1. Bernard Sklar, MD: Online Continuing Medical Education December 2006 Online CME – An Update Review of December 2006 Bernard M. Sklar, M.D., M.S. www.cmelist.com/list.htm bersklar@netcantina.com

2. Bernard Sklar, MD: Online Continuing Medical Education December 2006 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 December 2006 Master’s Thesis This review is based on the December 2006 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 December 2006 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 December 2006 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 This year I also searched the Internet again for “online + continuing + medical + education”

6. Bernard Sklar, MD: Online Continuing Medical Education December 2006 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. Bernard Sklar, MD: Online Continuing Medical Education December 2006 Extensive Updates I have been maintaining the list for about nine years, beginning in 1997 The database was updated for my master’s thesis in February 2000, and every six months since. From March through December 2006, I visited and updated the review of each site on the list.

8. Bernard Sklar, MD: Online Continuing Medical Education December 2006 Database Created from List The database contains information about the 300 sites offering CME in early December 2006. 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 300 sites offering CME in early December 2006. 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.

9. Bernard Sklar, MD: Online Continuing Medical Education December 2006 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

10. Bernard Sklar, MD: Online Continuing Medical Education December 2006 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

11. Bernard Sklar, MD: Online Continuing Medical Education December 2006 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 286 This method counts only those sites which offer original content and not 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)

12. Bernard Sklar, MD: Online Continuing Medical Education December 2006 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

13. Bernard Sklar, MD: Online Continuing Medical Education December 2006 Size of Sites – December 2006 No. of Credit- Hours Number of Sites Number of Hours % of Sites % 0f Hours Greater than 100 40208841479 50-99332163128 25-49461643166 10-24801201285 5-939273141 < 5 48123171 Total28626287100100

14. Bernard Sklar, MD: Online Continuing Medical Education December 2006 The Largest Sites Dec 2006 - I Name of Site No. of Activities No. of Hours eMedicine CME 63919586 Challenger402800 CMEWeb8561284 ArcMesa Educators97350 JournalBytes (All Specialties) 108346 McGill Cont Medical Education 346346 Oncologist (The) 318318 Clinical Directors Network 300300 FreeCME179300 Rad Soc North America300 TheAnswerPage5300 NetCE32250 CardioVillage10231 PriMed Online173220 Ohio State University205

15. Bernard Sklar, MD: Online Continuing Medical Education December 2006 The Largest Sites Dec 2006 - 2 Name of Site No. of Activities No. of Hours CME Institute (Psychiatry) 200200 Johns Hopkins Adv Study courses 100166 CMELectures.org110165 Pediatrix University 110165 Audio Digest 73146 Amer Soc Clin Path Check Sample 145145 NEJM Weekly CME Program 140140 BioCritique271135 JAMA & Archives 130130 MedRisk Online 27127 University of Wisconsin 62126 ACP Medicine Online Version 1120 Amer Acad Ped Self Assessment 3120 Epocrates Mobile CME 120120

16. Bernard Sklar, MD: Online Continuing Medical Education December 2006 The Largest Sites Dec 2006 - 3 Name of Site No. of Activities No. of Hours Johns Hopkins Adv Study Journal 36117 American Psychiatric Association 17116 Amer Acad Peds Other Courses 14114 Children’s Minnesota Grand Rounds 110110 Washington Univ St Louis 106110 Anesoft Medical Simulation 6106 EMed Home Concert program 3105 DiabetesConnect.org99103 The heart.org 100100

17. Bernard Sklar, MD: Online Continuing Medical Education December 2006 Fee Structure – Free Sites There has been a leveling off in the number of sites offering free CME – from 177 sites (70%) to 168 sites (59%) in December 2006. There has been a similar leveling off in the number of free credit-hours – from 5075 hours (20%) in June 2005 to 5740 (21%) in December 2006.

