THINK TANK: A New Formula for CME

Continuing Medical Education is evolving at a rapid pace these days with a new mix of learning objectives, evidence-based guidelines, content areas, multimedia modalities, performance-based criteria, and sponsors. PM360 asked several industry experts their thoughts on the best practices in CME today, the role of commercial support, and any overlapping interests of physicians, patients, and pharmaceutical companies.

MIKE SAXTON, MEd, FACME, CCMEP
Pfizer
Senior Director, Team Leader
Medical Education Group
Glen Gardner, NJ
mike.saxton@pfizer.com

What is the value of CME to commercial supporters? This question is asked more frequently in light of what is perceived to be an increasingly restrictive environment for commercial support of continuing medical education (CME/CE). To answer this question, we need to recognize the tremendous and accelerating pace of change in the medical education and healthcare environments. Some of the changes associated with CME/CE are interventions that use learning as a strategic component in healthcare systems for accelerating improvement in healthcare performance and patient safety.

Where does industry support for CME fit in this emerging framework? The figure below illustrates the strategic fit for business at the intersection of the zones representing patient needs, healthcare system quality gaps, healthcare provider performance gaps, and business needs. The overlapping circles define the boundaries within which industry needs are appropriately placed because they address healthcare goals.

The appropriate business need that aligns with CME/CE support most often occurs when a company recognizes market expansion as a core strategy. It is never appropriate for industry to consider independent medical education a strategy to enhance market share. Industry support needs to be free of proprietary bias, and the CME forum must remain an environment that allows for the open exchange of research findings and the best available evidence.

Effectively using the right treatment plan at the right time for the right patient requires many healthcare provider competencies that characterize the overlap of these four interests. They include patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice. This paradigm—espoused and increasingly embraced by agencies and groups concerned with healthcare quality and professional education (Joint Commission, AHRQ, AAMC, and IOM, to name a few)—is being adopted by leading organizations providing CME/CE. The change represents an opportunity for industry to move away from its limited focus on a largely ineffective “meetings-based”

CME economy that has higher compliance risks and offers little mutual value based on the data of what works in CME/CE. The only beneficiaries are those that prosper from this outdated meetings-based model of support. Industry, along with the medical profession and patients, see valuable and increasingly scarce resources wasted. It is time to change.

Fully adopting this Convergence of Interests Model can reshape commercial support of CME/CE. Applying this model can improve the quality of grants awarded and simultaneously reengage commercial parts of organizations in appropriate strategic dialogue. This model may also facilitate improvement in other operational aspects of commercial support. Policies and procedures can be simplified, compliance risk mitigated, and overhead costs reduced. One example of change using this model might be industry adoption of a “block grant” or “pooled funding with a purpose” approach to grants. By forgoing “one-grant-at-a-time decisions” in favor of a more accountable and effective approach, there will be increased opportunities for reengaging commercial in strategic-level discussions in which the compliance concern of individual grant-making bias is removed. In many companies, CME/CE support has become so siloed by compliance issues and other policy requirements that internal dialogue intended to identify resources for patients no longer occurs. The Convergence of Interests Model can be the foundation for a new dialogue and transformation of commercial support of CME/CE.

References
1. Common Program Requirements: General Competencies. Revised 2007: http://www.acgme.org/outcome/comp/GeneralCompetenciesStandards21307.pdf.

2. Fletcher SW, M.D, al e. Continuing Education in the Health Professions: Improving Healthcare through Lifelong Learning: Josiah Macy, Jr. Foundation; 2008.

3. Report of the AAMC Task Force on Industry Funding of Medical Education: Association of American Medical Colleges; 2008.

4. Steinbrook R. Financial support of continuing medical education. JAMA : the Journal of the American Medical Association. 2008;299(9):1060-1062.

5. Brennan TA, Rothman DJ, Blank L, et al. Health industry practices that create conflicts of interest: a policy proposal for academic medical centers. JAMA: the Journal of the American Medical Association. 2006;295(4):429-433.

6. Spyridon S. Marinopoulos M.D. MBA, Todd Dorman MD, Neda Ratanawongsa MD, et al. Effectiveness of Continuing Medical Education. Rockville, MD: Agency for Healthcare Research and Quality; January 2007.

7. Compliance Program Guidance for Pharmaceutical Manufacturers. In: General OoI, ed. Federal Register; 2003:23732 - 23739.

