1. Bernard Sklar, MD: Online Continuing Medical Education July 2009 Online CME – An Update Review of July 2009 Bernard M. Sklar, M.D., M.S. www.cmelist.com/list.htm bersklar@netcantina.com

2. Bernard Sklar, MD: Online Continuing Medical Education July 2009 Plan of Presentation Results of Recent Surveys Types of Instruction Physician Use of CME and Online CME Obstacles to Physician Use Predictions

3. Bernard Sklar, MD: Online Continuing Medical Education July 2009 Master’s Thesis This review is based on the July 2009 update of the database initially created for the master’s thesis, The Current Status of Online Continuing Medical Education (June 2000). Find the thesis online at http://www.cmelist.com/mastersthesis http://www.cmelist.com/mastersthesis The June 2000 thesis was based on a review of the CME literature and a survey of online CME done in February 2000.

4. Bernard Sklar, MD: Online Continuing Medical Education July 2009 How Was the Survey Done? The original survey was done by searching multiple search engines using the search string “online + continuing + medical +education” Following up leads from those searches Information from ACCME Email from viewers and CME providers

5. Bernard Sklar, MD: Online Continuing Medical Education July 2009 Updating the Database For the past several years, I have relied mostly on contacts from Online CME providers and users to add sites to my list I add 3-4 new sites each month (and remove those sites that are no longer functioning) This year I again searched the Internet for “online + continuing + medical + education”

6. Bernard Sklar, MD: Online Continuing Medical Education July 2009 Description of the List Each entry shows the name and URL of the site, when it was last visited, how many credit hours are available, who awards the credit, the cost per unit, when the educational material was last updated, a statement about financial support, and a description of the site and its contents. Each entry shows the name and URL of the site, when it was last visited, how many credit hours are available, who awards the credit, the cost per unit, when the educational material was last updated, a statement about financial support, and a description of the site and its contents.

7. Bernard Sklar, MD: Online Continuing Medical Education July 2009 Thanks to Volunteers Although I visit most of the sites myself, this last year a number of people volunteered to help keep the List current You will find their names and titles in the “Reviewed by…” section of each review at http://www.cmelist.com/list.htm http://www.cmelist.com/list.htm Thanks to all!!

8. Bernard Sklar, MD: Online Continuing Medical Education July 2009 Extensive Updates I have been maintaining the list for about twelve years, beginning in 1997. In 2008- 2009 I had the assistance of volunteer reviewers The database is continually updated. From June 2008 through July 2009, we visited and updated the review of each site on the list.

9. Bernard Sklar, MD: Online Continuing Medical Education July 2009 Database Created from List The database contains information about the 300 sites offering CME in July 2009. This information includes the number of activities, number of hours of instruction, types of instruction, target audiences, cost to users, the name of the accrediting organization and sources of financial support. The figures in this report are based on the 284 sites offering original CME. The database contains information about the 300 sites offering CME in July 2009. This information includes the number of activities, number of hours of instruction, types of instruction, target audiences, cost to users, the name of the accrediting organization and sources of financial support. The figures in this report are based on the 284 sites offering original CME.

10. Bernard Sklar, MD: Online Continuing Medical Education July 2009 Growth of Sites, Activities and Hours I Date Searched Number of Sites Number of Activities Number of Credit Hours April 1997 13 Not counted December 1997 18 Not counted August 1998 61 Not counted May 1999 68 Not counted December 1999 87 Not counted February 2000 9618743064 August 2000 13536595659 December 2000 15035105500 December 2001 1971202617523 June 2002 2091095218266

11. Bernard Sklar, MD: Online Continuing Medical Education July 2009 Growth of Sites, Activities and Hours II Date Searched Number of Sites Number of Activities Number of Credit Hours December 2002 2291148519105 July 2003 2531134620299 January 2004 2711239521700 June 2005 2831496325075 December 2006 3001574426287 July 2009 3001296820666

12. Bernard Sklar, MD: Online Continuing Medical Education July 2009 Explanation of calculations on next several slides Although the number of sites is now estimated at 300, the number used for the following calculations is 284. This method counts only those sites which offer original content and not the approximately 16 those sites which only link to or re-package content offered elsewhere (Nothing wrong with doing that, but I don’t want to count the same activity twice).

