Overview of Online CME
The Seventh Annual Meeting
of the
Global Alliance for Medical Education
June 23-25, 2002
The McGill Faculty Club
Online CME – An Update
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Review of June 2002
Bernard M. Sklar, M.D., M.S.
www.cmelist.com
bersklar@netcantina.com
Plan of Talk
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Results of Survey
Types of Instruction
Physician Use of CME and Online CME
Obstacles to Physician Use
Master’s Thesis
• This review is based on a recent update of the
database that I created for my master’s thesis, The
Current Status of Online Continuing Medical
Education (June 2000). Find the thesis online at
http://www.cmelist.com/mastersthesis
• The thesis was based on a review of the CME
literature and a survey of online CME done in
February 2000.
How Was the Survey Done?
• Internet search of multiple search engines
using search string “online + continuing +
medical +education”
• Following up leads from those searches
• Information from ACCME
• Email from viewers and CME providers
Description of the List
Each entry shows the name and URL of the
site, when I last visited, how many credit
hours are available, who awards the credit,
the cost per unit, when the educational
material was last updated, a description of
the site and its contents and links to
individual courses found at the site.
Extensive Updates
• I have been maintaining the list for about 5
years
• The list was updated for my master’s thesis
in February 2000, again in August and
December 2000, in December 2001 and in
June 2002.
List of Online CME
Database Created from List
Based on examining each site, I created an
Access database of the 207 sites actively
offering CME in June 2002. The DB
contains the number of activities, number of
hours of instruction, types of instruction,
specialty audiences, cost to users, sources of
financial support and other parameters.
Results of Study I
• The number of sites and activities is rapidly
increasing
• April 1997 – 13 sites
• December 1997 – 18 sites
• August 1998 – 61 sites
• May 1999 – 69 sites
• December 1999 – 87 sites
Results of Study II
• February 2000
– 96 sites, 1874 activities, 3064 credit hours
• August 2000
– 135 sites, 3659 activities, 5659 credit hours
• December 2000
– 150 sites, 3510 activities, 6553 credit hours
– Because of overlap, duplication, and
miscounting , the “true number” of hours
should have been about 5500.
Results of Study III
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December 2001
197 sites
12026 activities
17523 hours
Results of Study IV
• June 2002
• 209 sites
• 10952 activities
• 18266 hours
Size of Sites – December 2000
No. of CreditHours
Greater than 100
Number of
Sites
Number % of % 0f
of
Sites Hours
Hours
6
4082
4
62
50-99
12
779
8
12
25-49
10-24
5-9
<5
21
41
29
41
717
681
193
100
14
27
19
27
11
10
3
2
Total
150
6553
100
100
Size of Sites – December 2001
No. of CreditHours
Greater than 100
Number of
Sites
Number % of % 0f
of
Sites Hours
Hours
14
14587
7
83
50-99
9
596
5
3
25-49
10-24
5-9
<5
29
56
38
51
1046
918
271
103
15
28
19
26
6
5
2
1
Total
197
18266
100
100
Size of Sites – June 2002
No. of CreditHours
Number of
Sites
Greater than 100
Number % of % 0f
of
Sites Hours
Hours
12
14615
5
80
50-99
16
1119
8
6
25-49
10-24
5-9
<5
31
62
33
54
1137
1036
227
129
15
30
16
26
6
6
1
<1
Total
209
18263
100
100
The Largest Sites December 2000
Name of Site
No. of
Activities
907
No. of
Hours
1360
7
901
CMEWeb
507
759
