Policy and Medicine

ACCME Launches International Academy for CPD Accreditation and other ACCME News

This month, the Accreditation Council for Continuing Medical Education (ACCME) has been busy with a number of activities and announcements.  Below is a summary of some of the events, activities, and other information regarding the CME industry and stakeholders contained in their March 2013 newsletter. 

International Academy for CME/CPD Accreditation Leaders 

The ACCME and the Royal College of Physicians and Surgeons of Canada have joined together to create the International Academy for CPD Accreditation. The purpose of the Academy is to provide an opportunity for interchange for leaders serving in continuing medical education (CME) and continuing professional development (CPD) accreditation systems and for those seeking to establish CME/CPD accreditation systems. 

The Academy aims to support networking, facilitate mentoring, promote innovation, and enhance the development and implementation of CME/CPD accreditation systems internationally. Accreditation leaders will have the opportunity to learn about each other’s values, principles, and metrics; explore educational and ethical accreditation standards; and to foster evaluations to assess the effect of CME/CPD accreditation systems on physician learning, competence, health care team performance, and health care outcomes. 

The Academy has invited accreditation leaders from around the world to join. Currently, the Academy includes members from the US, Canada, Hong Kong, Oman, and Australasia. The inaugural meeting of the Academy will be held via webinar on May 23. 

ACCME Invited to Join World Federation of Medical Education Standards Revision Task Force 

The World Federation of Medical Education (WFME) has invited the ACCME to participate in the revision of its standards for postgraduate medical education and continuing professional development.  Murray Kopelow, MD, ACCME President and CEO, will serve on an international task force to prepare the draft revision. 

WFME’s mission is to strive for better health care for all people.  Its primary objective is to enhance the quality of medical education worldwide, through the promotion of the highest scientific and ethical standards in medical education.  The ACCME said it is pleased to participate in the initiative as part of its commitment to supporting collaboration within the global CME community. 

ACCME Workshop Includes Public Health Imperatives Forum 

The ACCME has added a new session to its 2013 CME as a Bridge to Quality™ Accreditation Workshop, which is scheduled for April 24-26 in Chicago.  The two-part “Public Health Imperatives Forum” will feature representatives from several federal government agencies. The following agencies have accepted our invitation to participate: the National Institute on Drug Abuse (NIDA), the National Human Genome Research Institute (NHGRI), and the Office of the National Coordinator for Health Information Technology (ONC).  In the first part, the government representatives will discuss how CME can be a strategic partner in addressing public health priorities.  A breakout session will follow, giving participants the opportunity to engage directly with federal representatives about collaboration opportunities to address public health priorities. 

New Videos: How CME Can Support Health Care Professionals’ Continuing Professional Development 

In three new videos, Murray Kopelow, MD, ACCME President and CEO, discusses the role of CME as a strategic asset to health care professionals’ continuing professional development. 

• Accredited Continuing Medical Education as an Educational Home to Support Continuing Professional Development
• Can your CME Program support accredited continuing education for the health care team?
• What are the biggest misconceptions that physicians may have about CME? 

Additional Compliance Examples Posted for Accreditation with Commendation Criteria 

The ACCME added new examples of compliance with the criteria for achieving Accreditation with Commendation to the Examples of Compliance and Noncompliance: Findings Based on the ACCME Accreditation Criteria. Here is the list of new examples. 

• Criterion 16: Compliance Examples 10–26
• Criterion 17: Compliance Examples 12–23
• Criterion 18: Compliance Examples 10–19
• Criterion 19: Compliance Examples 10–16
• Criterion 20: Compliance Examples 10–22
• Criterion 21: Compliance Examples 11–23
• Criterion 22: Compliance Examples 8–14

The Examples of Compliance and Noncompliance: Findings Based on the ACCME Accreditation Criteria enables providers and CME stakeholders to learn from each other and to understand how the ACCME determines compliance and noncompliance with its requirements.  Examples of compliance and noncompliance with each of the Accreditation Criteria, drawn from the accreditation review process, are included. The ACCME created a PDF of the Examples, with the new examples highlighted. 

AMA Selects 31 Medical Education Proposal to Continue Next Phase in $10 Million Initiative

As we noted back in February, the American Medical Association (AMA) announced a $10 million competitive grant initiative to attract bold, innovative projects to transform the way medical schools train future physicians.  Consequently, the AMA announced in late March that it had selected 31 innovative proposals from the initial pool of 119 applicants to move forward in the AM’s $10 million Accelerating Change in Medical Education initiative aimed at transforming the way future physicians are trained. 

“More than 80 percent of U.S. medical schools submitted brief letters of intent outlining their ideas to redesign medical education – an outstanding response that demonstrates medical schools are ready and willing to implement bold, transformative and innovative ideas,” said AMA President Jeremy A. Lazarus, M.D.  “We’ve narrowed these initial applications down to 31 exciting ideas, and we look forward to reviewing the full proposals in the coming months to find the ones that can best align with the changing needs of our health care system.” 

The schools selected will develop a more comprehensive proposal outlining the specifics of their innovations and must submit their full proposals by May 15. The AMA, with the help of a national advisory panel, will select 8-10 grant awardees to be announced in June at the AMA's semi-annual policymaking meeting in Chicago. 

Performance Improvement CME Improves ADHD Clinical Outcomes 

At the recent 2013 Alliance for CE in the Health Professions Conference, CME research was presented on a performance improvement (PI) CME activity designed to improve primary care providers diagnosis and management of adults with attention deficit/hyperactivity disorder (ADHD).  The target audience was HCPs in primary care.  The activity followed the American Medical Association’s 3-stage methodology for PI CME.  

In Stages A and C, the pre-assessment stage and post-assessment stage, participants evaluated their practices with respect to performance measures to diagnose and treat adults with ADHD.  They completed a self-assessment survey, answered questions from chart reviews of adult patients with ADHD in their practice, and selected one or more Quality Improvement Plans (QIPs) to implement in their practice to improve care given to adults with ADHD. 

In Stage B, the action stage, participants were supplied with educational material (National Association of Continuing Education Adult ADHD Toolkit) designed to inform them about caring for adults with ADHD and to help them implement their chosen QIP(s). Performance change was measured by comparing data sets from their self-assessment surveys and patient chart reviews obtained at Stages A and C. 

A total of 92 participants completed the self-assessment surveys and 926 chart reviews prior to and after Stage B. Analysis of the self-assessment survey data gathered indicated that participants more frequently used the performance measures and that they reported feeling more confident in evaluating and treating adults with ADHD at Stage C than they did in Stage A. As a result of the PI CME intervention, medium to large positive effect sizes were found in participants’ utilization of the measures and their confidence in applying the measures with study patients.  

With respect to practice behavior as indicated in the chart reviews, compared to Stage A, participants who completed the PI CME activity were significantly more likely (P < .001) to execute comprehensive initial assessments (91% vs. 97%) and use rating scales (71% vs. 90%) to evaluate adults with ADHD in their practice during Stage C.  Also, more participants confirmed symptom severity using corroborating evidence, recommended pharmacologic and psychosocial treatments, and provided follow-up after establishing a treatment plan. 

Based on these findings, this study concluded that the participants of the PI CME activity often selected more than one QIP to implement in their practice, made improvements across key performance measures that would serve to enhance their practice and improve clinical outcomes for their adult patients with ADHD, and reported increased confidence in providing care to adults with ADHD.  The data derived from the activity, combined with participants’ comments about the value of the educational materials and the instructional format used, validated the educational effectiveness of this 3-stage performance improvement mode of instruction.

CME's Critical Role in Improving Quality and Outcomes

Over the years, we have emphasized the critical role continuing medical education (CME) provides to improving patient outcomes, reducing healthcare costs, and enhancing the overall quality and efficiency of the U.S. healthcare system—both in terms of more education and proficient physicians and through serving as a conduit for medical progress and innovation.   

CME covers a number of topics and disease areas, and has been proven to improve patient outcomes in areas such as multiple sclerosis, hypertension, COPD, ICU patients, improved taking of family history by physician assistants, Sepsis, healthcare-associated infections, reduction in CT scans, and several other areas.  

Interestingly, a recent article published in the Journal of the American Medical Association (JAMA) called for new steps to educate physicians about the inefficiencies that cause billions in lost healthcare dollars every year.  More work is needed to ensure doctors are aware of “program integrity” -- a term payers use to refer to losses due to inappropriate payments or exploitation, Shantanu Agrawal, MD, medical director for the Center for Program Integrity at the Centers for Medicare and Medicaid Services (CMS) in Baltimore, and colleagues wrote, as reported by MedPage Today. 

“While federal and state governments are vital participants, leaders in medical education, licensure, and specialty certification would ideally work together to ensure that all physicians have sufficient awareness to safeguard public and private healthcare programs, patients, and themselves,” the authors wrote.  Waste accounts for 30% of overall healthcare costs.  “Few physicians intentionally abuse or defraud the healthcare system, but nearly all contribute to waste,” they said.  For example, CMS found insufficient documentation, lack of medical necessity, and coding errors contributed to nearly $30 billion in fee-for-service overpayments in 2011. 

“Despite the enormous resources at stake, physicians receive little education in how to manage and steward finite resources, making formal education of physicians in ‘program integrity’ an essential component of medical professionalism,” the viewpoint stated. 