13. Bernard Sklar, MD: Online Continuing Medical Education July 2009 Growth of large sites (offering more than 100 Credit Hours) Date Searched Number of Sites Number of Hours % of Sites % of hours December 2001 1414587783 December 2002 1615404881 July 2003 21163881080 January 2004 25175491181 June 2005 34204561380 December 2006 40208841479 July 2009 44155341575

14. Bernard Sklar, MD: Online Continuing Medical Education July 2009 Size of Sites – July 2009 No. of Credit-Hours Number of Sites Number of Hours % of Sites % 0f Hours Greater than 100 44145871575 50-993120121110 25-49401445147 10-24761236275 5-945337161 < 5 4310015<1 Total28426287100100

15. Bernard Sklar, MD: Online Continuing Medical Education July 2009 The Largest Sites July 2009 - I Name of Site # of Activities # of Hours Contemporary Forums-Online CE Library 13282325 Audio Digest 9901980 Challenger Online Lecture Hall 541560 CMEWeb8141221 Medscape CME Center850850 Virtual Lecture Hall 28502 Clinical Directors Network (CDN) 469469 Pri-Med Online 300450 NetCE Continuing Education on the Internet 55425 American Society for Clinical Pathology 259332 RSNA (Radiological Soc North America)300 TheAnswerPage5300 Practical Reviews Online (was JournalBytes)88264 CardioVillage10250

16. Bernard Sklar, MD: Online Continuing Medical Education July 2009 The Largest Sites July 2009 - II Name of Site # of Activities # of Hours Sullivan Group (The) 98216 theheart.org210210 CME Institute 200200 CMELectures.org130195 Oncologist (The)195195 Harvard Online CME 43181 Drexel MCP Hahnemann Virt Grand Rounds 115172 MedRisk Online 36169 Johns Hopkins Advanced Studies Courses 100166 American Acad Ped PREP Self-Ass Online 3156 Neurology (J American Acad Neurology)100150 Washington University (St Louis)149147 Childrens of Minnesota Grand Rounds143 FreeCME67140

17. Bernard Sklar, MD: Online Continuing Medical Education July 2009 The Largest Sites July 2009 - III Name of Site # of Activities # of Hours NEJM Weekly CME Program 140140 American Acad of Orthopaedic Surgery OKO 66137 JAMA & Archives 130130 Ohio State University Center for CME129129 ACP Medicine Online Version1120 CMEDownload120120 Epocrates Mobile CME 120120 Texas Heart Institute 92118 American Acad Allergy Asthma Immunology 68115 Cleveland Clinic 134112 McGill CME111 American Psychiatric Association69105 PedsEducation.org165105 PeerView Press Online CME103

18. Bernard Sklar, MD: Online Continuing Medical Education July 2009 The Largest Sites July 2009 - IV Name of Site # of Activities # of Hours American Academy Ped Online Courses 37100 CE Central 50100

19. Bernard Sklar, MD: Online Continuing Medical Education July 2009 Fee Structure – Free Sites There has been a modest increase in the number of sites offering free CME – from 168 sites (59%)in December 2006 to 180 sites (63%) in July 2009. There has been a larger increase in the number of free credit-hours – from 5740 (21%) in December 2006 to 7066 (34%) in July 2009.

20. Bernard Sklar, MD: Online Continuing Medical Education July 2009 Fee Structure – Pay for Credit Sites There has been very little change in the median fee for a paid credit hour. The bulk of the fee instruction (about 62%) continues to cost $5 to $15 per credit hour

21. Bernard Sklar, MD: Online Continuing Medical Education July 2009 Fee Structure by Site July 2009 Dominant or Average Fee Number of Sites % of Sites Free18063 <$5 per hour 124 $5 per hour 62 $6-9 per hour 114 $10 per hour 124 $11-14 per hour 31 $15 per hour 259 $16-19 per hour 31 $20 per hour 114 $21-24 per hour 31 $25 per hour 52 >$25 per hour 73