18. Bernard Sklar, MD: Online Continuing Medical Education December 2006 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

19. Bernard Sklar, MD: Online Continuing Medical Education December 2006 Fee Structure by Site Dec 2006 Dominant or Average Fee Number of Sites % of Sites Free16859 <$5 per hour 155 $5 per hour 83 $6-9 per hour 145 $10 per hour 166 $11-14 per hour 41 $15 per hour 2810 $16-19 per hour 31 $20 per hour 103 $21-24 per hour 41 $25 per hour 62 >$25 per hour 103

20. Bernard Sklar, MD: Online Continuing Medical Education December 2006 Hourly Fee Structure Dec 2006 Dominant or Average Fee No of Hours % of Hours Free574022 <$5 per hour 12035 $5 per hour 1004238 $6-9 per hour 24489 $10 per hour 9043 $11-14 per hour 781 $15 per hour 438417 $16-19 per hour 3041 $20 per hour 4072 $21-24 per hour 2721 $25 per hour 1991 >$25 per hour 2301

21. Bernard Sklar, MD: Online Continuing Medical Education December 2006 Financial Support Summary: There has been very little change in relative percentages of financial support since December, 2001. As the number of free sites increases, the number of fee sites decreases

22. Bernard Sklar, MD: Online Continuing Medical Education December 2006 Financial Support Dec 2006 Source of Support No. of Sites % of Sites Commercial Companies 15251 University/Medical School 9833 Government3311 Medical/Specialty Association 6622 Foundation134 User Fees/Partial or Complete 118 (approximate) 41

23. Bernard Sklar, MD: Online Continuing Medical Education December 2006 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

24. Bernard Sklar, MD: Online Continuing Medical Education December 2006 Specialty – Primary Care Dec 2006 No. of Sites % of Sites Primary Care Sites including: including: Family Practice 10836 Internal Medicine 9732 Pediatrics3712 Obstetrics/Gynecology289 Multiple Specialties (>6) 3512

25. Bernard Sklar, MD: Online Continuing Medical Education December 2006 Subspecialties Dec 2006 Subspecialty sites Number of Sites % of Sites including: including: Cardiology279 Infectious Disease/HIV 248 Psychiatry207 Oncology207 Radiology207 Endocrine165 Surgery134 Neurology124 Pulmonary-Critical Care 103 Geriatrics83 Urology83

26. Bernard Sklar, MD: Online Continuing Medical Education December 2006 Sites by Specialty-Dec 2006- 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 5 or fewer sites

27. Bernard Sklar, MD: Online Continuing Medical Education December 2006 Five “Different” Sites Dec 2006- I CE Medicus CE Medicus has no CME of its own, but offers access without fee to about 6100 activities (about 9000 hours) produced by 20 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 2000 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

28. Bernard Sklar, MD: Online Continuing Medical Education December 2006 Five “Different” Sites June 2005 II 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

29. Bernard Sklar, MD: Online Continuing Medical Education December 2006 Email Reminders Dec 2006 It is becoming increasingly common for the larger sites to send email reminders on request of the users about their new courses. At least 55 sites are 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 55 sites are doing this regularly

30. Bernard Sklar, MD: Online Continuing Medical Education December 2006 Types of Instruction There has been little recent change in the proportion of instruction types. (But see my comments about podcasts and point-of- service models below.) 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

31. Bernard Sklar, MD: Online Continuing Medical Education December 2006 Types of Instruction Dec 2006-I Instruction Type Number of Sites % of Sites Text only 8629 Text-and-graphics6522 Slide-audio6722 Slide-video5619 Guidelines52 Question-and-answer103 Case-Based-Interactive5719

32. Bernard Sklar, MD: Online Continuing Medical Education December 2006 Types of Instruction Dec 2006-II Instruction Type Number of Sites % of Sites Correspondence41 Games41 Journal186 Journal with multiple subjects 124 Board Review/Self-Assessment 52 Streaming Video 145 Self-Directed Search (POS) 31 Text-Audio52 Pod cast 52

33. Bernard Sklar, MD: Online Continuing Medical Education December 2006 More about Question & Answer Instruction Only 10 sites (3%) feature Q&A, BUT the number of hours is relatively large (3545) Challenger - 2800 hours TheAnswerPage – 300 hours Am Acad Pediatrics Self-Assessment – 120 hours EMedHome Concert – 105 hours Am Acad Orthopedic Self-Assessment – 75 hours Orthopedics Hyperguide – 50 hours Ecore Family Practice – 40 hours Medical Letter – 26 hours Medical Education Opportunities – 20 hours Interactive Testing in Psychiatry – 7 hours Total about 3545 hours (13 % of all CME hours)

