3,662,701 MD registrants for these activities. The overwhelming majority of CME activities have been of the "live" or "home study" (not online). In 1998, about 80% of all CME was obtained in live sessions, and 19% was obtained in home study, while only about 1% was obtained online. Developments in Physicians' Use of
Computers and the Internet Khonsari (1996) studied the readiness of Florida physicians to use computer-based programs to conduct CME. She found that respondents' attitudes were systematically related to age, majority of practice, level of board certification, years of practice, location of practice, level of experience and familiarity with computer applications, specifically computer-based distance CME, and their preferred methods of receiving information. On average, respondents' attitudes were slightly to moderately positive toward computer-based CME. Kripilani, Cooper, Weinberg and Laufman (1997) reported on a 1995 survey of primary care physicians about their preferences for computer-assisted CME. Although they had only 102 respondents to their survey, Kripilani et al. concluded, "Most physicians are currently interested in computer-assisted CME." Olson (1999) studied the preferences of pediatricians and family practitioners for CME distance modalities in Illinois, Iowa, Michigan, Minnesota and Wisconsin. While 78.4% of Olson's
respondents indicated they had used or were willing to use distance
education, 21.6% stated they were unwilling to use "any"
distance education methods. The most
common reasons given were: prefer
“live” interaction; too impersonal; need flexibility in scheduling;
lack computer skills; simpler ways available (journals, conferences);
alternatives readily available; and don't want to pay for CME. Olson concluded that there is a significant level of interest among Pediatricians/Family Physicians in using distance education technologies for CME. Physicians who are more likely to be interested in distance education are relatively close to traditional sources of comprehensive CME programming, live in areas that are more urban than rural and are less than 55 years of age. He also concluded that cost is a primary factor in the acceptability of CME programming offered via distance technology. An additional conclusion was that recovering costs of delivering high quality CME programming offered at a distance by fees charged participants requires a target audience that goes beyond the regional level. The University of Wisconsin (1999) did an email survey of 4870 physicians in Iowa, Illinois, Indiana, Michigan, Minnesota, North Dakota, South Dakota, and Wisconsin. The Wisconsin online survey included seven questions: age of
participant; specialty; current access to internet; if not connected,
would earning CME credits online be an incentive to get hooked up;
interest level in earning accredited hours on the internet; topics
physicians were most interested in taking online; and how many CME hours
were earned within the past year. Of the 3008 physicians contacted, plus 17 physicians who saw the survey on their web site, 112 physicians (3.7%) answered the survey. Of these, 84%, mostly in the 41-60 year age range, were interested in taking courses online. Primary care physicians showed the greatest response rate (about 40%). The topics most commonly suggested included: administration (business practices, managed care, faculty development), pharmacology, and cardiovascular medicine. Physicians stated that they had earned an average of 57.63 credits in the past year. Some of their conclusions are: Despite the low (3.7%) response, they considered the results important due to the total number who responded. They found the overwhelming interest in administrative courses (about 27%) to be of particular interest. Based on this survey, the University of Wisconsin decided to start an online CME program. Lundberg (2000) listed these percentages of physicians who know how to use the Internet: 1995, 3%; 1996, 15%; 1997, 32%; 1998, 60% and 1999, 80%. Surveys of Online CME Sites
Peterson
(1999) searched the Internet between July 1 and August 31, 1998, for
sites offering online CME. He identified 53 sites offering online CME,
but was able to access instructional material at only 39 sites. Peterson
was mainly concerned with issues of quality of the web sites and with
the issue of whether the Internet might allow commercial sites to gain
ascendance over the University-sponsored sites. Peterson concluded,
“as of 1998, universities may be losing their traditional leadership
in CME using the new Internet medium. Many sites offering CME do not
meet minimal standards for quality control.” Erickson (1999) discussed the MedicalMeetings.com Seventh Annual Physician Preferences In CME Survey in January 2000. Medical Meetings mailed 1,000 surveys with a dollar incentive enclosed. They received 160 usable responses, for a 16 percent response rate. They also posted the survey to their corporate Web site, and sent e-mails to a list of 5,000 physicians. While most of the Medical Meetings survey concerned the more general questions of physician preferences, it made several observations regarding online CME. Women physicians appeared to have very little interest in online CME. While 14 percent of their "male respondents are using electronic media as an option for obtaining CME," and earning about 7% of their CME credits that way, not a single woman physician reported using an online product. Since the percentage of women respondents increased from 17% (in 1994) to 30% (in 1999), this led to a reduction in the percent of all physicians (using online CME) from 19% to 14%. This is an apparent, but not real, decrease, since all other reports showed the actual numbers of (online) courses taken to be steeply increasing. All providers of ACCME-accredited CME must file an annual report of their activities with the ACCME. The ACCME then publishes an annual compilation derived from these reports. This report encompasses all CME, whether live or "enduring materials," and includes courses, regularly scheduled conferences, journals and Internet. The 1997 report (ACCME, 1998) shows that in 1997, Internet CME accounted for 166 activities (0.33% of total activities), 1,299 credit hours (0.24% of total credit-hours) and 13,115 physician-registrants (0.34% of physician-registrants). The 1998 report (ACCME, 1999) shows that in 1998, Internet CME accounted for 1516 activities (2.45% of total activities), 5,357 credit hours (0.9% of total credit-hours) and 37,879 physician-registrants (1.03% of physician-registrants). The 1999 report will be available in mid-summer, 2000. Comparison of Online CME to Traditional CME