22. Bernard Sklar, MD: Online Continuing Medical Education July 2009 Hourly Fee Structure July 2009 Dominant or Average Fee No of Hours % of Hours Free706634 <$5 per hour 262413 $5 per hour 6284 $6-9 per hour 18759 $10 per hour 229511 $11-14 per hour 901 $15 per hour 354117 $16-19 per hour 3542 $20 per hour 11846 $21-24 per hour 4122 $25 per hour 4522 >$25 per hour 1421

23. Bernard Sklar, MD: Online Continuing Medical Education July 2009 Financial Support Summary: There has been very little change in relative percentages of financial support since December, 2001. As the number of free sites and activities increases, the number of fee sites and activities decreases

24. Bernard Sklar, MD: Online Continuing Medical Education July 2009 Financial Support July 2009 Source of Support No. of Sites % of Sites Commercial Companies 14651 University/Medical School 8630 Government3312 Medical/Specialty Association 6121 Foundation228 User Fees/Partial or Complete 10437

25. Bernard Sklar, MD: Online Continuing Medical Education July 2009 Primary Care and Specialty Sites Family Practice and Internal Medicine content continues to dominate the Primary Care sites (about 40% of all sites). Among the Specialty Sites, Cardiology, Psychiatry, Infectious Disease/HIV, and Oncology content appear most frequently (about 20% of sites for each specialty). Many sites offer instruction for more than one specialty group

26. Bernard Sklar, MD: Online Continuing Medical Education July 2009 Specialty – Primary Care July 2009 No. of Sites % of All Sites Primary Care Sites 21776 including: including: Family Practice 10838 Internal Medicine 9333 Pediatrics4215 Obstetrics/Gynecology2710 Multiple Specialties (>6) 3312

27. Bernard Sklar, MD: Online Continuing Medical Education July 2009 Subspecialties July 2009 Subspecialty sites Number of Sites % of Sites Oncology3011 Cardiology2810 Infectious Disease/HIV 248 Psychiatry197 Surgery197 Gastroenterology186 Radiology166 Anesthes/Pain Management 135 Neurology145 Endocrine124 Rheumatology104

28. Bernard Sklar, MD: Online Continuing Medical Education July 2009 Sites by Specialty-July 2009- Other 36 sites (12%) offer subjects of interest to many specialists: ethics, legal, practice management, risk management, tobacco cessation, addiction, alcoholism, genetics, basic science Many other specialties are included at 8 or fewer sites

29. Bernard Sklar, MD: Online Continuing Medical Education July 2009 “Portal” Sites July 2009 These two sites offer no original CME activities, but do offer convenient starting places for a large number of activities:These two sites offer no original CME activities, but do offer convenient starting places for a large number of activities: CE Medicus offers access without fee to about 3000 activities (probably about 4000 hours) produced by about 11 content providers. Instruction is free.CE Medicus offers access without fee to about 3000 activities (probably about 4000 hours) produced by about 11 content providers. Instruction is free.CE Medicus CE Medicus Doctor’s Guide also has no CME of its own, but offers descriptions of over 2000 activities (free and fee) with links to those coursesDoctor’s Guide also has no CME of its own, but offers descriptions of over 2000 activities (free and fee) with links to those coursesDoctor’s Guide Doctor’s Guide

30. Bernard Sklar, MD: Online Continuing Medical Education July 2009 Large Sites where Hours cannot be counted American College of Cardiology American College of Cardiology - CME content is interspersed through the Cardiosource site and cannot readily be counted; but there are probably several hundred hours. American College of Cardiology Medical RoundsMedical Rounds is a Canadian site which does not offer US CME credit. However, many Canadian medical schools have contributed to several hundreds of lectures to this series. All talks were originally presented at grand rounds of quality educational institutions or at accredited medical meetings. Medical Rounds MedPage TodayMedPage Today - Each day, important medical events and studies are summarized and presented in the form of news stories as brief (0.25 hours) CME activities. In addition there are links to about 38 longer CME activities in a variety of specialty areas. Each of these longer activities offers 1.0-2.5 credits. MedPage Today

