1. Online CME – An Update Review of June 2005 Bernard M. Sklar, M.D., M.S. www.cmelist.com/list.htm bersklar@netcantina.com

2. Plan of Presentation Results of Recent Surveys Types of Instruction Physician Use of CME and Online CME Obstacles to Physician Use Predictions (This report summarizes my most recent review and does not include much of the past data. (To see details of past data, please contact me at bersklar@netcantina.com) bersklar@netcantina.com

3. Master’s Thesis This review is based on the June 2005 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 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. 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. Updating the Database For the past several years, I have relied 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 go offline

6. 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 statement about financial support, a description of the site and its contents and links to individual courses found at the site. 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 statement about financial support, a description of the site and its contents and links to individual courses found at the site.

7. Where is the List? The Annotated List of Online CME is found at www.cmelist.com/list.htm www.cmelist.com/list.htm

8. Extensive Updates I have been maintaining the list for eight years, beginning in 1997 The database was updated for my master’s thesis in February 2000, and every six months since. From November 2004 through mid-June 2005, I visited and updated the review of each site on the list.

9. Database Created from List The database contains information about the 284 sites offering CME in mid-June 2005. 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 database contains information about the 284 sites offering CME in mid-June 2005. 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.

10. 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. 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

12. 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

13. Size of Sites – June 2005 No. of Credit- Hours Number of Sites Number of Hours % of Sites % 0f Hours Greater than 100 34204561380 50-9922139296 25-49481660197 10-24701161145 5-941293161 < 5 3911215<1 Total25425074100100

14. The Largest Sites June 2005 - I Name of Site No. of Activities No. of Hours eMedicine CME 65819871 Challenger402800 CMEWeb8951342 Am CollegeCardio Cardiosource12467 BioCritique900450 Medscape319422 Free CME 300400 ArcMesa95350 Journal Bytes 108348 Radiologic Soc North America300 TheAnswerPage5300 Pri-Med Online173220 The Oncologist198 NetCE23183 Surgical pathology Unknowns183

15. The Largest Sites June 2005 - 2 Name of Site No. of Activities No. of Hours CardioVillage10169 University of Wisconsin 115166 Pediatrix University 110165 Am Soc Clin Path Check Samples 152152 AudioDigest73146 Johns Hopkins Advanced Studies 100144 NEJM Weekly CME Program 140140 JAMA & Archives 130130 ACP Medicine 1120 ACS Surgery 1120 Baylor College of Medicine 139106 Anesoft Medical Simulation 6106 Ohio State University 106106 cmecourses100100

16. Fee Structure – Free Sites There has been a rapid growth in the number of sites offering free CME – from 98 sites (50%) in December 2001 to 177 sites (70%) in June 2005. There has been a similar rapid growth in the number of free credit-hours – from 1979 hours (11%) in December 2001 to 5075 hours (20%) in June 2005

17. Fee Structure – Pay for Credit Sites There has been very little change in the median fee for a credit hour. The bulk of the fee instruction (70-80%) continues to cost $5 to $15 per credit hour

18. Fee Structure by Site June 2005 Dominant or Average Fee Number of Sites % of Sites Free17770 <$5 per hour 135 $5 per hour 42 $6-9 per hour 135 $10 per hour 156 $11-14 per hour 52 $15 per hour 249 $16-19 per hour 31 $20 per hour 83 $21-24 per hour 52 $25 per hour 42 >$25 per hour 83

19. Hourly Fee Structure June 2005 Dominant or Average Fee No of Hours % of Hours Free507520 <$5 per hour 7853 $5 per hour 1003040 $6-9 per hour 281011 $10 per hour 7583 $11-14 per hour 118<1 $15 per hour 436117 $16-19 per hour 186<1 $20 per hour 2211 $21-24 per hour 3901.5 $25 per hour 45<1 >$25 per hour 2771

20. Financial Support Summary: There has been very little change in relative percentages of financial support since December, 2001. But as the number of free sites increases, the number of fee sites decreases Source of Support % of Sites Commercial Companies 50-54 University/Medical School 34-42 Government6-11 Medical/Specialty Association 24-31 Foundation6-9 User Fees/Partial or Complete 30-50

21. Financial Support June 2005 Source of Support No. of Sites % of Sites Commercial Companies 13751 University/Medical School 9134 Government3011 Medical/Specialty Association 6123 Foundation83 User Fees/Partial or Complete 8030

22. Primary Care and Specialty Sites Family Practice and Internal Medicine content continues to dominate the Primary Care sites (about 40% of 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

23. Specialty – Primary Care June 2005 No. of Sites % of Sites Primary Care Sites including: including: Family Practice 10740 Internal Medicine 10138 Pediatrics3513 Obstetrics/Gynecology2710 Multiple Specialties (>6) 2810

24. Subspecialties June 2005 Subspecialty sites Number of Sites % of Sites including: including: Cardiology249 Psychiatry218 Infectious Disease/HIV 218 Neurology156 Oncology208 Pulmonary-Critical Care 135 Radiology135 Geriatrics135 Endocrine124 Surgery83 Urology124