EZRA T. ERNST
MedscapeCME
SVP, General Manager

Continuing medical education (CME) is the primary education medium for physicians after they complete their residency or fellowship; it is critical to keeping physicians current on advances in disease diagnosis, treatment, and patient management. Two benefits of CME that are not widely appreciated are that its learnings are measurable and its impact on patient care can be quantified. The best medical education employs a combination of relevant curriculum, meaningful participation, and empirical results to measure its intended effect on clinical practice and impact on patient health. The advent of evidence-based medicine has made the significance of CME even more important as curriculums now commonly “teach the evidence.” Clinical guidelines developed on the basis of evidence have become a powerful tool in an educator’s arsenal. Medical societies issue formidable, voluminous guidelines which can be challenging for a busy practitioner to digest and incorporate into practice. Online CME is often the best means to explain the guidelines effectively and efficiently.

Performance-improvement measures, while not new to medical education, have recently become a hot topic in CME. Specialty medical societies issue specific performance measures for certification and validation of physician competency. CME is useful for revealing critical knowledge gaps and providing interventions that allow physicians to meet current standards of practice. The AMA has designated a new format for awarding AMA PRA credit to physicians to validate improvement in practice. Performance-improvement activities provide structured processes by which a physician or group of physicians can learn about specific performance measures, retrospectively assess their practice, apply these measures prospectively over a period of time, and reevaluate their performance. This practice allows for self-discovery and, in the context of CME, an opportunity to develop “teachable moments” at regular intervals and continue the valuable work of educating healthcare professionals with the latest information when it matters the most.
New York, NY eernst@medscape.net

JAMES A. SHIFFER, RPh, CCP
CE Health Interactive
Medical Director
Richmond, VA

The use of technological advancements, including interactive media and video, is an established, effective method for assuring adult retention. The application of adult learning principles, which tailor information to the needs of individuals, increases the value of education and improves the likelihood of knowledge, comprehension, and performance. New, innovative, and interactive digital methods of communication that provide a self-directed learning environment are on the leading edge of CME. Websites such as The CME Lounge allow the participant to view unbiased, educational activities when it’s convenient and support established retention rates for CME. These Websites also provide the participant with the ability to interact with providers to identify educational gaps and recommend learning objectives for future programs. CDC maps, such as those developed by the Behavioral Risk Factor Surveillance System, help uncover areas in which education is most needed. This maximizes limited budgets and allows for aggressively targeted initiatives.

Industry supporters have recently revamped processes to include more restricted and comprehensive requests for proposals, or RFPs. RFPs provide for specific disclosures that ensure the unbiased nature of the CME activity by ascertaining whether or not the vendor has implemented specific firewalls. While RFPs allow industry supporters to continue to partner with vendors, they also include details that confirm that the needs of the target audience, as well as the long-term educational goals of the supporter and CME provider, are met. The RFP process is also helpful in determining educational gaps that exist, leading to the development of CME activities that fulfill the educational needs of the participant.

The published literature provides the results of many supporting studies provided by groups that identify and evaluate educational gaps. The business goals of the commercial supporter should be treated as global awareness and educational goals of the healthcare community and must be tailored and directed at improving patient care. Therefore, by addressing patient care, the business, global awareness, and educational goals of all involved will ultimately improve the quality of life for patients, caregivers, and healthcare providers.
jshiffer@cehealthinteractive.com

LAIRD R. KELLY, CCMEP
RSi/FocalSearch
President
Englewood Cliffs, NJ
laird.kelly@rsifocalsearch.com

Until recently, Category 1 CME credit was limited to meetings, publications, or other media produced by an Accredited Provider who conducted surveys or performed literature analyses to determine the educational needs of a group of physicians. The Provider-to-physician approach produced high-quality, innovative programs, but their needs analysis necessarily reflected documented information needs from the past. Learner-initiated CME, such as the recently approved Internet Point of Care CME, reflects physicians’ real-time needs for information and learning.

Physicians have questions at the rate of about one for every other patient seen. About 40% of those questions require some online research. Physicians who use online resources approved by a Provider and who document their experience properly can earn one-half credit for each completed search. The physician conducts, in effect, a “needs analysis for one,” since she or he needs the information to make a clinical judgment.

As a side benefit, the Provider is able to aggregate hundreds or thousands of these clinical questions to provide a real-time needs analysis of the doctors in the given specialty. Pharmaceutical companies can participate in learner-initiated programs by funding research collections in areas of therapeutic or specialty interest. Such collections typically include thousands of scientific articles, are updated frequently, and provide a valuable professional service to physicians.

About the “CCMEP” designation, it stands for Certified CME Professional and is awarded by the nonprofit National Commission for Certification of CME Professionals. Those who use the CCMEP have demonstrated their competence through experience, through continuing education activities, and by passing a peer-developed examination. Some pharmaceutical companies have had their entire CME staff earn the credential, as have some medical education companies.