31. Bernard Sklar, MD: Online Continuing Medical Education July 2009 Types of Instruction The one major change in types of instruction is the rapid increase of podcasting (up from 5 sites in December 2006 to 23 sites in July 2009. Text (with or without graphics) remains the dominant mode, followed by slide-audio or slide- video lectures, case-based interactive and question-and-answer instruction. For definitions of these and other types of online instruction, see Types of Online CME Instruction Defined Types of Online CME Instruction DefinedTypes of Online CME Instruction Defined

32. Bernard Sklar, MD: Online Continuing Medical Education July 2009 Types of Instruction July 2009 I Instruction Type Number of Sites % of Sites Text only 8931 Text-and-graphics5720 Slide-audio Lecture 8630 Slide-video Lecture 6924 Guidelines31 Question-and-answer104 Case-Based-Interactive4817

33. Bernard Sklar, MD: Online Continuing Medical Education July 2009 Types of Instruction July 2009 II Instruction Type Number of Sites % of Sites Correspondence00 Games83 Journal207 Journal with multiple subjects 155 Board Review/Self-Assessment 62 Streaming Video 124 Self-Directed Search (POS) 1<1 Text-Audio135 Podcast (Audio and/or Video) 238

34. Bernard Sklar, MD: Online Continuing Medical Education July 2009 Sites I Could Not View There are a number of proprietary sites, e.g., staff model HMOs, like Kaiser-Permanente, where access to instruction is limited to staff members of that organization. Those sites are not reviewed in this report.

35. Bernard Sklar, MD: Online Continuing Medical Education July 2009 Point of Care/Self Study I count only one site currently offering “Point of Care” CME (also called “self- directed study”); this is the College of Family Physicians of Canada College of Family Physicians of CanadaCollege of Family Physicians of Canada The several other sites seem to have abandoned the effort

36. Bernard Sklar, MD: Online Continuing Medical Education July 2009 Sites that have closed I About 110 sites disappeared between December 2008 and July 2009, either because credit expired or without with an explanation

37. Bernard Sklar, MD: Online Continuing Medical Education July 2009 Sites that have closed II The most significant closure, numerically, is eMedicine, whose CME has been folded into Medscape. I had been attributing 6391 activities and 9586 hours to eMedicine. The closure of eMedicine has led to a major decline in the overall number of activities and hours and likewise to a major decline in the number of activities in the “$5 to 10 per hour” fee bracket

38. Bernard Sklar, MD: Online Continuing Medical Education July 2009 CME Participation by Location Based on ACCME Figures for 2008 Live meetings and conferences accounted for 40% of “physician-participants” Home study CME (“enduring materials”) and journals accounted for 20.4% of physician-participants Online CME accounted for almost 41% of physician- participants

39. Bernard Sklar, MD: Online Continuing Medical Education July 2009 Physician Usage of Online CME Physician usage of online CME is increasing, and now accounts for almost 41% of all CME According to ACCME: 1997: 13,115 physician-participants (0.34%) 1998: 37,879 physician-participants (1.03%) 1999: 79,536 physician-participants (1.79%) 2000: 181,922 physician-participants (3.57%) 2001: 230,055 physician-participants (4.44%) 2002: 329,110 physician-participants (6.08%) 2004: 895,120 physician-participants (14%) 2005: 1,368,335 physician-participants (18%) 2006: 2,184,460 physician-participants (26%) 2007: 2,673455 physician-participants (30.7%) 2008: 4,365,013 physician-participants (40.9%)

40. Bernard Sklar, MD: Online Continuing Medical Education July 2009 Some important caveats about the numbers The numbers I have quoted in this and all previous reports are quoted in “physician- participants.” This term is not explained at the ACCME site, but it is certainly not the same as “credit-hours” earned. The numbers I have quoted in this and all previous reports are based on the reports of the 725 providers certified directly by the ACCME and NOT on the reports of the 1600 providers accredited by the State Medical Societies (those 1600 providers provide a very small amount of online CME)

41. Bernard Sklar, MD: Online Continuing Medical Education July 2009 Changes and Trends I For the first time since 1997, there has been a reduction in the number of online CME activities and hours available. This is mostly explained by the disappearance of the 9586 hours formerly provided by eMedicine. About 100 sites have vanished since December 2006, and about 100 new sites have appeared during that There has been a significant increase in the number of free CME hours (7066 vs. 5740) over the past 2 ½ years. There has been little change in the specialty groups targeted. There are considerably more slide- audio and slide-video lectures and a large increase in podcasts.