Medscape**
539
726
63
232
6
104
HealthStream*
Challenger
ArcMesa
Milliman/Robertson**
*
The Largest Sites December 2001
Name of Site
eMedicine CME
CMEWeb
Challenger
cmecourses (HS)
WEBMD Just in Time
Medscape CME
ArcMesa
No. of Activities
No. of Hours
6500
976
10
300
1400
200
80
10000
1400
897
500
350
300
293
The Largest Sites June 2002
Name of Site
No. of Activities
No. of Hours
6500
10000
CMEWeb*
976
1400
Challenger
14
964
TheAnswer.com*
5
300
cmecourses (HS)*
300
500
JournalBytes (All Spec)
108
372
Medscape CME**
200
300
ArcMesa
80
293
Radcourses (HS)
28
128
127
127
83
122
109
109
eMedicine CME*
RSNA Education Exhibits
Natal U
Mypatient.com
Fee Structure by Site Dec 2000
Dominant or Average Fee
Free
<$5 per hour
$5 per hour
Number of Sites
74
2
6
% of Sites
49
1
4
$6-9 per hour
$10 per hour
$11-14 per hour
16
14
6
11
9
4
$15 per hour
10
7
$16-19 per hour
$20 per hour
5
6
3
4
$21-24 per hour
$25 per hour
2
5
1
3
>$25 per hour
4
3
Fee Structure by Site Dec 2001
Dominant or Average Fee
Free
<$5 per hour
$5 per hour
Number of Sites
98
6
6
% of Sites
50
3
4
$6-9 per hour
$10 per hour
$11-14 per hour
13
22
9
7
11
5
$15 per hour
19
10
$16-19 per hour
$20 per hour
3
5
2
3
$21-24 per hour
$25 per hour
2
10
1
5
4
2
>$25 per hour
Fee Structure by Site June 2002
Dominant or Average Fee
Free
<$5 per hour
$5 per hour
Number of Sites
105
5
6
% of Sites
50
2
3
$6-9 per hour
$10 per hour
13
24
5
11
$11-14 per hour
$15 per hour
8
25
4
12
$16-19 per hour
$20 per hour
$21-24 per hour
4
3
1
1
1
<1
$25 per hour
10
4
>$25 per hour
5
2
Hourly Fee Structure Dec 2000
Dominant or Average Fee
Free
<$5 per hour
$5 per hour
No of Hours % of Hours
1587
24
103
2
223
3
$6-9 per hour
$10 per hour
$11-14 per hour
1183
1050
524
18
16
8
$15 per hour
1505
23
$16-19 per hour
$20 per hour
170
51
3
1
$21-24 per hour
$25 per hour
18
61
0
1
>$25 per hour
79
1
Hourly Fee Structure Dec 2001
Dominant or Average Fee
Free
<$5 per hour
$5 per hour
$6-9 per hour
$10 per hour
$11-14 per hour
No of Hours % of Hours
1978
11
365
8
10285
59
1712
1447
470
10
8
3
845
5
$16-19 per hour
$20 per hour
55
87
<1
<1
$21-24 per hour
$25 per hour
9
114
<1
1
>$25 per hour
155
1
$15 per hour
Hourly Fee Structure June 2002
Dominant or Average Fee
Free
<$5 per hour
$5 per hour
No of Hours % of Hours
1763
10
566
3
10203
56
$6-9 per hour
$10 per hour
$11-14 per hour
2153
1643
434
12
9
2
$15 per hour
1009
5
$16-19 per hour
$20 per hour
137
57
1
<1
$21-24 per hour
$25 per hour
7
115
<1
<1
>$25 per hour
177
1
Financial Support Dec 2000
Source of Support
No. of Sites % of Sites
Commercial Companies
43
32
University/Medical School
54
40
7
5
13
10
Foundation
7
5
Insurance or Managed Care
4
3
76
51
Government
Medical/Specialty Association
User Fees/Partial or Complete
Financial Support Dec 2001
Source of Support
No. of Sites % of Sites
Commercial Companies
99
50
University/Medical School
83
42
Government
11
6
Medical/Specialty Association
47
24
Foundation
17
9
5
3
99
50
Insurance or Managed Care
User Fees/Partial or Complete
Financial Support June 2002
Source of Support
Commercial Companies
No. of Sites % of Sites
113
54
University/Medical School
86
41
Government
15
7
Medical/Specialty Association
58
28
Foundation
15
7
104
50
User Fees/Partial or Complete
Sites by Specialty – Primary Care Dec 2000
No. of Sites
% of Sites
93
62
Family Practice
83
55
Internal Medicine
80
53
Pediatrics
22
15
Obstetrics/Gynecology
22
15
Primary Care Sites
including:
Sites by Specialty – Primary Care Dec 2001