The vast
majority of CME credits are still earned using the older, more
traditional, forms of instruction. In this section, the traditional
forms of CME are described and each of these traditional forms is
compared and contrasted with its online counterpart. Many physicians attend meetings at their local hospital. Typically these meetings consist of a lecture discussing a medical condition or a procedure. Sometimes the lectures may be based on a case of a real or simulated patient (this kind of meeting is often called "grand rounds"). Typically the lecturer talks for 40-45 minutes and leaves time for a 5-10 minute question and answer period at the end. The speaker may simply talk without any audiovisual aids or just using a chalkboard. More typically he or she uses slides or overheads. Sometimes the speaker may distribute a handout to use for future reference. There is generally no pre-lecture or post-lecture test of knowledge. Physicians earn credit by putting their names on a signup sheet. The instruction is primarily "teacher-centered"; the lecturer has a set of pre-determined points to make and expects that these are the points that the listeners need to learn. Although the live "teacher-centered" lecture remains the dominant form of CME, it has been difficult to prove that this form of CME results in any change in the physician-student's practice behavior (Davis et al., 1999) However there can be important non-academic benefits of attending such a presentation. The physician-student may learn that the lecturer, often a physician who practices in the same or nearby community, has an interest in seeing patients with the disease presented or performing the procedure discussed. The usual reward for the speaker is the spread of his or her reputation and the possibility of future referrals. Another advantage of attending these meetings is social; the physician gets to see old friends, make new friends and learn what is happening at the hospital and in the local medical community. Physicians can participate in lecture-based meetings at their specialty society's monthly regional dinner meeting or at drug company-sponsored evening or weekend talks. The format at these meetings is generally the same as at the hospital meetings. Much of online CME is organized in the same manner as the hospital meetings, specialty society meetings and drug company-sponsored conferences. The student "attends" a lecture on the Internet either by reading a text or text-and-graphics article, or looking at and listening to a slide-audio presentation or slide-video presentation. Sometimes there is a post-instruction test; sometimes the physician must merely state his or her opinion as to the quality or relevance of the instruction. There are some potential advantages of "attending" online CME lectures (compared to the live local lectures). Given an efficient and comprehensive online CME search engine, the user could select a presentation on almost any medical topic from the best expert in that medical area. The physician could "attend" this lecture in the evening or over the weekend and view or listen repeatedly to those parts of the presentation that are most interesting or most difficult. The major disadvantage to "attending" a lecture on the Internet is the loss of the social relationships that occur in the live setting. Also, online CME lectures share the general disadvantage of the lecture-based, "teacher-centered" approach. The extended live course or conference is an enlarged version of the local hospital lectures. These meetings may occupy half a day to a full week. Typically a physician attends 4-6 hours a day of lectures. The topics at most of these meetings are generally relevant to the physician's specialty. The arrangements are generally better than at the local hospital; slides are polished; audio-visual arrangements are more solid; there is often a syllabus that the physician can take home and study later. The speakers and topics have been chosen by a committee of leaders in the field based on their beliefs about what their members need to learn. Research (see Studies of Effectiveness below) has shown that these lecture-based conferences are not effective in changing physician performance. There may be however, some less tangible benefits: the physician may achieve rest and recreation away from practice concerns; he or she may return to work feeling refreshed and invigorated. Medscape offers an experience that attempts to emulate the multi-day single specialty meeting in its conference summary section. These summaries are generally text-based and cover one to two hours of instruction per conference day. Users need to take a test to obtain CME credit. Earning CME by remote asynchronous "attendance" has the same advantages and disadvantages as those described for the individual one-hour lectures but with the added advantages of saving travel time and the costs of travel, hotel and conference registration. Sometimes conference speakers are videotaped and their presentations placed on the Internet as online CME. Audio and video teleconferences take place at the hospital or the clinic on a scheduled basis. Many groups of physicians in widely scattered areas watch and listen to a live lecture or discussion by experts in the field. Near the end of the presentation, a few questions are taken from the local sites. This format is essentially the same as the hospital lecture except that the students are participating by audio or video. A good example of video teleconferencing is OMEN-TV from Ohio State University. If the video