Physician directed Internet CME and Performance Improvement: Where we can take CME

1. Physician directed Internet CME and Performance Improvement:Where we can take CME SACME Fall Meeting November 2004 Charles E. Willis, MBA Director, AMA PRA Policy Continuing Physician Professional Development American Medical Association

2. Physician directed, interactive Internet CME • Started in December 2000 • Seek to capture, as learning, use of professional literature at or near point of care • Technology made it possible, molecular biological revolution made it imperative • What changes does the AMA PRA need? • Departure from static needs assessment, learning objectives CME -- to dynamic, practice based learning

3. Physician directed, interactive Internet CME The four pilot participants: • SKOLAR, Inc. • UpToDate, Inc. • American College of Physicians (PIER) • MerckMedicus

4. Physician directed, interactive Internet CME • Retain link to time only to establish physicians have adequately engaged this learning activity • Learning associated with searching on a specific topic documented through search criteria • Increase credit awarded based on level of engagement • Initial, point of care search: average 2-3 minute interaction, quick answer needed

5. Physician directed, interactive Internet CME • Deeper search: time as gross measure, for credit a structured response to several questions expected (describe clinical question, review of sources and application to practice) • Asynchronous, could be done later (review of practice patterns) • Keep it simple: physicians and providers can choose the depth (rigor) they want to pursue

6. Physician directed, interactive Internet CME (draft credit metrics) • Education prevailed over assessment • Small increment of credit for initial inquiry: 0.10 • Deeper search (return to topic) would require documented physician response (reflection): • Review question, relevant citations and the application to practice • AMA PRA category 1 credit: 0.50

7. Physician directed, interactive Internet CME • Provider driven: awarding, tracking credit • Content integrity: AMA PRA definition and ACCME content validation guidelines • Final stage would link to documented practice change • Becomes a performance improvement activity…

8. A Quick History… • AMA Performance measurement [improvement] pilot started in August 2001 • Goal: To examine how physicians could efficiently & effectively accrue AMA PRA category 1 credit for PM&I activities • Five organizations invited to join as participants in the pilot • Recommendations to converge with Physician-directed Interactive Internet CME project

9. AMA Performance Improvement Pilot • Find flexible operating definitions that describe performance improvement activities • Leverage provider expertise in developing educational materials that support physician performance measurement and improvement • Keep it simple! AMA PRA credit system guidance must work for both the physician and the diverse CME provider communities

10. AMA Performance Measurement Pilot Participants • University of Pittsburgh Medical Center • U.S. Department of Veterans Affairs (Employee Education System) • Accreditation Association For Ambulatory Health Care, Inc. (IQI) • Iowa Foundation for Medical Care (QIOs) • American College of Physicians

11. Principal Challenges for Performance Improvement as CPPD • Retain a link to exposure model for physician learning (i.e., study of appropriate guidelines)? • How do we allocate credit? Base it on incremental completion of the process? • Where does cognitive change fit the stages of the performance improvement cycle (did the physician learn something)? • Need to find optimal definition of performance improvement as a physician driven process

12. AMA Performance improvement pilot • Faced with finding flexible operating definitions that describe performance improvement activities • Leverage provider expertise in developing educational materials that support physician performance measurement and improvement • Again, keep it simple! AMA PRA credit system guidance must work for both the physician and the diverse CME provider communities

13. Electronic Medical Record • EMRs are still nowhere near serving as the performance improvement panacea (documentation conundrum) • Most EMRs do not have PI capability, limited as decision support tools, and expensive/difficult to retrofit • AMA and CMS staff met with EMR companies to address this problem

14. Defining a Performance improvement (PI) activity • Settled on a name: measurement in the service of improvement so it is now PI activities • Simplified to three stages, focus on PI components • Implement and understand the standards (expect an active physician learner) • Integrity of the process warrants partial credit for completing stages of the activity • Final AMA PRA language approved by the Council on Medical Education on September 17

15. Stages for a PI activity designated for AMA PRA credit • Stage A: Learning from current practice assessment (5 credits) • Stage B: Learning from the application of performance improvement to patient care (5 credits) • Stage C: Learning from the evaluation of the performance improvement effort (5 credits)

16. Performance improvement (PI) credit assignment • Time metric could not capture the learning • Encourage engagement with all Stages • Additional credit is awarded for completing PI activities as an organic whole (maximum of 20 credits) • Providers as critical partners, will develop the learning materials • Documentation also critical, requirements to evolve over time • www.ama-assn.org/ama/pub/category/13151.html

17. Assigning credit • Physician practice settings complex and varied: late entry (Stage B or C) to the PI cycle may be accommodated • Need to document this work (equivalent to expectations for Stages A/B) • Not mandatory! Providers may determine credit can awarded only for completing the full cycle • To succeed, we will all have to think differently: a work in progress

18. Approaches to documentation • Stage A: Written statement about choice of performance measure and assessment of current practice • Stage B: Document intervention, data collected, and inferences drawn; additional data where appropriate (meeting minutes, etc.) • Stage C: Individual summary of what physician has learned, compare practice assessment with implemented performance change (invitation to reflective thinking!)

19. How it fits together… • Access to primary clinical and biomedical literature – Physician directed Internet CME (AMA PRA category 1 credit for useful searches) • Formally designed educational activities could still capture, communicate and set priorities for the clinical knowledge of greatest relevance (traditional CME)

20. How it fits together (cont’d)… • Performance improvement offers Category 1 credit for implementation (translating clinical knowledge into practice) • Internet CME and performance improvement activities buttress traditional CME • Closing the loop: bringing physician professional development closer to interactive, practice based learning

21. Thank you!