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CME at hand: Information you need, when you need it

Pilot projects are giving physicians CME credit for point-of-care learning with handhelds as a way to apply practice guidelines more effectively.

By Myrle Croasdale, amednews staff. Nov. 24, 2003.

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Family physician Daniel F. McCarter, MD, has a library of evidence-based medicine, diagnostic calculators and best-practice guidelines at his fingertips via his handheld computer.

When a patient complains of an inflamed leg and shortness of breath and mentions that he's recently taken a plane trip, Dr. McCarter can look up the clinical decision rules for a pulmonary embolism on the handheld instead of reaching for a textbook.

He sees 20 to 25 patients on a typical day and uses his handheld on a regular basis during those interactions.

"I use [the handheld] so much I don't really think about it. It's almost like using the stethoscope," said Dr. McCarter, an associate professor of clinical family medicine and director of clinical affairs at the University of Virginia School of Medicine's Dept. of Family Medicine in Charlottesville.

But one thing is missing from his learning experience -- CME credit.

"If I could get credit for what I'm doing here, that would be tremendously helpful," he said. "Going to a conference and sitting there being put to sleep by the lecturer doesn't change behavior long term. When you actually get the information when it makes a difference -- that's the way to go."

Soon Dr. McCarter and other physicians who are using handhelds or other tools to learn on the job might get their wish.

Learning while doing

It's well documented that adults learn best by solving problems, CME experts say, and for physicians this means learning in the exam room or at the patient's bedside. But the creation of CME that brings learning into the physician's office and then tracks the impact on patient outcomes has been slow in developing.

John Kues, PhD, immediate past president of the Society of Academic Continuing Medical Education, said the pieces needed to bring this to fruition have required more work than anticipated. Pilot programs can't move forward until good evidence-based sources are created, valid self-assessment tools are developed and ways to integrate and monitor these systems are working. The complexity of such learning models has meant a longer lead time in getting a product into physicians' offices, he said.

A few projects are now being rolled out.

If successful, they are sure to become more widely available.

The University of Florida College of Medicine in Gainesville is piloting a program that uses InfoRetriever, the same software used by Dr. McCarter at the University of Virginia. Two group practices are participating in the University of Florida program, with the first starting this fall after an introduction to the software by its creator Mark Ebell, MD, associate professor in family medicine at Michigan State University College of Human Medicine, East Lansing.

"Doctors tend to learn best when they are answering their own clinical questions, and we want them to use high-quality information at the point of care, which should translate into better practice," Dr. Ebell said.

Keyword searches can be done by symptom, diagnosis or ICDA code. When the doctors participating in the pilot project do their weekly sync between their handhelds and their office computers, a tracking program collects data on what the doctors have been looking up. The physicians also are required to record the question they were answering on a form provided by the university to qualify for credit.

The pilot is being conducted in cooperation with the American Academy of Family Physicians, which has yet to determine precisely how much credit will be awarded. But all of the elements required for Physicians Recognition Award category 1 CME credit are addressed in the pilot, so the University of Florida, as an accredited provider, will be awarding this level of credit.

One selling point: easy access

By giving physicians an evidence-based source of information they can access easily, Dr. Ebell and his colleagues hope they're breaking down barriers that deter a doctor from researching answers. Dr. Ebell said doctors commonly have 10 to 15 questions a day that would require research to answer but seek out solutions to only a third of them because they don't have time, don't know where to look or aren't near an information resource.

Floyd Pennington, PhD, associate director of continuing medical education at the University of Florida College of Medicine, who is also involved in the pilot project, said giving CME credit for researching activities like this is based on the participant using an approved evidence-based information source and going through the process of raising a question, looking for information, making a decision about what to do and recording the outcome. Whether this happens in a matter of seconds or hours, it's still valuable learning and worthy of credit, he said.

Dr. Pennington estimates that a third of the physicians will really get into using the handhelds, a third will use them on occasion and a third will forget how to turn them on.

"We may find out it's just a bother," he said, "Then the next question would be, 'What would be of value?' "

The American College of Physicians also is planning to roll out a point-of-care information/CME system in early 2004. Its software, called the Physicians' Information and Education Resource, will be available through Allscripts Healthcare Solutions Inc.'s electronic medical records system. The idea behind the ACP pilot is to give credit to physicians for changing their behavior and improving patient outcomes, not just answering questions.

"If you used this for a year and had eight changes in your pattern of behavior that resulted in improved outcomes, then that would be correlated to CME credit," explained Michael Strange, vice president of the college's medical knowledge and education division.

Other organizations also are digging into linking CME with quality-of-care improvements. In addition to a national pilot being done through the Centers for Medicare & Medicaid Services, which has an estimated 6,000 physicians in 40 states enrolled to date, the Texas Medical Assn. has a CME project that gives credit for tracking the use of best-practice guidelines for cardiac patients.

The TMA's program, called HeartCare Partnership, was developed after a CMS report showed that Texas was 49th among U.S. states and territories in the secondary prevention of cardiovascular disease.

In the language of medical educators, TMA's program would be learner-driven CME on a grand scale. Texas doctors identified a problem and they came up with a solution, a CME program that doesn't just teach about the disease but shows how to treat it and gives the physician a structure for actually doing this during a patient exam. It also provides the software for collecting this information and tracking results.

The program is based on the American Heart Assn. and American College of Cardiology guidelines on secondary prevention of cardiovascular disease. Two hours of CME credit are given for the initial workshop, and an additional two hours are given for each audit of 35 patient charts, with audits completed after three months, six months and one year.

Participating doctors also will be listed on the Texas Dept. of Health Web site as physicians who meet cardiac care guidelines.

Allan Anderson, MD, a cardiologist at North Texas Heart Center, Dallas, and a member of the TMA's committee on cardiovascular diseases and practice, said he had been above the target standards from the start but had been able to lift these numbers even higher by making the standards part of a template for his patient notes.

From July 2001 to September 2003, Dr. Anderson has seen his average for smoking cessation move from 76.8% to 83.3%, the use of statin drugs jump from 55% to 77.8% and angiotensin-converting enzyme (ACE) inhibitors climb from 86.3% to 94%.

"These programs are the first ripples on the beach," he said. "Medicine and physicians in particular need to create a tidal wave of change. "

Ralph McCleskey Jr., MD, medical director of cardiac rehabilitation at Hendrick Medical Center in Abilene, Texas, and a member of the TMA committee on cardiovascular care, said 90% of doctors know what the standards are, but surveys show that only 20% of patients actually get care that meets these standards.

The problem, Dr. McCleskey said, lies in the system of care, and the HeartCare audit gives physicians a systematic way to remember and document what they need to do.

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