(Full disclosure: Laird Kelly is a board member and treasurer of NC-CME. Both are volunteer positions.)

WENDY HECKELMAN, PhD
President
WLH Consulting
Fort Lauderdale, FL
wendy@wlhconsulting.com

As a minimum standard, all CME must be designed, funded, and delivered in a compliant fashion, e.g., based on ACCME standards. Many providers and supporters of CME have already taken this reactive stance. However, pharmaceutical companies need to take a proactive role in driving education reform forward to demonstrate the value of industry support for CME. This includes providing funding for innovative programs that focus on quality and practice improvement, produce outcomes which demonstrate performance and patient health changes, and support local community education. They should play a collaborative role to enable the production of programs that support broader initiatives, have multiple touches, and reach wider audience targets.

Pharmaceutical companies that are already doing so should continue to fund innovative educational programs in a compliant fashion. They should help the industry move from traditional CME to professional development initiatives with demonstrated impact on treatment practices and patient health. Companies can also partner with education providers and institutions to advance common goals, like ensuring that education programs meet identified healthcare provider or patient knowledge gaps, and help to close these gaps. These partnerships would also have the added benefit of restoring trust and confidence in their practices.

Commercially supported CME should also address the convergence between the unmet educational needs of healthcare providers and the pharmaceutical industry’s business needs. Education programs that address this convergence include those targeted at broader population health outcomes and at translating knowledge into practice. These programs provide value to Pharma because any innovative educational program that can demonstrate improved medical treatment or outcomes for patients would fit the mission statement of every major pharmaceutical company. Education programs on emerging scientific trends or treatments are also of interest to pharmaceutical companies because they help healthcare providers understand the science and technology behind innovations and more rapidly adopt them once they become available.

DONALD J. M. PHILLIPS, BSc, PharmD
Vox Medica Holdings
Principal and CEO
Philadelphia, PA
dphillips@vmholdingsinc.com

The best practice I can think of for ensuring compliance with ACCME guidance for commercial support is very simple as always: Use common sense. As it relates to CME, I define common sense as playing by the rules, behaving in a transparent manner, and acting with integrity.

The ACCME, along with just about every professional society and accrediting body, offers good guidance on the nature of behaviors that will ensure commercial interests do not interfere with the independence and validity of continuing education. We should live by that guidance.The same guidance mentioned above requires disclosure of any possible or real conflict of interest. This disclosure should include anyone involved with the identification of need and the development and presentation of educational content.

If conflicts exist, then steps must be taken to resolve them. Disclosure by itself does not resolve direct conflicts. Lastly, if all involved use common sense and act with honesty, integrity, and the interests of patients above all others, then many of the opponents of commercial support for CME would be allies in the great challenges we face in healthcare access, delivery, quality, and affordability. As commercially supported CME looks to empower professionals with timely and relevant information to improve health outcomes, we are ethically charged to be unbiased and objective always. Working together with other ethical stakeholders and with transparency at all times, we can yield greater results for years to come.

VENKAT GULLAPALLI, MD
Gullapalli & Associates
CEO
Jersey City, NJ
vg@gullapalliandassoc.com

CME planners should view the Accreditation Council for Continuing Medical Education (ACCME) guidelines as minimal requirements for developing programs; aiming higher ensures excellence, educational effectiveness, creativity, and durability of the planners. Collaborating with other organizations and stakeholders has become an unsaid requirement, allowing inter-organizational synergies to enhance CME offerings. Having organizations say that they can do everything is misleading, and such positions will continue to foster perceptions of bias. CME planners should also focus on patient care and outcomes when considering the value of programs.

The challenge for pharmaceutical companies lies in striking a balance between the commercial interest and educational value of CME. CME grant reviewers should adopt a vision for improving patient outcomes as part of their educational mission in much the same way as they do drug development. As grant reviewers, they are uniquely empowered to impact the landscape of educational design. Grant reviewers should focus on supporting programs that bring together CME stakeholders to collaborate on multi-interventional, multi-disciplinary initiatives designed to provide documented evidence of improved patient outcomes.

The business of healthcare is improving patient outcomes, and CME stakeholders should focus on the true goal: improving patient care through education. Achieving alignment between business goals and effective education makes the appearance of bias moot. Areas of alignment include improving diagnosis, optimizing treatment strategy and therapy selection, improving medication adherence and persistence, and striving to impact overall patient outcomes. To attain these, CME organizers should identify areas in which global educational gaps or needs exist for healthcare providers and abandon old practices of identifying therapy-related needs only. Further, CME organizers should develop the curriculum free from the direct influence of the commercial supporters, ensure high-quality presenters, and leverage proven performance improvement models that measure the impact of interventions on patient outcomes.