To handle this costly situation, physicians could receive program integrity training during residencies and fellowships.  “Training could be specialty-specific, and trainees may be more likely to internalize the material if it comes from trusted educators,” the authors wrote.  Only 44% of medical schools and 68% of institutions supporting graduate medical education offer any instruction in program integrity, they said. 

“States could specify that a certain amount of continuing medical education (CME) be earned in program integrity as a condition for licensure,” the authors wrote.  State medical boards could develop their own courses and encourage doctors to participate regularly.  “Similarly, specialty boards could require competence to claim diplomate status and maintenance of certification requirements.  Such education could be specialty-specific,” they suggested. 

Currently, there are few opportunities for education in program integrity.  “CMS does not mandate such education to participate in Medicare and Medicaid,” Agrawal and colleagues wrote.  “To our knowledge, no state medical board requires program integrity education for licensure, and no specialty board requires it for board certification.” 

Need for CME to Update Physicians on Drug Alerts 

In addition for the potential need for CME regarding billing, a recent article from Medpage Today highlighted the need for CME regarding caring for epilepsy patients and the drugs they receive.  Specifically, a recent online survey of American Academy of Neurology (AAN) members showed that roughly 20% of healthcare professionals caring for epilepsy patients were not aware of major electronically reported FDA drug safety warnings for anti-epileptic medicines, such as valproate, according to Sarah Bell, of Johns Hopkins University, and colleagues.  Of those who were aware of the safety alerts, as few as 23% said they remembered specific knowledge of the risks presented in a given alert, Bell presented during an oral session at the AAN meeting. 

Such shocking findings underscore the importance of CME programs and events that can educate physicians about such updates and new clinical and safety data.   

Secondarily, they also emphasize the importance of physicians speaking with sales representatives to learn about these updates at least initially, so that the physician can request more information or know whom to contact for questions.  We previously noted that physicians who fail to meet with sales representatives are even less likely to know about such safety updates, including the addition of an FDA black box warning.  The AAN survey, however, did not ask whether such members see drug reps. 

The FDA issues medication safety warnings via email and through postings on its website. However, these updates are only emailed to participants signed up to receive Drug Safety Communications and MedWatch Alert emails.  These emails are also communicated to healthcare professionals through physician specialty organizations, black box warnings or “Dear Healthcare Provider” letters, as well as in published articles on company and third-party websites. 

“FDA drug safety warnings are not being systematically delivered to neurologists,” she explained, highlighting not only the disparities in knowledge acquisition, but in the variety of sources where healthcare professionals received information from. 

Web-based CME and Pediatric Surgeons 

In other CME news, MedCity reported that doctors from across the globe are getting specialty medical training via a studio tucked inside Akron Children’s Hospital by participating in a web-based CME conference offered by GlobalCastMD.  Dr. Todd Ponsky, a pediatric surgeon who joined the staff of Children’s last year, is co-founder of GlobalCastMD, which offers low-cost, virtual medical conferences to surgeons throughout the United States and internationally.   

Recently, about 1,200 doctors logged onto a secure website to watch Ponsky and leading experts from as far away as England and France share updates about treating childhood traumas. P articipants were able to chat with each other and ask questions of the experts while watching the five-hour virtual conference.  “People can call in and talk to these key opinion leaders and see like they're there,” Ponsky said. 

The webinar concept is a “quick and efficient” way to provide doctors worldwide with details about the latest approaches to treating patients, said Dr. Wayne Meredith, chair of the Department of Surgery at Wake Forest University and executive director of the Childress Institute for Pediatric Trauma.  The nonprofit institute -- which co-sponsored Thursday’s conference -- raises awareness, supports research and provides education about pediatric injuries worldwide. 

Immediately after a similar conference last year, Meredith said, he heard back from a participant who said he learned techniques that saved a child’s life.  “The benefits of this could be huge,” he said. 

Dr. Fayza Haider, a pediatric surgeon at Salmaniya Medical Complex in Bahrain, has participated in 19 virtual conferences organized by Ponsky on topics ranging from urologic surgery to adolescent obesity.  In an email interview, Haider said the GlobalCastMD conferences let her learn about medical advances without traveling -- or changing out of her PJs. 

Through her participation, she said, she has learned surgical techniques that she has been able to use on her patients in Bahrain.  “It gives me a chance to discuss live with the experts and interact with other attendees from all around the world,” she said.

Global Education Group Survey: 98% Credit CME as Helpful in Improving Patient Care

A recent survey developed by Global Education Group and Medical Meetings magazine, sought to determine whether attending continuing medical education (CME) events—both live and online—are actually worth the time and effort of physicians.  According to the results of the survey, recently reported by Meetingsnet.com, physicians overwhelmingly answered “yes.”   

Moreover, healthcare providers rated accredited CME activities as more valuable for their practice improvement and patient outcomes than journal articles and other publications, speakers bureau programs, and promotional and other non-certified education. 

Among the important findings, 98% of respondents said CME/CE activities provided them with information that has helped them improve patient care. In addition, almost 60% believe the information that they gathered from accredited CME has helped them reduce the cost of the care they provide. 

The survey also highlighted another important sing of CME’s value: “Even though most physicians are required to complete just 30 hours of CME each year, 89% of the surveyed HCPs said they routinely complete more hours than required by their state boards.”  In fact, among the 89% of HCPs who complete more hours than are required, 28% said they complete more than 50 hours of certified CME annually. 

Forty-five percent of the respondents said they do more than they have to so they can learn more about new and emerging therapies, while 27% participate in additional accredited CME in order to gain additional unbiased/evidence-based information.  Another 21% seek out additional CME to learn beyond their core areas of expertise.  

As one respondent said, “The farther I get from medical school, the more I know I don’t know.”  Another explained, “I need to stay current to teach staff and share new information with them.”  Yet another elaborated, “You can never know enough, or everything.” 

That wish to know enough is, in part, the philosophy that spurred the research to begin with. “The success of our education depends on the knowledge we have of our learners,” says Amanda Glazar, PhD, CCMEP, Global’s director of adult learning and outcomes. “If we want to thrive in an evidence-based CME/CE environment, we need to collect and incorporate sound data from the learners themselves.” And while what they had to say does provide data to back up CME providers who are sick of arguing whether what they do has value, it also points to barriers that still exist when it comes to gaining real value from the hours HCPs spend on CME. 

The survey is the second phase of quantitative and qualitative study designed to analyze the perceived and in-practice value of CME compared to other forms of physician information. The first phase of the research was conducted in 2011 and reported in 2012.  This second phase expanded the scope of analysis to learn more about physician learning preferences and CME outcomes.

Background 

Global Education Group developed the 20-question survey with input from Medical Meetings.  The CME/IME departments of multiple academic centers, pharmaceutical CME teams, and education companies reviewed the survey.  It was disseminated via online tool SurveyMonkey to 6,500 U.S. healthcare providers.  A survey link also was sent to more than 62,000 members of the proprietary CME education Web site, CMEZone.com, which is owned and operated by Applied Clinical Education.  

The survey was sent in December 2012 with a follow up in January 2013.  A total of 1,417 HCPs responded to the survey; 42% were physicians;35% were nurses or nurse practitioners, and 16% were pharmacists; the rest were physician assistants, PhD/research scientists, case managers, or other non-specified types of healthcare providers.  

“Participants hailed from 49 of the 50 U.S. states, plus Washington, D.C., Guam, and Puerto Rico.  10% of respondents were from states that do not currently require CME for state licensure. (Six states currently do not require physicians to complete CME for state licensure.)” 

Anesthesiology was the most common primary clinical specialty (18%), with primary care a close second (16%) and oncology third at 9%. The rest named surgery, obstetrics/gynecology, pain management, psychiatry, cardiology, pharmacy, neurology, infectious disease, and other clinical areas.  64% had been in practice longer than 20 years, 22 percent from 11 to 20 years, and 14 percent 10 years or less. 

Certified CME's Value to HCPs 

Participants ranked CME on a four-point scale—where 1 means the item in question is not a valuable source of information/education to support professional practice and patient outcome improvement and 4 means it is a very valuable step toward those goals. 

• CME garnered a 3.6.
• Journal articles and publications came in second at 3.4,
• Speakers bureau programs (2.6)  
• Medical science liaison visits (2.3)
• Promotional/other non-certified education and sales rep visits both were rated 2.1, and
• Direct-to-consumer advertising came in last with a 1.7 rating. 

Drivers and Barriers 

The survey also asked respondents to break down their reasons for participating in either live or online/print CME/CE activities.  For live activities, almost 30% said that networking with their professional peers was a main driver.  Not far behind was the ability to interact with faculty and thought leaders (27%), and 25% said that live activities mesh best with their particular learning style. 

Another 10% said they find content that is more applicable to their practices offered in live-format activities.  Plus, live events make it easier for them to dedicate the time to concentrate just on learning, allow them to ask questions in real time, and enable them to acquire a lot of new information in just a few days, they noted in the write-in section.  

As one explained, live activities provide the “interaction and development of critical evaluation of information that is only possible when a group of professionals convene.” And, while it’s a hassle to be out of the office, they also appreciate the opportunity to combine learning from experts with travel and recreation.  “But all is not completely rosy in the live accredited CME world.”   