teleconference is recorded and converted for the Internet, e.g., OMEN Online, it can then become online CME. Non-online home study CME courses vary widely in goals, length, expense, goals of instruction, medium of delivery and type of instruction. These courses range from one-hour text-based articles to one-hour videotapes on a single topic to 100-hour text, audio and CD-ROM board recertification reviews. Some examples of home study courses are AAFP Home Study Self-Assessment (text), Audio-Digest (audiotapes), AAFP Video CME (videotapes) and ArcMesa OPERA (CD-ROM). The main similarity of these courses to online CME is that they tend to be pursued at home in the unscheduled hours of a physician's day; they are generally solitary; and the user can proceed at his or her own pace. The non-online home study CME courses, especially the more extensive ones, often require more of a commitment of time and money (25 to 100 hours and $250-$1000) than the typical online courses. Some of the non-online home study courses are organized as question/answer type of instruction or as the interactive type. Physicians may also attend procedure-oriented courses, where the primary goal is to learn how to perform a particular surgical operation or examination such as colposcopy, sigmoidoscopy, or application of casts and braces. Theories of Effective Online
Instruction Ritchie and Hoffman (1997) describe seven elements that should be incorporated into the design of web-based instruction. These are: motivating the learner; identifying what is to be learned; reminding learners of past knowledge; requiring active involvement; providing guidance and feedback; testing; and providing enrichment and remediation. Reeves and Reeves (1997) present "a model of interactive learning via the World Wide Web based upon research and theory in instructional technology, cognitive science, and adult education." The proposed model includes
ten dimensions of interactive learning on
the World Wide Web, including (1) pedagogical philosophy, (2) learning
theory, (3) goal orientation, (4) task orientation, (5) source of
motivation, (6) teacher role, (7) metacognitive support, (8)
collaborative learning, (9) cultural sensitivity, and (10) structural
flexibility. This set of ten dimensions is by no means exhaustive, and
enhancements to strengthen its utility are expected. Nonetheless, this
model addresses a fundamental misunderstanding, i.e., what is unique
about WBI (web-based-instruction) is not its rich mix of media features
such as text, graphics, sound, animation, and video, nor its linkages to
information resources around the globe, but the pedagogical dimensions
that WBI can be designed to deliver (emphasis added). In short, the
World Wide Web is only a vehicle for these dimensions. Although WBI may
be more efficient or less costly than other vehicles, it is the learning
dimensions that will determine its ultimate effectiveness and worth. Multimedia, Simulation and Interactivity in Online CME
The vast
majority of current online CME offerings are of the
"teacher-centered, disease-centered lecture" type. This is
true whether the instruction is by text, text or graphics, slide-audio
or slide-video. The present study reveals that only 17% of the online
CME sites reviewed offered case-based interactive instruction and 4%
offered interactive question/answer instruction. There are, however, some notable exceptions to this rule. One of the earliest (1995) case simulations on the Internet is The Interactive Patient, Case #1 by Marshall University School of Medicine; unfortunately there have been no additional cases since 1995. In an example from e-core family practice at the Virtual Lecture Hall, the learner is presented with a realistic case scenario, e.g., a "32 year old woman with depression". After a brief case description, the program presents the user with choices of how to proceed (Appendix G). If the physician makes an incorrect choice (Appendix H), the program gives an "incorrect" response and asks the user to try again. When the physician finally gets the correct answer, the program presents more information about depression and how to treat it most effectively. In addition the program presents a bar graph showing how other physicians have responded to this question (Appendix I). In an online CME about asthma from MedConnect Family Practice, the program presents a brief description of a teenager with wheezing. (You will need to register to view this instruction.) Before the student can proceed, the program presents three multiple-choice questions. For each question, the student is presented with a "Correct!" box for the correct answer, and with an explanation and instruction for an incorrect answer. In a third example using interactive sound and graphics, Case Study of Congestive Heart Failure, the program presents the case of a sixty-one year old man with shortness of breath. After the presentation of a brief case history, the user performs a physical examination, chooses laboratory tests, views results of laboratory tests with comments and goes on to other aspects of treatment and follow-up. At each step, the program gives feedback to the user. A recent addition to online CME utilizing interactivity, multimedia and simulation in the teaching of cardiology, can be found at CardioVillage, sponsored by the University of Virginia. This site offers a pre-instruction test, multimedia tutorials, literature review, case simulations, board review and a post-instruction test. Studies of Effectiveness of CME
Davis and
his group at the University of Toronto have been collecting and
analyzing randomized controlled studies of the effectiveness (in
changing physician behavior) of many forms of CME (not online) for many
years. In their most recent review (Davis et al,
1999), they state,
"Our data show...evidence that interactive CME sessions that
enhance participant activity and provide the opportunity to practice
skills can effect change in professional practice and, on occasion,
health care outcomes." They also write, "didactic sessions do
not appear to be effective in changing physician performance."