Primary Care Sites
including:
Family Practice
Internal Medicine
Pediatrics
Obstetrics/Gynecology
Multiple Specialties
No. of Sites
% of Sites
114
58
95
86
29
25
6
48
44
15
13
3
Sites by Specialty – Primary Care June 2002
Primary Care Sites
including:
Family Practice
Internal Medicine
Pediatrics
Obstetrics/Gynecology
Multiple Specialties (>6)
No. of Sites
% of Sites
123
59
98
91
37
29
10
47
44
18
14
5
Sites by Specialty – Subspecialties Dec 2000
Subspecialty sites
including:
Neurology
Number of Sites
113
21
% of Sites
75
14
Psychiatry
Cardiology
Oncology
Infectious Disease
23
20
13
13
15
13
9
9
Radiology*
Dermatology
Gastroenterology
10
7
7
7
5
5
Pulmonary
Surgery
General Interest
9
7
26
6
5
17
Sites by Specialty – Subspecialties Dec 2001
Subspecialty sites
including:
Neurology
Number of Sites
140
14
% of Sites
71
7
Psychiatry
Cardiology
Oncology
Infectious Disease
21
19
10
14
11
10
5
6
Radiology
Geriatrics
Pulmonary
12
12
9
6
6
5
Surgery
General Interest
6
26
5
17
Sites by Specialty – Subspecialties June 2002
Subspecialty sites
Number of Sites
% of Sites
123
59
Cardiology
23
11
Psychiatry
20
10
Oncology
17
8
Neurology
15
7
Radiology
14
7
Infectious Disease
13
6
Urology
11
5
Endocrine
10
5
Pulmonary
10
5
Geriatrics
9
4
Surgery
9
4
including:
Sites by Specialty-2001- Other
• 26 sites (13%) offer subjects of interest to
many different specialties; for example,
ethics, legal, practice management,
genetics, and basic science
• Many other specialties were included at 5 or
fewer sites
Sites by Specialty-June 2002- Other
• 33 sites (16%) offer subjects of interest to
many different specialties: for example,
ethics, legal, practice management, risk
management, tobacco cessation, genetics,
basic science
• Many other specialties are included at 5 or
fewer sites
Five “Different” Sites I
• CE Medicus has no CME of its own, but offers access
without fee to about 600 activities at five sites
(apparently by special arrangement)
• Digiscript contains many hundreds of audio and video
slide lectures recorded at medical meetings. The yearly
charge is $400. Some activities offer CME and some do
not. The site is searchable by medical topic and by
sponsoring organization. You may have to pay an
additional fee for CME credit by any given sponsor.
• Doctor’s Guide also has no CME of its own, but offers
descriptions of over 600 activities (free and fee) with
links to those courses
Five “Different” Sites II
•Stanford SKOLAR offers credit for performing
Internet literature searches on topics of your own
interest
•University of Wisconsin Professional Courses offer
credit for courses on non-medical subjects which
could be expected to improve your practice or your
life.
Sites I Could Not View
• There may be a number of proprietary sites,
e.g., staff model HMOs, like KaiserPermanente, where access to instruction is
limited to staff members of that
organization. Those sites are not reviewed
in this report.
Email Reminders June 2002
About 25 sites send out regular email reminders about
additions to their lists of activities on request by users:
American College of Cardiology, Boston University,
Cancer Education, CME Reviews, Cyberounds,
Doctor's Guide Webcasts, Ecornell, EMedHome,
EMedicine, cmecourses (HealthStream), Journal of
Clinical Psychiatry, Medscape, Medinfosource,
Medsite, MMWR, mypatient.com, Natal U, PDR.net,
Pedsref.org, psychLINK, Psychiatrist.com (NetSociety),
Serono, University of Wisconsin, Virtual Lecture Hall,
and World Medical Leaders.