• 70% of the HCPs said they complete their CME via live events less than half the time.
• Among the barriers they cited were time constraints (53%) and the cost of travel (36%).
• Only 3% said their most relevant barrier to participating in live CE activities is a lack of educational value—as one person in that minority wrote in, it can be “hard to find the pearl in the oyster full of sand.” 

“But what hurts participation in live activities is a big plus for online and print CME/CE activities.” 

• 44% said the time savings are the most relevant reason they participate in online/print CE,
• 25% like the lower costs associated with these forms of CME.
• Another 16% prefer the online or print format because it is more in line with their style of learning.  They also like that it is available on demand. As one person wrote, “I can spend sufficient time to digest, and perhaps re-read, and highlight and underline pertinent information.  I can then return to the highlighted printed material for future studying.”  And for those in areas with few live programs available, online and print CME may be their only alternatives. 

Even in an on-demand world, however, time constraints are an issue.  More than half of respondents consider it the most relevant barrier to HCP participation in online/print CE activities.  The educational value also can be lacking, said 17%, while 8% cited technology challenges as a barrier to online CME.  Among the specific complaints:  

• A lack of feedback and interaction related to the material;
• Difficulty finding content that is directly relevant to their practices and interests; and
• Just a general lack of appeal. As one person said, “[I’m] tired of being in front of my computer all day. It’s not a great way to learn for me.” 

 Does It Get Results?

“Two of the main thrusts in healthcare in the U.S. these days are improving patient care while simultaneously lowering costs.  The ongoing debate is whether or not CME really does help push that agenda forward.” According to the survey results,  

• A full 98% of respondents said CME/CE activities provided them with information that has helped them improve patient care.
• Close to 60% believe the information that they gathered from accredited CME has helped them reduce the cost of the care they provide. 

When it comes to improving patient care, the majority—almost half—said that CME activities does so by giving them awareness of additional or more effective treatment options.  13% said it helps them identify their own areas for improvement, while almost 10% said the connection it provides to peers and/or faculty aids in furthering their knowledge, competency, or skills. Other benefits cited include improved patient and/or caregiver education (9%), and improvement in how they approached challenging cases. 

When asked for specific examples, one wrote, “During a cardiac arrest in the OR, I was able to identify the need for a drug that had been recently added to the algorithm . I was able to suggest it because I had recently attended a lecture on this and the others in the OR had not.” 

Looking at healthcare costs, 29% said CME/CE gave them knowledge that enabled them to consider more cost-effective treatment options, and one-quarter of respondents said using the more-effective treatment options had resulted in fewer patient follow-up visits and/or less consult time.  Other cost-reducing benefits they cited:  

• They learned to better use their healthcare team resources, resulting in a streamlined approach to patient care; and
• They learned how to better manage their patients, which resulted in patients improving their adherence to recommended treatments.  

CME also helps make them more efficient in diagnosing their patients, according to 12% of respondents.  Specifically, respondents said CME helped them avoid unnecessary and/or ineffective drug therapies; choose the most effective drug for their formulary instead of having to supply multiple drugs of the same class; and reduce the number of colonoscopy tests by following the guidelines they learned.  

One said that using the American College of Radiology Appropriateness Criteria for Imaging for evaluating abdominal pain enabled him to reduce the use of CT for abdominal cases, lowering both the cost and the radiation exposure to patients. 

“This new data can be added to a growing pile of evidence that CME does, in fact, help healthcare providers do their jobs better and that, in turn, results in improved patient outcomes and lower costs,” the article writes.  And the survey results bode well for the future of CME, says Stephen Lewis, MA, CCMEP, Global’s general manager and a Medical Meetings columnist: “The combination of this quantitative and qualitative data with the recent Sunshine Act decision to carve out an appropriate CME exemption makes for a more positive outlook than we have seen for years.”

Resolving Conflicts of Interest in CME

With increased focus on transparency and reporting or monitoring conflicts of interest (COI), there is more and more pressure on all stakeholders in the healthcare industry, particularly continuing medical education (CME) providers and supporters, to manage and reduce potential COIs.  While the Accreditation Council for Continuing Medical Education (ACCME) Standards for Commercial Support (SCS) provide clear guidelines for accredited CME providers, sometimes providers and staff can forget to pay attention to the planners of the activity in advance, and end up resolving their conflicts with content review at the end of the planning process, rather than prior to the development of the activity.

As recently pointed out by Meetings.net, ACCME requirements state that all individuals who influence content must participate in the provider’s process to identify and resolve relevant conflicts of interest.  The article noted that “more attention [is] being paid to planner resolution during ACCME site surveys” and “some instances of noncompliance for ACCME Criterion 7 have arisen out of the lack of satisfactory planner resolution early in the planning process.” 

“The selection of the lead planner, the course chair, should be made with eyes wide open relative to his or her financial relationships,” the author writes.  “Because the planning team usually shapes the activity content—they select the topics, faculty, venue, formats, etc.—making the right choices early on in the planning process is critical.”  “Since the planners are the content experts, it’s not really an option to exclude them from participating.”  In order to ensure that potential conflicts are resolved and the planners’ relationships do not unduly affect the content of the course, the article provides several practical tips for identifying and resolving planner COI: 

• Let the course directors/planners know the requirements for disclosing relevant conflicts of interest and for their participation in the process; consider a planner/faculty agreement form that requires independence from relevant COI. 
• Inform senior management about the need to ensure the content is based on valid needs assessment data and not driven by faculty/planner selection. As a starting point, consider revising your policy on the identification of financial relationships and resolution of COI to include clear direction on planner issues and processes. 
• Think about the issue of planner conflicts the minute you start planning an activity. Choose a course chair and other planners who don’t have conflicts in the first place, or who have minimal conflicts. If this is not possible, consider adding a non-conflicted planner to the committee to serve as a check-and-balance for the conflicted planner. 
• Collect financial relationship information from planners early enough so that their relevant COI can be resolved, or if resolution is not possible, they can be replaced.
  If you work in a hospital or academic center, ask the CME committee to review the activity to ensure that content is not influenced by planners’ relationships and that it is driven by the physicians’ need for further education on the specific topic. 
• Limit the conflicted planners’ involvement to aspects of planning that are not related to the reported conflict. 
• Partner the conflicted planner with a non-conflicted planner to ensure reported relationships do not influence the selection of content, formats, faculty, or any other aspect of the course. 
• Document, document, document! Consider using a COI management documentation form, which you maintain in the activity’s file. The form provides evidence of how you resolved planner COI. 

Ultimately, the author emphasized the importance of clearly identifying planners (and all other persons who affect the content of CME) by type of participant (i.e., planner, faculty, reviewer, writer, etc.) and to provide this information to the learners prior to the commencement of the activity in course materials or in the opening slides.   

Meetings.net has developed samples of documents to assist CME providers in maintaining compliance with these rules, including a sample faculty/planner agreement, a sample policy, and a documentation of resolution of COI form.  You should contact them directly if you would like a copy.

Connecticut Senator Proposes Expanding CME Requirements to Specialty Instruction Once Required Courses are Completed

A recent article from Stamford Plus news in Connecticut discussed recently proposed legislation regarding continuing medical education (CME) for physicians practicing in the state. 

State Representative Mike Molgano (R-144) testified on his proposed co-sponsored bill “An Act Concerning Continuing Education Courses For Physicians” in a public hearing of the Public Health Committee on Wednesday.  The bill (S.B. 466) would allow physicians to extend required continuing education courses with courses related to their specialty.

“Connecticut statute section 20-10b requires physicians to earn at least 50 contact hours of continuing medical education (CME) over a two-year period.  The statute stipulates education pertain to the physician’s area of practice, reflect the needs of the physician’s license, and include at least one hour of education or training in each of the areas of infectious diseases, risk management, sexual assault, domestic violence, and cultural competency,” Rep. Molgano said.

Molgano cited concerns from physicians about the stringent requirement.  Most of these physicians have taken and passed the same courses multiple times, and are eager to take courses relevant to their respective specialties. “It would be like if I went to College and took Algebra I all four years after having passed it the first time,” Rep. Molgano said. These courses would come after taking classes on infectious diseases, risk management, sexual assault, domestic violence, and cultural competency.

“The courses would be germane to their practices, reflective of their licenses, and of the subject matter pertaining to the topics enumerated in state statute. By extending course offerings, not only is redundancy eliminated, Connecticut physicians are afforded even greater opportunity to expand their professional skills necessary to meet the health care needs of the public,” Rep. Molgano added.

If the bill is enacted it would amend title 20-10b of the general statutes to allow a physician who has previously completed a required continuing education course to substitute a different course that is related to the physician's specialty.  The bill was originally introduced by Senator Toni Boucher (R-26).

 

ACCME and ACGME: Next Accreditation System

The Accreditation Council for Continuing Medical Education (ACCME) recently announced a new four-part video interview series that discusses how the ACGME’s Next Accreditation System (NAS) supports physicians’ continuous professional development and explores opportunities for medical education accreditors and hospital leaders to collaborate to improve health care safety and quality.  The interview series is with Timothy P. Brigham, MDiv, PhD, Chief of Staff and Senior Vice-President, Department of Education, Accreditation Council for Graduate Medical Education, (ACGME). 