Davis et al. go on to say, (instructions)
that used interactive techniques such as case discussion,
role-play, or hands-on practice sessions were generally more
effective changing those outcomes... (and) sessions that were sequenced
also appeared to have more impact. (Instruction is more effective when
it is) learner-centered, active rather than passive, relevant to the
learner's needs, engaging, and reinforcing. Davis et al. also found that, "the learn-work-learn opportunities afforded by sequenced sessions, in which education may be translated into practice and reinforced (or discussed) at a further session, may explain the success of sequenced interventions." Bero et al. (1998) discuss some of the issues involved in transforming medical diagnosis and treatment guidelines into practice. They performed a meta-analysis of research into the effectiveness of interventions to promote behavioural change among health professionals. They found these "consistently effective interventions:" Educational
outreach visits (for prescribing in North America); reminders (manual or
computerised); multifaceted interventions (a combination that includes
two or more of the following: audit and feedback, reminders, local
consensus processes, or marketing); (and) interactive educational
meetings (participation of healthcare providers in workshops that
include discussion or practice) Interventions of "variable
effectiveness" were found to include audit
and feedback (or any summary of clinical performance); the use of local
opinion leaders (practitioners identified by their colleagues as
influential); local consensus processes (inclusion of participating
practitioners in discussions to ensure that they agree that the chosen
clinical problem is important and the approach to managing the problem
is appropriate); and patient mediated interventions (any intervention
aimed at changing the performance of healthcare providers for which
specific information was sought from or given to patients) Bero et al. further found that interventions having "little or no effect" included "educational materials (distribution of recommendations for clinical care, including clinical practice guidelines, audiovisual materials, and electronic publications) and didactic educational meetings (such as lectures)." Combinations of CME Instructional Modalities
Studies
such as those by Davis et al. and Bero et al. have contributed to a
growing belief that effective CME should involve combinations of
learning modalities, opportunities to practice and repeat learning
activities and institutional change. Lane (1997) describes a "multimethod package" of interventions in a study designed to "increase primary care physician adherence to national guidelines for breast cancer screening." The package included "formal CME conferences, a physician newsletter, breast examination skills training, a breast cancer CME monograph, a 'question-of-the-month' at hospital staff meetings, and primary care office visits." Physicians in the multimethod intervention group had a much greater increase in compliance with the recommended practices than did physicians in the control group. Emphasizing the importance of institutional participation in effective CME, Lewis (1998) describes the intense involvement of management in planning and putting a CME program to help doctors learn to take sexual histories in AIDS-related clinical scenarios. Lewis believes that effective CME requires "a motivated learner," "a competent teacher and/or an effective intervention" and "the elimination of structural barriers." Barnes (1998) envisions a "fully-integrated practice-learning environment." In this model,
(continuing
medical) education…will be driven by and measured by clinical
performance...practitioners will systematically analyze clinical,
financial, and patient satisfaction information, determining the impacts
of educational interventions by objective measurement of patient
outcomes. A variety of educational resources will be made
available to accommodate individual information needs, learning styles,
motivation, and commitment to change practice behaviors (emphasis
added). Training programs will be developed to support the
specific competencies required for practice, including both clinical and
non-clinical skills. Strategies will be devised for implementing
the varied mandates and recommendations being imposed on the medical
profession by payers, health care networks, and public health agencies. Barnes goes on to predict that
In
the practice-learning environment, a physician will begin an educational
activity … by reflecting on his or her practice performance.