25. Sites by Specialty-June 2005- Other 38 sites (14%) 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 5 or fewer sites

26. Eight “Different” Sites June 2005 - I CE Medicus CE Medicus has no CME of its own, but offers access without fee to about 6285 activities produced by six content providers. Instruction is free. CE Medicus Doctor’s Guide Doctor’s Guide also has no CME of its own, but offers descriptions of over 1800 activities (free and fee) with links to those courses Doctor’s Guide DigiscriptDigiscript contains many hundreds of audio and video slide lectures recorded at medical meetings. The yearly charge is $400. Some activities offer CME and others 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. Digiscript University of Wisconsin Professional Courses offer credit for courses on non-medical subjects which could be expected to improve your practice or your life.University of Wisconsin Professional Courses

27. Eight “Different” Sites June 2005 - II Stanford SKOLAR offers credit for performing Internet literature searches on topics of your own interestStanford SKOLAR MerckMedicus CME Credit Program for Searching and Researching. Physicians can earn up to 25 CME credits per calendar year for every hour they spend researching medical questions, reading online medical references, or gathering information for patients on MerckMedicusMerckMedicus CME Credit Program for Searching and Researching Challenger now requires subscribers to buy a CDROM for each course. Once you purchase that CD, you have unlimited access to the website corresponding to that course. Thus, it is no longer “pure” online CME; I have included the number of Challenger’s courses and hours in this report for sake of consistency.Challenger American College of Cardiology Self-Selected CME allows subscribers to earn credits for reading parts of articles of interest.American College of Cardiology

28. Email Reminders June 2005 It is becoming increasingly common for the larger sites to send email reminders on request of the users about their new courses. At least 40 sites are now doing this regularly It is becoming increasingly common for the larger sites to send email reminders on request of the users about their new courses. At least 40 sites are now doing this regularly

29. Types of Instruction There has been very little change in the proportion of instruction types since December 2001. 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

30. Types of Instruction June 2005 Instruction Type Number of Sites % of Sites Text only 9034 Text-and-graphics6223 Slide-audio6424 Slide-video4316 Guidelines52 Question-and-answer114 Case-Based-Interactive4818 Correspondence31 Games31 Journal218 Journal with multiple subjects 145 Board Review/Self-Assessment 52 Streaming Video 2<1 Self-Directed Search 31

31. More about Question & Answer Instruction Only 11 sites (4%) feature Q&A, BUT the number of hours is relatively large (3423). Some larger sites are: Challenger - 2050 hours TheAnswerPage – 300 hours Ecore Family Practice – 40 hours Familypractice.com - 30 hours Am Acad Orthopedic Self-Assessment – 75 hours Am Acad Pediatrics Self-Assessment – 40 hours Medical Education Opportunities – 20 hours Orthopedics Hyperguide – 50 hours Total about 3423 hours (14 % of all CME hours)

32. CME Participation by Location Based on ACCME Figures for 2004 Live meetings and conferences account for 62.6% of “physician-registrants” Home study CME (“enduring materials”) and journals account for 23.6% of physician-registrants Online CME accounts for 13.8% of physician- registrants

33. Physician Usage of Online CME Physician usage of online CME is increasing, and now accounts for about 14% 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%) 2002: 329,110 physician-registrants (6.08%) 2004: 895,120 physician-registrants (13.8%)

34. Changes and Trends I There is a gradual upward trend in the numbers of sites, courses and hours (about 16% increase over the past 18 months) Some of that upward trend is “new”; some is accounted for by counting sites not previously found There has been another 50% increase in the number of free CME hours (5074 vs. 3380) over the 18 months. There has been little change in the specialty groups targeted, types of instruction or the sources of financial support (except that the number of small one- disease free sites seems to be growing).

35. Changes and Trends II Number of physician-registrants 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. The number of physicians registering for online CME has doubled in the past two years.

36. Why is Online CME use Still So Low? I These observations about the causes of the “low” use of Online CME are still true, BUT much less true than before: Some physicians are still 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

37. Why is Online CME Use Still So Low? II These observations remain true, BUT, again, to a lesser extent than 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

38. 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) Part of larger medical site Help with CME reporting Recommendation by colleagues, medical group Special arrangements with physician group

39. What do Physicians Want? Do physicians really want online CME? (I believe that, with usage now at 14%, the answer is YES)

40. 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

41. 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.

42. 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.

43. Conclusions I The number of online CME activities and credits is growing rapidly Online CME is becoming nicer to look at, with more graphics, lots more audio and video, and a bit more interactive programming

44. Conclusions II The percentage of CME hours earned online has risen to about 14% 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 set of educational interventions will be needed to accomplish behavior change

45. Conclusions III The future lies in the integration of medical practice, quality assessment and user-specific CME The challenges and opportunities are great

46. 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 2004 ACCME Annual Report 2004

47. Questions or Comments? Send email to bersklar@netcantina.com bersklar@netcantina.com