As Brigham explained, the NAS moves away from a catch them being bad model to a quality improvement model.  In other words the ACGME is moving away from torturing the really good programs to find the toxic ones to one where we celebrate and reward the really good ones and everybody, the ACCGME, the ARCs within the ACCGME and the good programs work to help the programs that are struggling a little bit to move up.  A fundamental building blocks of that are the CLER visits, which CLER stands for Clinical Learning Environment Review, where the ACGME visiting every institution , every sponsoring institution in the country, every 18 months to ascertain how the residents are integrated into the safety and quality movements of the hospital.  

And that has all kinds of ramifications from duty hours to supervision to handovers to seeing how the residents are involved, all of the residents not just one or two who are on a committee of safety, are really integrated into learning about safety and quality and helping their institutions become a safer place.  In most institutions, ACGME found there’s a bit of parallel play going on, where the residents are doing one thing, taking care of most of the patients and there’s this sort of rigorous robust safety and quality movement that does not engage them at all.  So, they’re not learning, they’re not contributing to it and the hospital’s struggling because the residents are doing a lot of the patient care if not most of it.  

The second piece of the next accreditation system if you move from the CLER as sort of the foundation, making sure that the institution has all those qualities that the ACGME wants to see in an institution that will be educating our residents, future physicians , is a model of continuous improvement.  Accordingly, the RRCs instead of episodically biopsying the program, will be getting information on an annual basis that they can look at and say, this indicates that the program is going along in a fine way or there may be something going on in here and we’re going to have to take a look at it.   

• Understanding the ACGME Milestones: Applications and Opportunities for Accredited CME (Part 2 of 4)  
• Clinical Learning Environment Review (CLER) Visits: A Meeting Point for GME and CME (Part 3 of 4) 
• Knitting the Continuum Together: Seizing the Opportunity to Improve Medical Education (Part 4 of 4)

ACCME Updates : CME Providers Submit Year End Reporting By March 29, 2013

The Accreditation Council for Continuing Medical Education (ACCME) continued along with a number of important activities, announcements and updates for continuing medical education (CME) providers and stakeholders, according to their monthly newsletter.  As we previously noted, ACCME recognized that the Centers for Medicare & Medicaid Services (CMS) final rule implementing the Physician Payment Sunshine Act recognized the value of ACCME Standards for Commercial Support.   

As a reminder, ACCME-Accredited Providers must complete their Year-End Reporting by March 29, 2013.  So far, 488 ACCME-accredited providers have entered 32,039 activities into PARS for the 2012 reporting year.  The Program and Activity Reporting System (PARS) is always open and ACCME encourages CME providers to start entering 2012 activity data now in anticipation of the year-end reporting deadline.  Providers are welcome to enter basic information about an activity before it has taken place and complete the entry after the activity.  ACCME also provided several tips to support data entry: 

Enduring Material Activities: Who Counts as a Participant?  When reporting the number of physician and nonphysician participants for an enduring material activity, whether it is Internet-based, printed, or another format, you should count all learners who completed all or a portion of the activity and whose participation can be verified in some manner.  The ACCME would not consider individuals who only downloaded or received the activity but did not actually complete all or a portion of it to be participants. 

Regularly Scheduled Series: Is This an RSS and — If so — How Do I Report it?  First determine if your “series” is an RSS.  The ACCME considers an RSS to be planned as a series with multiple sessions, planned to occur on an ongoing basis (offered weekly, monthly, or quarterly), and planned and presented primarily to the accredited organization’s professional staff.  Examples of RSS activities include grand rounds and tumor boards.  Organizations that provide RSS activities should report each series (not session) as one activity in PARS.  Click here for more info on how to report RSS in PARS. 

ACCME Reports on Strategic Discussions with Stakeholders about CME’s Future 

The ACCME Board of Directors engaged in strategic planning in 2011 to discuss the future of the ACCME system and the role of accredited CME in supporting practice-based learning and health care quality improvement.  Through this process, the Board identified three strategic imperatives: 

1. Foster ACCME Leadership and Engagement
2. Evolve and Simplify the Accreditation Standards, Process, and System
3. Explore and Build a More Diversified Portfolio of ACCME Products and Services 

The Board incorporated feedback from stakeholders to identify these priorities, and then, throughout last year, the ACCME continued engaging with stakeholders about how to fulfill them.  The ACCME convened more than 20 focused discussions about the strategic imperatives with more than 1,100 stakeholders including member organization liaisons, ACCME volunteers, Recognized Accreditors, ACCME-accredited providers, and intrastate providers.  These discussions were held in a range of national, regional, and state forums, including accreditation workshops, town halls, volunteer meetings, Recognized Accreditor conferences, and events for intrastate CME providers.  A summaryof Key Themes from Stakeholder Conversations included: 

• Clarity: The ACCME should communicate its expectations clearly. It will be a lot easier for providers to do what the ACCME asks if they can easily understand the ACCME’s expectations. Commercial support requirements could be restructured to more easily apply to various scenarios such as activities that are commercially supported, those that are not commercially supported, and those that do not include advertising and exhibits.
• Fewer criteria may suffice: Some expectations are redundant (for example, Criterion 4, scope of practice); some are not readily measured (Criterion 5, choice of educational format); and some could be collapsed into one (Criteria 12-15, self-assessment and improvement).
• Criteria 16 and 22 are too easy: Stakeholders pointed out that providers were de facto in compliance with Criteria 16 and 22 by virtue of the organization existing and producing CME designed to change performance.
• Evolve the Commendation Criteria: Providers want to retain a criterion-referenced system for Accreditation with Commendation, but they want more attributes to be recognized as commendable. They like the concept of a menu of options, from which they could choose a certain number to fulfill in order to achieve Accreditation with Commendation.
• Maintain high expectations: Stakeholders do not want the ACCME to lower the bar. They value the Plan-Do-Study-Act approach combined with the Standards for Commercial Support.
• Push providers to higher level outcomes: Stakeholders feel that the ACCME should evaluate whether CME providers cause change—not just measure change—in learners. This should be an ACCME measurable, if not an actual requirement. Also, while stakeholders recognize that learners’ achievement of knowledge and competence are necessary steps in the change process, some stakeholders believe these objectives may no longer be adequate outcomes, if the accredited CME system is positioning itself as a strategic asset for initiatives to improve health care and public health.
• Keep pushing stakeholders: Stakeholders expect and want the ACCME requirements for the accredited CME enterprise to be drivers for their organizations’ change and improvement–—so that their CME programs are in fact relevant and serve as strategic assets to initiatives to improve health care and public health.
• Require organizational competence and-buy-in: It may be time to reintroduce requirements that organizations explicitly demonstrate their commitment to CME. (This expectation was specified in previous ACCME requirements.) Examples could include expecting CME staff to meet certain qualifications, evidence of direct, hands-on oversight by CME leadership, explicit involvement of senior organizational leadership.
• Retain three-part reaccreditation process: Providers see the triad of self-study report plus performance-in-practice review plus interview as a valuable process that should be retained, although they offered suggestions for improvement. One suggestion was to make interviews optional. To ease documentation requirements, providers suggested that the ACCME develop a structured abstract for providers to use when verifying performance-in-practice, which would take the place of labels and facilitate the process of submitting activity files.
• Retain verification by documentation: Providers feel that creating and maintaining adequate documentation of compliance is a lot of work—but that the ACCME’s random selection of activities for performance-in-practice verification is critical to the credibility and overall validity of the accredited CME enterprise in the eyes of our customers. The providers have asked that the ACCME examine how documentation requirements can be reduced while maintaining the important benefits of performance-in-practice verification.
• Templates: Providers want the ACCME to develop (optional) tools, instruments, and resources for providers to use in order to streamline the reaccreditation process and to promote compliance findings.
• Formative feedback: Providers want information about their compliance during their term of accreditation, as opposed to every four or six years. They want to know how they are doing in real-time and they want the opportunity to make mid-course adjustments, so as to avoid noncompliance findings.
• Engage leadership: Stakeholders believe that their institutional leadership and the leadership of the health care system in general is not engaged with continuing professional education—and this engagement must be developed in order to realize the full value of CME. They want the ACCME’s help in achieving this engagement.
• Regulatory alignment: Stakeholders believe that it is critical to achieve a congruence of values and expectations across regulatory systems.
• Validation by MOC and MOL: Stakeholders believe that the accredited CME enterprise needs explicit validation from the emerging systems of Maintenance of Certification^® (MOC) and Maintenance of Licensure (MOL) in equal measure.
• Support MOC and MOL: Stakeholders believe that the accredited CME enterprise must fulfill the needs and expectations of the emerging systems of MOC and MOL. In addition, and perhaps more important, the accredited CME enterprise must fulfill the needs and expectations of those directly involved in improving health care or population health. 

Video Interview Series: ACGME’s Next Accreditation System 

In a four-part video interview series, Timothy P. Brigham, MDiv, PhD, Chief of Staff and Senior Vice-President, Department of Education, Accreditation Council for Graduate Medical Education, (ACGME), discusses how the ACGME’s Next Accreditation System (NAS), supports physicians’ continuous professional development and explores opportunities for medical education accreditors and hospital leaders to collaborate to improve health care safety and quality.  This series is part of ACCME’s efforts to support alignment across the medical education continuum. 

• An Introduction to the ACGME's Next Accreditation System (NAS) (Part 1 of 4)
• Understanding the ACGME Milestones: Applications and Opportunities for Accredited CME (Part 2 of 4)
• Clinical Learning Environment Review (CLER) Visits: A Meeting Point for GME and CME (Part 3 of 4)
• Knitting the Continuum Together: Seizing the Opportunity to Improve Medical Education (Part 4 of 4) 

The ACCME has also produced the following video interviews focusing on the strategic value CME brings to graduate medical education. 