34. Bernard Sklar, MD: Online Continuing Medical Education December 2006 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 December 2006 Podcasts I only counted five sites offering podcasts, but I may have missed some sites that added podcasts after my visit I believe that podcasting will catch on quickly because the technology is easy to apply and because most younger doctors and many older ones have I-Pods or other portable players

36. Bernard Sklar, MD: Online Continuing Medical Education December 2006 Point of Care/Self Study I counted only three sites offering “Point of Care” CME, but I believe some have been added since my count. I know that some providers (Skolar, MerckMedicus) have given up the effort Time will tell; it’s a great idea, but may be too awkward to use in practice

37. Bernard Sklar, MD: Online Continuing Medical Education December 2006 Sites that have closed About 44 sites offering about 800 credit hours disappeared between July 2005 and November 2006 In about half the cases, this was planned because credit expired In the other half, the site disappeared, sometimes with an explanation and sometimes without

38. Bernard Sklar, MD: Online Continuing Medical Education December 2006 CME Participation by Location Based on ACCME Figures for 2005 Live meetings and conferences accounted for 52% of “physician-registrants” Home study CME (“enduring materials”) and journals accounted for 30% of physician-registrants Online CME accounted for about 18% of physician- registrants

39. Bernard Sklar, MD: Online Continuing Medical Education December 2006 Physician Usage of Online CME Physician usage of online CME is increasing, and now accounts for about 18% 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 (14%) 2005: 1,368,335 physician-registrants (18%)

40. Bernard Sklar, MD: Online Continuing Medical Education December 2006 Changes and Trends I There is a gradual upward trend in the numbers of sites, courses and hours (about 5% increase over the past 18 months) Some of that upward trend is “new”; some is accounted for by counting sites not previously found; about 44 sites offering about 800 hours have discontinued operation There has been a small increase in the number of free CME hours (5740 vs. 5074) over the 18 months. There has been little change in the specialty groups targeted, types of instruction or the sources of financial support.

41. Bernard Sklar, MD: Online Continuing Medical Education December 2006 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 to 1,368,335 (18%) in 2005. The number of physicians registering for online CME has tripled in the past three years.

42. Bernard Sklar, MD: Online Continuing Medical Education December 2006 Why is Online CME use Still So Low? I Pretty soon I hope to eliminate the ”Why is Online CME Use so low?” portion of this report. My points about the “low” use of Online CME are still pertinent, BUT much less so than just a few years ago: Some physicians are still uneasy with computers and the Internet Some physicians are 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

43. Bernard Sklar, MD: Online Continuing Medical Education December 2006 Why is Online CME Use Still So 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

44. Bernard Sklar, MD: Online Continuing Medical Education December 2006 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

45. Bernard Sklar, MD: Online Continuing Medical Education December 2006 What do Physicians Want? Do physicians really want online CME? (I believe that, with usage now at 18%, the answer is YES) What do they like and dislike? (According to most studies, lectures are still the preferred mode of instruction)

46. Bernard Sklar, MD: Online Continuing Medical Education December 2006 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

47. Bernard Sklar, MD: Online Continuing Medical Education December 2006 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.

48. Bernard Sklar, MD: Online Continuing Medical Education December 2006 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.

49. Bernard Sklar, MD: Online Continuing Medical Education December 2006 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

50. Bernard Sklar, MD: Online Continuing Medical Education December 2006 Conclusions II The percentage of CME hours earned online has risen to about 18% 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

51. Bernard Sklar, MD: Online Continuing Medical Education December 2006 Conclusions III The future lies in the integration of medical practice, quality assessment and user-specific CME The challenges and opportunities are great

52. Bernard Sklar, MD: Online Continuing Medical Education December 2006 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 2005 ACCME Annual Report 2005

53. Bernard Sklar, MD: Online Continuing Medical Education December 2006 Questions or Comments? Send email to bersklar@netcantina.com bersklar@netcantina.com