Information systems will … (supply) aggregated, trended, and
benchmarked data reflecting clinical outcomes, resource utilization, and
patient satisfaction. Of particular significance will be the
incorporation of feedback from managed care networks and quality
improvement programs, measuring the data against national outcomes (from
HEDIS and other databases) as well as in terms of compliance with
practice guidelines and other standards for care. Information systems
must…offer the type of information that will assist physicians in
clarifying and making the best use of learning opportunities;
facilitating the choice of the most effective information resources; and
determining the subsequent effect of the learning intervention. Barnes mentions three examples of "innovative projects (which) demonstrate how information technology can support an expanded view of CME." They are the Canadian Maintenance of Competence Program (MOCOMP), which encourages physicians to reflect on practice in order to develop structured plans for learning. Using the PC Diary software on which the program is based, practitioners record issues that they would like to learn more about. Before proceeding with an educational intervention, the computer program prompts the physician to determine the stimulus or event that caused him or her to identify the issue as well as the anticipated impact that the subsequent learning activity will have on physician's practice. Over time, the database becomes a learning portfolio. By requiring that physicians reflect on learning issues and define the intended outcomes, the learning activities are more focused, intentional, and systematic. Physicians report that using the PC Diary software gives them a sense of control over their CME planning and also decreases their sense of information overload. The Stanford Health Information Network for Education (SHINE) offers an integrated collection of core content, including texts, pharmaceutical databases, a differential diagnosis system, a bibliographic database, national consensus statements and guidelines, online journals, multimedia resources, and custom-developed educational activities, all of which can be accessed through a unified interface on the Internet. The system permits a user to distribute a query simultaneously to different types of resources (such as texts, guidelines, and journals), providing a consolidated search. SHINE will have the capability of supporting teleconsultations with colleagues through the use of e-mail or videoconferencing. The system can also track a physician's use of the various resources and support the development of learning portfolios. Barnes' third example comes from the University of Indiana where Jay and colleagues have developed several computer simulation programs to encourage physicians to modify their practice behaviors, to evaluate the relative costs and benefits of various types of clinical interventions, and to determine the implications of patient demographics and physician practice patterns on the costs and outcomes of care. Physicians, individually or in groups, can use these programs to assess the implications of various approaches to patient care and to choose optimal courses of action. Being able to assess the likely impacts of various interventions in several perspectives, such as clinical outcomes and cost, can help providers begin to make rational decisions regarding resource allocation. The computer simulations, by presenting all possible outcomes, including unexpected ones, can also help users to identify additional learning needs. The simulation models can be applied to quality improvement efforts, health services planning, and business planning. Barnes
concludes, “The ‘killer app’ for improving physician performance
will involve integrating these types of applications with clinical
information systems, which will allow physicians to move between
practice and learning through a single interface.” Quality of Medical Information and CME on the Internet
Several groups have proposed
guidelines for medical information intended for consumers on the
Internet. Among these is the Health on the Net Foundation (1997) whose
Code of Conduct includes the principles of authority,
complementarity, confidentiality, attribution, justifiability,
transparency of authorship, transparency of sponsorship and honesty in
advertising and editorial policy. (Table
2). Jadad and Gagliardi (1998) found a total of 47 different systems intended to rate health information presented on the Internet, but concluded, "It is unclear... whether they should exist in the first place, whether they measure what they claim to measure, or whether they lead to more good than harm." Kim, Eng, Deering and Maxfield (1999)
searched "world wide web sites and peer reviewed medical journals
for explicit criteria for evaluating health related information on the
web" and found "29 published rating tools and journal
articles... that had explicit criteria for assessing health related web
sites." They observed that the most frequently cited criteria were those dealing with content, design and aesthetics of site, disclosure of authors, sponsors, or developers, currency of information (includes frequency of update, freshness, maintenance of site), authority of source, ease of use, and accessibility and availability. Medical Matrix has created a one to five "stars" ranking system for medical web sites to be used mainly by medical professionals (Table 3). In ranking each site, Medical Matrix considers peer review, application, media, feel, ease of access and dimension (Table 4). Peterson (1999), in evaluating the quality of 39 online CME sites, used the set of standards proposed by Silberg, Lundberg and Musacchio (1997). These eight standards include requiring registration by the user, identification of the author, provision of clear published references for the content, disclosure of sponsorship, date-stamped pages, whether or not there is peer-review, testing of the user and feedback. To date, this writer has found no widely accepted standard for quality of Internet CME sites. |