• Case Study: Integrating CME and GME—Jane Nester, DrPH, Executive Director for Medical Education/AHEC at Moses Cone Hospital, describes how she demonstrates the strategic value of CME to graduate medical education.
• Using CME to Engage Community Physicians in Quality and Teaching—Rani Gereige, MD, Director of Medical Education, Miami Children’s Hospital, discusses CME as a bridge between practice improvement, graduate medical education faculty development, and institutional goals. 

Registration Open for April 2013 CME as a Bridge to Quality™ Accreditation Workshop 

Registration is now open for the ACCME's 2013 CME as a Bridge to Quality™ Accreditation Workshop scheduled for April 24-26 in Chicago. A second workshop will be held July 31-August 2.  ACCME has invited providers whose next accreditation decisions are scheduled for July 2014, November 2014, and March 2015. 

ACCME Hosts Luncheon Discussion for Accreditation Surveyors 

The ACCME hosted a luncheon and discussion for ACCME accreditation surveyors during the Alliance for Continuing Education in the Health Professions (ACEHP) Annual Meeting.  The event was attended by more than 60 stakeholders, including ACCME accreditation surveyors; members of the ACCME Board of Directors, Accreditation Review Committee, and Committee for Review and Recognition; and staff and volunteers representing Recognized Accreditors. 

Murray Kopelow, MD, President and CEO, ACCME, discussed the accomplishments surveyors made during the previous year.  Thanks to surveyors’ contributions, the ACCME made 161 accreditation and reaccreditation decisions in 2012.  To support this decision-making, 107 surveyors conducted accreditation interviews. 

The ACCME asks providers to complete evaluations regarding their experience with the accreditation process and uses this feedback to analyze its current practices and make improvements.  Kate Regnier, MA, MBA, Deputy Chief Executive and COO, ACCME, presented data reflecting feedback from each of the three 2012 cohorts, which showed that providers reported positive experiences with surveyors and the accreditation interviews.  Dion Richetti, Director, Accreditation and Recognition Services, ACCME, reviewed the feedback, which showed that 95% or more of surveyors had a positive experience with the interview process.  Mr. Richetti also presented surveyor feedback regarding the Accreditation Compliance Review System (ACRS), which was implemented last year in order to simplify and streamline the process for accredited providers and accreditation surveyors.  The data shows that 97% of surveyors found the ACRS easy to use. 

CE Accreditors Meeting Focuses on Interprofessional Education 

The ACCME and its colleague accreditors, the Accreditation Council for Pharmacy Education (ACPE) and the American Nurses Credentialing Center (ANCC), hosted “Interprofessional Accreditation in Support of Interprofessional Education: An Exploratory Meeting of Accreditors” in February at the ACCME’s offices in Chicago.  The inaugural meeting brought together continuing education accreditors from a variety of health professions to identify areas of alignment among the accreditation systems and opportunities to support interprofessional collaborative practice. 

ACCME Hosts Commercial Supporters Forum 

The ACCME hosted a commercial supporters forum in January at its Chicago offices. ACCME executive staff and commercial supporters discussed current and emerging issues related to the health care environment and accredited CME, including the Food and Drug Administration (FDA) Risk Evaluation and Mitigation Strategy (REMS) for extended-release and long-acting opioid analgesics.  Participants discussed the importance of the ACCME Standards for Commercial Support: Standards to Ensure Independence in CME and explored strategies for supporting accredited CME that is independent from commercial influence. 

The ACCME hosts commercial supporter forums on occasion to provide an opportunity for participants to address emerging issues related to the health care environment and accredited CME funding and to reinforce their commitment to ensuring that commercially supported CME advances public health and serves the public interest. 

Genomics Medicine Conference Highlights Physician Education 

The National Human Genome Research Institute, National Institutes of Health, convened “Genomic Medicine IV: Physician Education in Genomics” in January in Dallas.  One of the goals of the conference was to identify ongoing efforts and needs related to physician education in genomics. 

Mira Irons, MD, Associate Chief, Division of Genetics, Boston Children’s Hospital; and member, ACCME Board of Directors, gave a presentation explaining that genomics education must move beyond general rules and principles and focus on providing physicians with relevant, practical information about how genomics applies to their scope of practice and their patients. 

The ACCME and the Accreditation Council for Graduate Medical Education (ACGME) were invited to discuss the roles of CME and GME in the medical education continuum. Thomas J. Nasca, MD, MACP, CEO, ACGME, addressed the importance of a multipronged approach to genomics education, which encompasses developing clinical proficiency in genomics in each specialty and includes practitioners and faculty. Murray Kopelow, MD, President and CEO, ACCME, described the scope of the ACCME accreditation system and the role of accredited CME as a strategic partner in efforts to advance physician education and practice related to genomics.  He explained how information about physician practice informs the medical education continuum, including undergraduate, graduate, and continuing medical education.  More information about the conference, including links to presentation slides and videos, is available here.

2012 AAMC/SACME Harrison Survey of Academic Medical Centers Links CME to Quality Improvement

Since 1981, the Society for Academic CME (SACME) Research Committee has surveyed continuing medical education (CME) units at medical schools in the U.S. and Canada.  Beginning in 2008, the Association of American Medical Colleges (AAMC) partnered with SACME to prepare this report.  The Biennial Survey of Society members includes questions about the organization of the CME unit, its relationship to the larger organization in which it resides, the ‘product’ of the CME unit (courses and other activities and interventions), its funding base, research and innovation, and other items related to the operation of the CME unit. 

The survey is electronically distributed to all U.S. and Canadian medical schools, teaching hospitals in the U.S., and clinical academic societies who are members of the AAMC’s Council of Academic Societies (CAS).  We covered the survey in 2010 and 2009.  Consequently, SACME recently released its 2012 data. 

The fifth iteration of the annual AAMC/SACME Harrison Survey documents a highly  viable and robust academic enterprise increasingly integrated into the functions and  mission of the academic medical centers (AMCs) and medical schools of the U.S. and

Canada.  While there are several limitations to interpretation of this survey, the survey generates broad but important findings for discussion and analysis, namely: 

• An increasing linkage of the academic continuing medical education (CME) unit to  the quality and performance improvement programs and initiatives of the hospital  and health system. In particular, extensive interaction among these areas has grown from below 10 percent to more than 15 percent since 2008, and the relationship has  become increasingly important over a five-year period.
• Continued well-developed relationships with programs for other health  professions, graduate medical education (GME), and faculty development; however,  missed opportunities for the academic CME unit and the AMC in building  collaborations with faculty practice plans, undergraduate medical education,  hospital accreditation, and other functions.
• A clear trend to assess outcomes beyond the scope of the traditional post-course  ‘happiness index’ using a variety of methods to assess competence, performance,  and patient outcomes to evaluate their impact on the health system.
• Growing institutional support, demonstrated by comparing median institutional  support to full-budget figures, representing commitment on the part of most, if not  all, institutions in support of academic CME.
• A widespread commitment to regional community-based hospitals, health  systems, and health professionals, reflected in a growing array of educational  methods, including academic detailing. This regional alignment is important to  considerations of ’accountable care’ structures.
• Increasing use of evidence-based educational methods that have been shown to  more frequently change clinical performance over a five-year period.
• A reasonably steady, if still relatively small, cohort of CME units committed to  scholarship that contribute to the research enterprise in health professional learning  and change, the product of collaboration both within and across AMCs, derived  from funding sources internal and external to the institution. 

“Thus, academic CME demonstrates, despite external financial and regulatory pressures  (and perhaps because of them), several major changes over a five-year period,” the report maintained.  “There is  evidence of an increasing integration into the functions of the AMC; an uptake in the  use of effective educational methods; a wide variety of outreach activities geared to the  needs of the communities served by AMCs; and an impressive, if not yet widespread,  record in scholarly activities and best practices.” 

Methods 

In June and July of 2012, an Internet search identified a total of 465 academic CME  units that comprised 315 U.S. teaching hospitals, 17 Canadian medical schools, and  133 U.S. medical schools for whom a defined CME office and/or institutional contact  information could be identified, and/or in which a central national or regional CME  office did not accredit the activities (e.g., VA hospitals).  

Regarding medical schools, only 45 academic CME units represented U.S. medical schools, while all 17 Canadian medical schools were represented by  CME units.  An additional 88 CME units in the U.S. indicated that they provided CME services to both their medical school and one or more teaching hospitals or health care systems, for a total of 150 such institutions. 

In all, this generated a total of 239 academic CME units—17 Canadian medical schools, 133 U.S. medical schools, and 89 teaching hospitals/health care systems, with cross-representation as indicated above.  The 2012 Harrison Survey report describes: 

• response rate and characteristics of the respondents
• mission and scope of activities of academic CME units
• organization of AMCs in relationship to their CME units
• use of effective CME methods
• funding issues in academic CME
• research, development, and best practices 

Of the 239 eligible CME units in U.S. teaching hospitals and in U.S. and Canadian  medical schools, 184 (77%) responded to the survey.  Of these, roughly 94% were U.S.- based and 6% Canadian-based.  One hundred twenty-seven (79% of all respondents)  reported national accreditation in the U.S. by the ACCME and 22 (14%) by state  accrediting agencies.  All 12 reporting Canadian schools (6% of the total) indicated accreditation by the Committee on Accreditation of Canadian Medical Schools  (CACMS).  