Types of Instruction-Definitions
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Text-Only
Text-and-Graphics
Slides-Only (or Slides and Text)
Slide-Audio
Slide-Video
Question-and-Answer
Case-Based Interactive
Guideline or Consensus (usually text only)
Correspondence
Games
Types of Instruction – Dec 2000
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Text only -- 37 sites; 25%
Text-and-graphics – 45 sites; 30 %
Slide-audio – 45 sites; 30 %
Slide-video – 21 sites; 14 %
Guidelines – 5 sites; 3 %
Question-and-answer – 6 sites; 4 %
Case-based Interactive – 27 sites; 18 %
• Many sites have more than one type of instruction
Types of Instruction – Dec 2001
• Text only -- 47 sites; 24%
• Text-and-graphics – 59 sites; 30 %
• Slide-audio – 57 sites; 29 %
• Slide-video – 21 sites; 11%
• Guidelines – 5 sites; 3 %
• Question-and-answer – 9 sites; 5 %
• Case-Based-Interactive – 26 sites; 13 %
• Correspondence – 3 sites; 2 %
• Games – 2 sites; 1 %
• Slides-Only – 4 sites; 2 %
Many sites have more than one type of instruction
Types of Instruction – June 2002
• Text only -- 57 sites; 27%
• Text-and-graphics – 71 sites; 34 %
• Slide-audio – 60 sites; 29 %
• Slide-video – 23 sites; 11%
• Guidelines – 8 sites; 3 %
• Question-and-answer – 6 sites; 3 %
• Case-Based-Interactive – 31 sites; 15 %
• Correspondence – 2 sites; 2 %
• Games – 2 sites; 1 %
• Slides-Only – 4 sites; 2 %
• Slides-and-Text – 4 sites; 2 %
Many sites have more than one type of instruction
More about Q&A Instruction
• Only 6 sites (2%) feature Q&A, BUT
the number of hours is relatively large
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Challenger - 964 hours
TheAnswerPage – 300 hours
E-core – 27 hours
Familypractice.com - 25 hours
Total about 1316 hours (7 %)
CME Participation by Location Based on
ACCME Figures for 2001
• Live meetings and conferences account for
76 % of “physician-registrants”
• Home study CME (“enduring materials”)
and journals account for 19.6 % of
physician-registrants
• Online CME accounts for only 4.4 % of
physician-registrants
Physician Usage of Online CME
• Physician usage of online CME is increasing, but
still accounts for less than 5% of all CME
• According to ACCME:
• 1997: 13,115 physician-registrants (0.34%)
• 1998: 37,879 physician-registrants (1.03%)
• 1999: 79,536 physician-registrants (1.79%)
• 2000: 181,922 physician-registrants (3.57%)
• 2001: 230,055 physician-registrants (4.44%)
Why is Online CME Use So Low? I
• Many physicians still uneasy with
computers and Internet*
• Many physicians unaware of online CME or
don’t know how to find it
• Much live CME, especially at the hospital,
is convenient, free and offers collegial
interaction
Why is Online CME Use So Low? II
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A series of “gates” for the user to pass through
Navigation; Download and install plug-ins
Registration hassle
Fear of giving out license, DEA, credit card
Paying in advance for content you can’t view
Get content free, leave without paying
Each site has a different procedure and password
Why Choose One Online CME Site
Over Another?
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Price
Preference for Type of Instruction
Email reminders
Part of larger medical site
Help with CME reporting
Recommendation by colleagues, medical group
Special arrangements with physician group
A Long Term Solution
• Eventually, CME will be totally integrated
with the physician’s daily practice life
• Systems will be developed which allow a
computer program to “know” when a
physician is making a mistake or needs
additional information
• The system will present instruction on the
spot to help the physician do the right thing
Other Problems to Solve
• Another problem will be to prove that a given
CME activity actually improves physician
performance.
• For now, CME providers and evaluating groups
will need to settle for some lesser measure, such as
the difference in scores between pre-tests and
post-tests, or statements by “experts” that the
course will correct the deficiency.
Opportunities for Research
• More sophisticated (and expensive)
methods of evaluation exist, such as
reviewing physician charts or interviewing
patients
• This is a great opportunity for research.
There is grant money available for research
into effective CME.
Conclusions I
• The number of online CME activities and
credits is growing rapidly (but not so
rapidly as in the previous periods)
• Online CME is becoming nicer to look at,
with more graphics, lots more audio and
video, and a bit more interactive
programming
Conclusions II
• The percentage of CME hours earned online
is still only about 4.4%
• Barriers to usage are still major
• Almost no proof that any kind of standalone
CME, whether live, home study or online,
and regardless of mode of instruction, is
useful in changing physician practice
Conclusions III
• The future lies in the integration of medical
practice, quality assessment and userspecific CME
• The challenges and opportunities are great
Important URLs
• Master’s thesis:
www.cmelist.com/mastersthesis/
• My home page: www.cmelist.com
• Online CME list: www.cmelist.com/list.htm
• Definitions of types of online CME
instruction:
www.cmelist.com/Instruction_Types_define
d.htm