Continuing Medical Education at the Point of Care

1
Continuing Medical Education at the Point of Care

• Nancy Davis, Ph.D.
• Director, Division of Continuing Medical
  Education
• American Academy of Family Physicians
• Charles Willis, MBA
• Director, AMA PRA Standards and Policy Liaison
  Activities
• AMA Division of Continuing Physician Professional
  Development (CPPD)

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Learning at the Point of Care

• Traditional CME not embedded in practice
• Clinical information sources often static and not
  X-referenced
• Reflection is critical component of learning

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Need for Point of Care learning

• Physicians cannot keep all the information they
  need in their heads, and even if they could,
  medical knowledge changes so rapidly that
  acquired information quickly becomes obsolete.
• Haynes, B, et al. Ann Intern Med 1990

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Dont Know What You Dont Know

• Goal is to train physicians to look for
• information and recognize when they
• need to know more

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Clinical Questions in Practice

• Two clinical questions generated every 3 patients
• Typical day25 clinical questions
• Covell, DG , et al, Ann Intern Med 1985

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How are we doing

• Of those questions in a typical clinic day
• Only 30 pursued
• Only 75 of those are answered

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Clinical Questions

• 33 Treatment
• 25 Diagnosis
• 15 Pharmacotherapeutics
• Barry Ward, BMJ, 1997

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Bottom-Up Individualized Approach

• Point of care learning provides
• individual physician learner-driven
• learning rather than faculty driven
• learning.

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Point of Care Learning

• Electronic clinical information resources
  (clinical decision support tools)
• Point of care/just-in-time
• Nirvana of needs assessment

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AMA/AAFP Pilots

• Started in December 2000
• Process to capture, as learning, use of
  professional literature at or near point of care
• Technology made it possible
• What changes did the AMA PRA AAFP need to award
  CME credit?
• Departure from static needs assessment, learning
  objectives CME -- to dynamic, practice based
  needs assessment

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Internet Point of Care (PoC) CME

• AMA Pilot
• SKOLAR, Inc.
• UpToDate, Inc.
• American College of Physicians (PIER)
• MerckMedicus
• AAFP added..InfoRetriever

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Internet Point of Care (PoC) CME

• How do we establish that physicians have
  adequately engaged this learning activity?
• Learning associated with searching on a specific
  topic documented through search criteria
• Credit should be awarded based on the level of
  engagement
• Initial, point of care search average 2-3 minute
  interaction, quick answer needed

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Internet Point of Care (PoC) CME

• Deeper search credit for a structured response
  to several questions expected
• describe clinical question
• review clinical sources
• evaluate application to practice
• Asynchronous, could be done later (assess
  practice patterns)
• Keep it simple physicians and providers can
  choose the depth (rigor) they want to pursue

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Internet PoC CME Credit

• Documentation allowing physicians to claim 0.50
  credits
• describe clinical question
• review clinical sources
• evaluate application to practice
• What the data told us.

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Internet Point of Care, use patterns

• Initial topic review will not exceed 2-3 minutes
• Consistent with use in patient care setting
• Physicians will not tolerate waiting longer than
  eight seconds for PoC tool (again, patient care
  constraints)

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Internet Point of Care, use patterns

• More extensive topic review
• 1990 and 1991, two studies found physicians
  averaged thirty minutes for online clinical
  research
• AMA pilot findings (post Internet age) 34 to 37
  minutes

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Internet Point of Care (PoC) CME

• Education has prevailed over assessment
• Provider driven awarding, tracking credit
• Credibility to outside stakeholders important
  (licensing boards, public, etc.)
• Approved by the AMA Council on Medical Education
  in March 2005

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Internet Point of Care (PoC) CME

• Content integrity AMA PRA definition and ACCME
  content validation guidelines
• ACCME commercial support and Internet delivery
  standards will apply
• Support for unbiased content and search engines,
  high quality evidence base

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Internet Point of Care (PoC) CME

• In a fully integrated system (with EMR), could
  link to documented practice change
• Becomes a performance improvement activity
• With link to new modes of physician learning,
  AMA PRA Category 1 credit will help meet the
  demand for transparent, documented and
  accountable CME