• Roughly three-quarters (76%) of these sites provided quality and  performance improvement activities, or planning and continuing education for  an inter-professional audience.  
• Similar percentages provided clinical professional development for faculty and staff and faculty development to improve teaching skills.  
• Of interest, 35% provided at least a small number of noncertified educational services, and
• 15% provided patient or public education programming.  

In addition to reporting staff with responsibilities in educational development, event planning, and support roles, CME units also reported staff expertise in: 

• Research and grant writing
• Accreditation and compliance
• Business analysis and operations
• Marketing and Communications
• Academic detailing
• Strategic affairs and planning 

Developing activities to achieve the missions of the academic medical center (AMC) requires an understanding of the organizational and reporting structures of CME units in modern health care settings. 

Internal Relationships 

The relationships developed within the AMC foster the achievement of goals of the entire center and those of the academic CME unit.  Respondents were provided a list of programs, departments, or units internal to the AMC, which may exist in their respective settings.  These included faculty development programs, library services, conflict of interest committees, medical student or resident educational programs, compliance education, physician performance or quality improvement units, faculty practice plans, continuing education for other health professions, health services research, public health, employee or staff professional development, and public education. 

Further, respondents were asked to describe the relationship between the CME office and each of those programs on a scale ranging from no or minimal interaction to

extensive interaction. In this case, minimal interaction was described as “irregular or occasional activity linked to the program or unit,” while extensive interaction was characterized as “ongoing planning or developmental activity, conjoint programming, shared goals and strategic directions, or shared resources.”  Of the 91 U.S. medical school-based units shown in 

• 74% indicated a combined moderate/extensive interaction with continuing education programs for other health professions,
• 62% described similar interactions with physician or hospital quality improvement programs, and
• 61% expressed a combined moderate/extensive interaction  with faculty development programs. 

One area represents an important change in the degree of interaction over a five-year period.  Previous Harrison Survey reports described relationships with QI/PI functions as fifth in frequency in 2008, with combined moderate to extensive interaction at roughly 58%.  In the 2012 survey, relationships with QI/PI now place second among relationships.  Further, the percentage of those selecting extensive interaction has also grown, accounting for virtually the entire growth in this area.  From 2008 to 2012, the total of combined moderate/extensive interaction improved from 58% to 63%, the product of growth in the ‘extensive interaction’ category. 

Also reported at levels of greater than 50% in this year’s survey was involvement at moderate or extensive levels with conflict of interest committees, with graduate or residency medical education, and with the allied health professions. Several interactions were much less frequently reported, providing examples of opportunities for academic CME, and the AMC itself.  

The 2012 Harrison Survey focuses on four aspects of programming that reflect a growing awareness of the literature driving changes in the delivery of continuing education and professional development activities, making them more effective in the process, namely: 

• use of evidence-based methods in regular course planning, implementation, and  follow-up
• use of assessment methods to determine the effect of these activities
• growing use of alternative methods and strategies to reach a diverse audience  external to the AMC
• role of faculty development 

Rigorous research evidence, including systematic reviews, demonstrates the positive effect on health professional performance when research-based educational methods are employed.  In particular, this research encourages CME providers to: 

• Use objective data and understand barriers to change as they plan activities (e.g.,  employing quality data in planning and development).
• Increase the use of interaction in planned educational sessions (e.g., by using case  discussion methods or simulations, or by providing in-program practice aids such  as flow charts).
• Employ sequential learning so that practice and education are mutually reinforced. 

Since the first AAMC/SACME Harrison Survey in 2008, respondents have been asked about the use of these methods, along with other activities in pre-activity planning, course development, and post-course evaluation.  

Pre-activity Methods 

Reported here are several pre-activity planning methods.  Among them, planning based on quality metrics to augment subjective needs assessments appears to be an important, evidence-based step.  Of the 145 reporting CME units, 

• 80% indicated regular use and 19% reported occasional use of these methods.  
• 47% percent occasionally and 35% regularly have developed meaningful interprofessional planning methods,
• 37% occasionally and 41% regularly consider barriers to changing professional performance.
• Only 40% of units occasionally or regularly undertake presenter training  of professional development in order to train these presenters in more effective  methodologies. 

Academic CME providers report using evidence-based educational methods—objective needs assessments, teaching methods such  as interactivity and simulations,  and post-activity follow-up—to a  significantly greater extent over a  five-year period. 

Several evidence-based educational methods in courses and conferences themselves are also reported as occasionally or regularly used by academic CME providers.  Chief among these was the use of ‘interactivity,’ defined as devoting more than a quarter of educational time to case discussion, audience interaction and participation, and/or question/answer sessions.  The majority of CME units reported employing such methods to a significant extent (>25% of programming time), with 60% reporting interactive techniques and methods regularly.  Other effective methods used regularly or occasionally included: 

• practice facilitators or enablers such as flow charts for use in the practice setting (81%),
• evidence-based tools and resources (69%),
• simulations (69%), and
• team-based learning (64%).
• Only 45% used methods described as  sequential i.e., learning sessions separated by practice periods, in which new knowledge  or skills can be acquired and then built upon in further educational sessions. 

Post-program Methods 

Respondents were asked about the use of quality metrics to assess the impact of their programs: 75% did so either regularly or occasionally.  In addition, adopting the research evidence that reinforcing strategies enabled the uptake of knowledge and practice change, respondents were asked if they followed up with their program participants post-course—emailing new information, reinforcing commitments to change, asking further questions—and 70 % reported doing so, more than half regularly.

Comparison with the first (2008) AAMC/SACME Harrison Survey report provides an instructive means to judge progress in academic CME.  Several items have been tracked annually or semi-annually since the publication of that report; the 2012 Harrison Survey report demonstrates a progressive change towards the current picture.  2008 data, in particular demonstrating: 

• the use of quality or performance improvement as needs assessment occasionally or  regularly (85%)
• in-program practice enablers (61%)
• simulations (56%)
• post-performance quality measures to track the outcomes of educational activities (54%)
• follow-up methods to reinforce participant learning (64%) 

Beyond the post course ‘happiness index’, many academic CME providers use measures of competence, self-reported or actual performance data, and (a smaller number) patient and population health data.  New to the 2012 survey, respondents were asked to indicate what percentage of activities used the outcomes measured. 

• 63% percent of respondents’ activities involved measures of competence (e.g., post-course multiple choice examinations),
• 40% employed general, self-reported performance measures,
• 16% used objective data such as quality measures to track outcomes,
• while smaller percentages (13% and 9% respectively) measured  actual patient or population health outcomes.  

When asked the question, “Does your CME unit participate in faculty development activities,” 119 units, or 84%, indicated ‘yes’.  The majority of these activities involved educational or accreditation aspects of faculty development that touched upon the teaching methods in UME, GME, and CME.   

• 91%had responsibilities of some type for CME teaching,
• 61% for GME (or in Canada PGME) teaching, and
• 52% for UME teaching improvements.  

This percentage of activity has remained relatively stable over several years.  One hundred and four CME units also reported some responsibility for faculty development activities involving basic research, regulatory matters, or clinical issues.  Ninety-six units (92%) developed faculty-focused activities in clinical issues such as team training or quality improvement, and 60 units (58%) in the area of basic research (e.g., regulatory, conflict of interest, or ethical issues). 

Reaching Out: Serving the Regional Community 

In addition to providing traditional courses and conferences, academic CME providers also reach out to regional community-based practitioners.  Respondents reported using live teleconferencing (audio or video) methods, visiting speakers’ programs, opinion leader, and train-the-trainer activities, academic detailing, social networking, and other means.  

Regional health professionals and systems are also served by academic CME providers, using teleconferencing, opinion leader and train-the-trainer programs, and (to a lesser but growing extent) social networking methods. Academic detailing—outreach visits by trained health professional—appears to have undergone substantial growth over a five year period.  Out of 140 respondents, CME providers said they engaged inthe following types of activities: 

• over 80% live teleconferences (video, audio, webcasts)
• over 70% visiting speakers at medical society or community hospital meetings series
• over 60% opinion leader/Train-the-Trainer programs
• almost 50% academic detailing
• over 40% individual traineeships or tutorials
• over 35% communities of practice
• ~35% learning/individuals coaching programs
• ~35% social networking 

Academic Detailing 

50% of CME units reported the use of academic detailing—educational visits by trained health professionals to individual or team-based physicians.  This method has been demonstrated to improve prescribing and health promotion/screening performance to at least a moderate extent.  Academic CME units have reported a steady rise in the numbers of such programs, from under 10 in 2008 to almost 70 in 2012 (an increase from ~45 in 2011). 

Academic CME Budgets 

For calendar year 2011, CME units were asked about the size of their total fixed  operating budgets, reflecting a wide spread of means, medians, and budget ranges by  institution type.  Less variability was noted among the eight reporting Canadian medical schools, which indicated budgets with the following characteristics: a median of $1.3 million, a maximum of $4.5 million, and a minimum of $364,000. 