42. Bernard Sklar, MD: Online Continuing Medical Education July 2009 Changes and Trends II The number of physician-participants for online CME went up from 181,922 (3.57%) in 2000 to 230,055 (4.44%) in 2001 to 329,110 (6.08%) in 2002 to 899,390 (14%) in 2004 to 1,368,335 (18%) in 2005 to 2,184,460 (26%) in 2006 to 2,673,455 (30.7%) in 2007 and to 4,365,013 (40.9%) The number of physicians registering for online CME has quintupled in the past seven years. Return to beginning of the Sklar Report, if desired, or just keep going down beginning of the Sklar Reportbeginning of the Sklar Report

43. Bernard Sklar, MD: Online Continuing Medical Education July 2009 Why is Online CME use Still Low? I I think we can soon retire this section. The 2008 ACCME figures show that online CME accounts for 40% of “physician- participants.” Other ways of calculation this ratio are somewhat less glowing, but still, the trend is obviously upwards My points about the “low” use of Online CME are still pertinent, BUT much less so than just a few years ago: Some physicians remain uneasy with computers and the Internet Some physicians are still 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 Many doctors still find attending their yearly specialty meeting satisfying and sufficient

44. Bernard Sklar, MD: Online Continuing Medical Education July 2009 Why is Online CME Use Still Low? II These observations remain true, BUT, again, to a lesser extent tan in past years: 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

45. Bernard Sklar, MD: Online Continuing Medical Education July 2009 Why Choose One Online CME Site Over Another? “Look and Feel” Your specialty’s “official” site Price (lower is better; free is best) Preference for Type of Instruction Email reminders (the more frequent the better) The CME is part of a larger medical site which offers additional services for doctors (“one-stop- shopping”) Help with CME reporting Recommendation by colleagues, medical group Special arrangements with physician group

46. Bernard Sklar, MD: Online Continuing Medical Education July 2009 What do Physicians Want? Do physicians really want online CME? (I believe that, with usage now at 40%, the answer is YES) What do they like and dislike? (According to most studies, lectures are still the preferred mode of instruction)

47. Bernard Sklar, MD: Online Continuing Medical Education July 2009 A Long Term Solution I believe that: Eventually, CME will be 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

48. Bernard Sklar, MD: Online Continuing Medical Education July 2009 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.

49. Bernard Sklar, MD: Online Continuing Medical Education July 2009 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.

50. Bernard Sklar, MD: Online Continuing Medical Education July 2009 Conclusions I The number of online CME activities and credits has leveled off. Online CME continues to become nicer to look at, with more graphics, lots more audio and video, and a bit more interactive programming. Podcasts are growing rapidly in popularity.

51. Bernard Sklar, MD: Online Continuing Medical Education July 2009 Conclusions II The percentage of “physician-participants” for online CME about 40% Barriers to usage are coming down There is very little 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 Results of most studies indicate that a coordinated set of educational interventions will be needed to accomplish behavior change

52. Bernard Sklar, MD: Online Continuing Medical Education July 2009 Conclusions III The future lies in the integration of medical practice, quality assessment and user-specific CME The challenges and opportunities are great

53. Bernard Sklar, MD: Online Continuing Medical Education July 2009 Important URLs Master’s thesis: www.cmelist.com/mastersthesis/ www.cmelist.com/mastersthesis/ My home page: www.cmelist.com www.cmelist.com Online CME list: www.cmelist.com/list.htm www.cmelist.com/list.htm Definitions of types of online CME instruction: www.cmelist.com/Instruction_Types_defined.htm www.cmelist.com/Instruction_Types_defined.htm ACCME Annual Report 2008 ACCME Annual Report 2008

54. Bernard Sklar, MD: Online Continuing Medical Education July 2009 Questions or Comments? Send email to bersklar@netcantina.com bersklar@netcantina.com