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Point of Care Learning

• The Process
• Identify the clinical question
• Search the evidence for the answer
• Implement (or not) with the patient

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Criteria for PoC Sources

• Provide consistent, reproducible evidence
• Document how evidence is reviewed and updated
• Describe how strength of evidence is evaluated
• Emphasize patient-oriented evidence over
  disease-oriented evidence
• Explicitly rate the strength of evidence

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Related efforts with PoC

• AMA and AAFP participating with MedBiquitious, an
  ANSI accredited developer of technology standards
  for medical education activities
• Specifically exploring how medical education
  content can be tagged and applied for varied CME
  learning projects
• Also, developing interoperable XML standards for
  data reporting (CME credit, activity
  descriptions, etc.)

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Electronic reporting of CME and Maintenance of
Certification

• CME providers are increasingly deploying online
  learning
• Proof of credit is usually printed by learners
• Difficult for learners to track their
  accomplishments
• Difficult for specialty boards and others to
  track required physician activities
• Portability physician learning portfolios that
  move among electronic PoC providers

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What would help

• Standard way to describe and report physician
  education and Maintenance of Certification (MoC)
  activities
• Benefits
• Facilitates tracking of physician CME activities
• Reduces administrative burden on physician
• Simplifies development of electronic reporting
  and tracking systems

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Reporting and Tracking CME
PoC provider A
Activity report
ltxmlgt
Dr. John Does CME Tracker Provider A Asthma
Management .5 cr Provider A Bronchodialators
.5 cr Provider B Pain Management .5 cr Report
to Board
CME Tracker
Activity report
ltxmlgt
PoC provider B
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Sample Activity Report MoC Part 4

• ltActivityReportgt
• ltOrganizationgtAmerican Academy of
  Pediatricslt/Organizationgt
• ltmMembergt
• ltmNamegt
• ltnFirstNamegtPercylt/nFirstNamegt
• ltnMiddleNamegtBysshelt/nMiddleNamegt
• ltnFamilyNamegtShelleylt/nFamilyNamegt
• ltnDegreegtMDlt/nDegreegt
• lt/mNamegt
• lt/mMembergt
• ltActivitygt
• ltActivityNamegteQIPPlt/ActivityNamegt
• ltModulegt
• ltModuleNamegtAsthmalt/ModuleNamegt
• ltStatusgtRegisteredlt/Statusgt
• ltStartDategt2003-27-01lt/StartDategt
• ltDueDategt2004-27-01lt/DueDategt
• lt/Modulegt
• lt/Activitygt

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Sample Activity Report CME Credit

• ltActivityReportgt
• ltOrganizationgtAmerican Medical
  Associationlt/Organizationgt
• ltmMembergt
• ltmNamegt
• ltnFirstNamegtMarklt/nFirstNamegt
• ltnFamilyNamegtTwainlt/nFamilyNamegt
• ltnDegreegtMDlt/nDegreegt
• lt/mNamegt
• lt/mMembergt
• ltActivitygt
• ltActivityNamegtJAMA CMElt/ActivityNamegt
• ltModulegt
• ltModuleNamegtEthics and Professional
  Medicinelt/ModuleNamegt
• ltStatusgtCompletedlt/Statusgt
• ltCompletedDategt2004-27-10lt/CompletedDategt
• ltCreditReceived providerAccreditation
  ACCME creditType CME activityCertificatio
  n AMA PRA Category 1gt 1.0lt/CreditReceivedgt
• lt/Modulegt
• lt/Activitygt
• lt/ActivityReportgt

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Reporting and Tracking CME
Information Resource
Activity report
ltxmlgt
Dr. John Does CME Tracker Provider A Asthma
Management .5 cr Provider A Bronchodialators
.5 cr Provider B Pain Management .5 cr Report
to Board
CME Tracker
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Contacts

• Nancy L. Davis, PhD, Director
• Division of Continuing Medical Education
• American Academy of Family Physicians
• 913-906-6000, Ext 6510
• ndavis_at_aafp.org
• Charles E. Willis, MBA, Director
• AMA PRA Standards and Policy Liaison Activities
• Division of Continuing Physician
• Professional Development
• American Medical Association
• 312-464-4677
• charles.willis_at_ama-assn.org

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Thank You! Questions and Discussion