In contrast, the 90 U.S. medical schools reported lower median budget figures (by roughly $500,000), but greater variability ($11.8 million in maximum, $25,000 in minimum).  CME Fixed Operating Budget (127 respondents) 

• Mean budget for U.S. Medical School $797,097
• Median budget U.S. Medical School $497,506

Even more variability was noted among U.S. teaching hospitals.  Twenty such units reported median figures of $275,000, indicating a maximum of $30 million and a minimum of $5,000. 

• Mean budget for Teaching Hospital $2,126,509
• Median budget for Teaching Hospital $275,000 of which $200,000 was derived from institutional (hospital and health system) sources—roughly 80%. 

The total revenue from institution to CME Unit (128 respondents) 

• Mean U.S. Medical School $235,536
• Median U.S. Medical School $141,461
• Mean Teaching Hospital $1,307,074
• Median Teaching Hospital $200,000 

Among Canadian medical schools with median budgets averaging $1.3 million, just under $400,000 (roughly one-third) come from institutional sources.  U.S. medical schools reported slightly less than $500,000 in median total revenues (though a wide range) and $141,000 in median institutional support (slightly under one-third).  

The 2012  survey asked the question, “As a percentage of the fixed CME budget, has institutional  support increased, decreased, or stayed the same in the last year?”   

• 54% of respondents indicated similar year-to-year support,
• 16% indicated an increase in support, and
• 30% a decrease. 

Research Activity 

Research activity is reported by a sizable minority of academic units, primarily in medical schools—totaling millions of dollars and over two hundred studies.  Research includes formal evaluation processes related to physician or health professional learning, the effect of CME, the outcomes derived from educational activities, and related matters.  Some research was externally funded by peer review or commercial sources, and some internally funded.  In the U.S. and Canada, 43 units reported research activity.  These units undertook:  

• a median of two research studies.
• 22 respondents indicated receiving grant support for CME-related research studies greater than $0. 
• The maximum reported grant for those with support was almost $10 million. 
• The minimum was $20,000, with the mean $924,337 and the median $70,000. 

Collaboration Within and Across CME Units 

Those units reporting research activity were then asked to what extent these studies were either cross-institutional or collaborative within the institution and/or multi-institutional.  The majority of respondents reported undertaking both cross- and multi-institutional studies.  86.4% said they engage in cross-institutional or collaborative research within their own institution (51 respondents), while 57.9% said they had multi-institutional or collaborative research with other medical institutions (33 respondents).  

Examples of research include: outreach activities, PI-CME or quality improvement strategies, personal learning programs, faculty development, and others; knowledge translation or implementation science; new technologies such as those in social networking or blended learning; new audiences including allied health professionals, patients, and public members; planning and assessment strategies; and outcomes assessment methods.  A host of administrative, financial, organizational, and collaborative activities were also described. 

Limitations of Survey 

There are several limitations to the interpretation of this survey.  First, the survey is based on a self-reported questionnaire to which 77% of academic CME units responded.  Thus, responses are absent from one-quarter to one-third of academic CME units.  Notably, traditionally defined teaching hospitals in the U.S. have not generally been the target of these surveys and are not, as a rule, members of the major co-sponsor of this survey—the Society for Academic Continuing Medical Education.  

Further, between-year comparisons may be marred by a sampling of non-identical CME units and by questions which have been worded slightly differently, the result of an ongoing process to improve the clarity of the questions asked.  Finally, the wide variation in reporting of some figures (e.g., those related to the budget) makes judgment difficult and casts some doubt on respondents’ understanding of specific questions; median figures were used in this regard.  

Academic CME: Internal Alignment and Value  

The first notable feature of this year’s report, when compared to similar surveys over a five-year period, is the increasing linkage of the academic CME unit to the quality and performance improvement programs and initiatives of the hospital and health system. In particular, extensive interaction has grown from below 10% to more than 15% since 2008, and the relationship moved from fifth to second place during this time.  Also apparent is a well-developed relationship internally with CE programs for other health professions, with GME, and, notably, with faculty development.  These linkages across the medical school, teaching hospital, and clinical settings appear to make the traditional teaching hospital and medical school structures arbitrary at best, leaving the clear conclusion that there exists an entity—academic CME—with significant roles and demonstrated impact within the AMC.  

The process of alignment, however, is not universal across sites and systems and appears to neglect areas of possible interest to continuing education providers and the AMC— namely building relationships with faculty practice plans, undergraduate medical education, hospital accreditation, and other functions.  Further, staffing of academic CME units rarely includes individuals skilled in such areas as quality measurement or performance improvement.  At a minimum, these observations identify missed opportunities.  

Academic CME providers appear to use a variety of methods to assess competence, performance, and even patient outcomes to evaluate their impact on the health system. A further, if arguable, means of assessing the degree of integration of academic CME into the mission of the AMC, is to judge the extent of funding support from institutional sources.  This, at least by comparing median institutional support to full-budget figures, notes a sizable commitment on the part of most, if not all, institutions that support academic CME. 

Research, Scholarship, and Evidence-based Education: How Academic is ‘Academic’ CME?  

First, and most notably, academic CME programmatic commitment appears to be more evidence-based over a five-year period, i.e., employing educational methods that have been demonstrated to more frequently change clinical performance.  These methods include pre-activity planning (e.g., using quality metrics as an objective means to determine performance), intraprogram activities (sequencing of learning activities, creating interactivity, and using enabling materials such as flow sheets and patient educational materials to support change in the clinical setting), and post-course methods to reinforce learning.  The growth in use of these methods over a five-year period is notable.  

This shift from traditional, didactic, and, thus, marginally effective CME, reflects more than just a contemporary trend. Instead, it demonstrates—much as the practices of academic physicians do—the uptake of best evidence with regards to practice.  In this case, the practice is educational and reflects the undertaking of scholarship, research, and study, to analyze the effect of educational interventions, to test new ones, and to study their outcomes.  

Second, it appears that there is a reasonably steady, if still relatively small, cohort of CME units which are committed to scholarship and which contribute to the research enterprise in health professional learning and change. This commitment is the product of collaboration both within and across AMCs, and is derived from funding sources internal and external to the institution.  

The 2012 Harrison Survey also makes apparent a strong commitment, equal to its internal integration, to regional community-based hospitals, health systems, and health professionals.  This is reflected in a growing array of educational methods such as teleconferencing, online learning activities, opinion leader and train-the-trainer programs, and the growing use of social networking to link to community-based health professionals. In addition, the growth of academic detailing during this time further shows CME providers’ innovation and attention to effective educational engagement and an awareness of external funding opportunities in this area.  Finally, this regional alignment is important to considerations of accountable-care structures in which community-based health professionals—and the linkage that academic CME represents to them—play a large and important role. 

Conclusion 

Academic CME demonstrates, despite external financial and regulatory pressures (and perhaps because of them), several major features: evidence of an increasing integration into the functions of the AMC; an uptake in the use of effective educational methods; a wide variety of outreach activities geared to the needs of the communities served by AMCs; and an impressive, if not yet widespread record in scholarly activities and best practices.  

Challenges are also presented in this report.  Academic CME providers, AMC leadership and faculty need to create significant, functional alignments among CME and other relevant internal units, and enhance community engagement strategies and methods. Support for and an understanding of the potential role of academic CME units in scholarship in improving patient care and in achieving other missions of the AMC remain incomplete and patchy.

Physician Payment Sunshine Act Final Rule: ACCME - CMS Validated the Standards for Commercial Support and AAFP Comments

As we noted earlier this month, the Centers for Medicare & Medicaid Services (CMS) released the final regulations to implement the Physician Payment Sunshine Act—Section 6002 of the Affordable Care Act.  Listening to the overwhelming majority of comments with respect to the continuing medical education (CME) industry, CMS exempted payments or other transfers of value provided as compensation for speaking at a continuing education if certain conditions are met—which are consistent with the ACCME’s accreditation standards and standards for commercial support.   

In response to the final rule, the Accreditation Council for Continuing Medical Education (ACCME^®) noted in press release that “accredited and certified continuing education systems have received important validation from the Centers for Medicare & Medicaid Services (CMS) in its final rule concerning payments to physicians.” 

“The CMS final rule regarding physician payment transparency is an important recognition of the value of the ACCME Standards for Commercial Support: Standards to Ensure Independence in CME Activities,” said Murray Kopelow, MD, President and CEO, ACCME.  “The final rule creates a special exclusion for payments to speakers at accredited continuing education programs, if certain conditions are met.  These conditions are completely consistent with the ACCME Standards for Commercial Support.  The Standards state that accredited providers must make all decisions regarding CME, including faculty selection, independent of industry influence, and that all commercial support must be paid directly to the CME provider, not to the faculty.   

The Standards are designed to ensure that accredited CME activities are independent, free of commercial bias, based on valid content, and contributing to health care improvement. We appreciate that the CMS recognizes the importance of accredited continuing education and the value of the Standards in safeguarding the independence of accredited continuing education.” 

Dr. Kopelow also provided an audio commentary about the CME rule and CME.  Kopelow noted that “The final rule creates a special exclusion for payments to speakers at accredited continuing education programs, if certain conditions are met.  This exclusion recognizes the value of the safeguards that currently protect the independence of accredited continuing education.”  He also explained that “The conditions for the exclusion are completely consistent with the Standards for Commercial Support.” 

“The ACCME Standards for Commercial Support were reviewed and approved in 2004 by each of the ACCME’s seven member organizations, which represent the profession of medicine.  The Standards demonstrate the ACCME’s leadership in medical education and the medical profession's commitment to effective self-regulation in the field of continuing education,” said James F. Burke, MD, Chair, Board of Directors, ACCME.

“The ACCME Standards for Commercial Support have succeeded in being recognized nationally, by the profession, by the regulators, and by the government as protecting the public from industry influence in continuing medical education. This is a peak moment,” said Norman Kahn, MD, Executive Vice-President and CEO, Council of Medical Specialty Societies (CMSS). CMSS is an ACCME member organization. 

In addition to CMS, a number of government agencies have recognized the value of accredited continuing education.  Federal agencies, including the Office of National Drug Control Policy, Centers for Disease Control and Prevention, National Coordinator for Health Information Technology, and Agency for Healthcare Research and Quality, have incorporated accredited CME as a strategic partner in their public health initiatives. I n July 2012, the Food and Drug Administration released its Risk Evaluation and Mitigation Strategy, or REMS, for extended-release and long-acting opioid analgesics, which includes a prescriber education program that is controlled, designed, and delivered by accredited continuing health care education providers. 

ACCME Rules 

In addition to providing these comments, the ACCME also reminded the public and providers about its various resources and policies regarding the Standards for Commercial Support.  For example, the ACCME explained that accredited CME providers must not ask a “commercial interest” for suggestions related to topics or speakers for CME.  The ACCME emphasized that “There is no reason for the CME provider to request suggestions for speakers or topics from commercial interests -- since it is unacceptable to act upon their suggestions.”  

The ACCME believes that CME can receive commercial support from industry without receiving any advice or guidance, either nuanced or direct, on the content of the activity or on who should deliver that content.  If the provider implements the suggestions of the commercial interest then this creates the situation where the independence of CME from the commercial interest is seriously undermined.  The provider must ensure that the content of the CME remains beyond the control of any commercial interest.  The process to develop the CME must be independent of any commercial interest. Accredited providers must not allow commercial interests to directly (SCS 1.1) or indirectly (SCS 3.2) control the content of CME. 

Next, the ACCME emphasized that commercial support must not be spent directly by the commercial supporter on costs related to the CME activity.  ACCME clarified that “commercial support must go first to the provider or a provider's joint sponsor or a provider's educational partner.” 

In addition, the ACCME explained that a commercial support must not supplement their contributions to the activity by additional direct payments to people involved in the activity.  The ACCME maintains that “All commercial support must be stipulated by a written agreement and must flow through the Provider and/or its educational partner. Only the Provider and/or its educational partner can make payments to people for their role(s) in the activity.” 

Last, but certainly not least, the ACCME explained that under the Standards for Commercial Support, it requires providers to have their own policies and proceures governing honoraria because the CME provide must “be the one to decide how much people are paid for their services as planners, faculty, and authors in CME activities.” 

American Academy of Family Physicians (AAFP) 

The American Academy of Family Physicians (AAFP) also released their comments recently on the finalized Sunshine Regulations.   CMS addressed some, but not all, of the issues raised by the AAFP and other groups.  For example, AAFP noted CMS exempted speaker fees for accredited and certified CME programs from the reporting requirements.  In this way, CMS acknowledged that “CME accrediting and certifying bodies, such as the AAFP, ensure that CME activities adhere to rigorous standards,” said Carly Harrington, M.Ed., manager of CME credit systems and compliance for the AAFP.

“These standards call for transparency, conflict-of-interest mitigation and structural firewalls between commercial entities and educational development,” said Harrington.  “It is important for the public to understand that there is a vast CME community dedicated to providing unbiased CME to physician learners.”

CME - When Old Beliefs Won’t Budge: Evaluating Entrenched Attitudes and Resistance to Change Among Healthcare Professionals

Each year, the Alliance for Continuing Education in the Health Professions (ACEHP) holds its annual meeting, bringing together hundreds of thousands of continuing education professionals and stakeholders.  During this past year’s meeting, there was an interesting poster entitled: “When Old Beliefs Won’t Budge: Evaluating Entrenched Attitudes and Resistance to Change Among Health Care Professionals.”   

The poster was presented by Carole Drexel, PhD, CCEMP, Anne Jacobson, MPH, CCEMP, and Jay M. Katz, MA, CCEMP, on behalf of the Potomac Center for Medical Education.  The presentation was part of a CME-certified dinner symposium, held in conjunction with the American Diabetes Association (ADA) 71st Scientific Sessions in June 2011 entitled, “Emerging Options for Type 2 DM Management: Glucose Control and The Kidney,” and was supported by an educational grant from Bristol-Myers Squibb and AstraZeneca, LP.  

Background 

Live activities remain popular educational formats in CME.  However, are stand-alone CME activities effective in addressing persistent gaps in knowledge and competency?  Accordingly, the authors sought to compare the performance of various qualitative and quantitative assessment methods, including pre-activity, post-activity, and follow-up tools, in measuring entrenched beliefs among health care professionals. 

Then the authors described the advantages and limitations of specific educational activity formats in addressing entrenched beliefs and facilitating change toward evidence-based clinical practice.  Finally, they identified opportunities to close knowledge and competence gaps with optimal program planning, design, and outcomes measurement, against a backdrop of entrenched beliefs.  Upon successful completion the symposium, participants were meant to be able to:  

• Cite the results of key clinical trials that have shown the long-term benefits of glycemic control in patients with T2DM
• Make therapeutic decisions driven by patient presentation, as well as the safety and efficacy of therapeutic agents
• Understand the role of the kidney in glucose regulation and outline how the mechanism of action of SGLT2 inhibitors differs from that of currently available hypoglycemic agents
• Highlight the data from key clinical trials of investigational SGLT2 inhibitors and discuss the potential role of these agents in the treatment of patients with T2DM     

The program was designed as a 2-hour satellite symposium with 4 live interactive lectures (20 to 40 min each), including polling questions using ARS, and interactive discussions with questions/answer sessions after each presentation.  Two lectures covered basic T2DM care, including ADA guideline recommendations, HbA1c targets, and first- and second-line drug management.  In addition, two lectures covered topics that were new to the target audience, including renal physiology, glucose metabolism, and clinical experience with SGLT2 inhibitors  

An outcome assessment was performed to evaluate the knowledge of a number of topics in the management of T2DM.  The results showed  that the audience had many years in practice and a high volume of patients with T2DM.  

• 29% endocrinologist;
• 13% PCP;
• 12% diabetes educator;
• 7% pharmacist;
• 7% RN/NP/PA;
• 33% others (including research)  

The activity also showed improvement in knowledge regarding the role of the kidney and the SGLT2 co-transporter in glucose regulation.  Participation in the activity resulted in increased knowledge of newer concepts that were taught (e.g. renal physiology and effects of SGLT2 inhibition):  

• Icrease from 44% (pre-activity) to 100% (post-activity) of participants who correctly identified the effects of SLGT2 inhibition on glucosuria, systolic blood pressure, and weight  
• Increase from 60% to 80% of participants who correctly identified the proportion of glucose filtered by the kidney  

The authors noted, however, that confusion remained about basic clinical concepts in T2DM management, including: The results from the tight glucose control trials (e.g. ACCORD, ADVANCE, VADT) (28% prior vs 35% post)     

Participation in the activity was not associated with an increase in self-ratings of competence; however, it was noteworthy that the participants self-assessment was already high in the following areas:  

• managing patients with type 2 diabetes to recommended HbA1c target goals, while minimizing weight gain and CV and hypoglycemia risks [mean rating 3.7]
• selecting an initial T2DM therapy [4.0]
• selecting add-on therapy [3.9]     

Gaps in Competency  

Despite these positive results, the recognized that noticeable discrepancies emerged between participants’ high perception of their own competence levels and their response patterns to key clinical challenges.  Even in this high-level audience, responses to clinical questions clearly indicated:  

• Confusion between the AACE and ADA guideline recommendations
• Lack of awareness of management strategies for a patient with renal impairment (guidelines)
• Lack of awareness about the armamentarium available to manage hyperglycemia and the role and place of the newest agents (e.g. incretins)
• Remaining confusion about individualization of HbA1c targets, specifically in patients with CV risk factors  

After participating in this educational activity:  

• Only one-quarter of clinicians selected the appropriate HbA1c target for a patient with T2DM and high cardiovascular risk
• Only 35% were able to apply evidence from trials of tight glucose control to current T2DM management
• Only 32% were able to identify appropriate treatment options for a patient with renal impairment
• Uncertainties about guideline recommendations also remained, with only 28% able to identify the correct steps for a patient with inadequate response to glyburide and metformin  

The authors noted that clinicians can make major gains in knowledge and competence related to new material by participating in a single, 2-hour, live CME activity.  However, many basic concepts in T2DM management remain unclear, even in high-level diabetes professionals.  

These data emphasize the need to proactively identify opportunities to incorporate “old material” in CME activities, even as new concepts are being taught.  This includes: 

• Making time in the program agenda to review basic concepts related to diagnosis, treatment goals, and guideline recommendations
• Reiterating “old material” in case studies; and
• Testing for knowledge and competence in the basics in all outcomes assessments 

Until incorrect “entrenched beliefs” are unlearned, clinicians will not be able to apply basic concepts in clinical practice.  Correction of “entrenched beliefs” is likely a major barrier to clinical change, the authors concluded.