Performance Improvement CME – The New CME?

For many years physicians have been asked, even required, to participate in formal CME activities and use the credits earned from that participation to retain their medical license, maintain practice privileges, be accepted as part of third party payer panels, and as an attestation to the public that they are staying current in their field. While formal CME has its place among the learning resources physicians should access to help them in their efforts to maintain their competence and improve their performance, there are much more reliable forms of CME to depend on to assure the care a physician s providing is leading to good patient outcomes. These are is Performance Improvement CME (PI CME) and Practice Based Learning.

I recently did a podcast with Norman Kahn, MD, Executive Vice President and Chief Operating officer of the Council of Medical Specialty Societies focused on PI CME. There appears to be a convergence of interest in PI CME that may soon make PI CME the dominant form of learning across a physicians career. You might find this brief conversation with Dr. Kahn very informative. Click here to listen.

If , in the coming years, PI CME emerges as the “New CME” , it will change the CME profession. It will change how physicians approach learning in their own care environments. The importance of consensus on medical evidence supporting clinical decisions will be critical. Physicians will engage in evidence based learning that provides the highest probability to impact the care they provide their patients. And they will have data from their practice to show how well it is working with their patients.

Thoughts?

PTSD – A major opportunity for CME?

Nearly 20 percent of military service members who have returned from Iraq and Afghanistan — 300,000 in all — report symptoms of post traumatic stress disorder or major depression, yet only slightly more than half have sought treatment, according to a new RAND Corporation study.

Many service members said they do not seek treatment for psychological illnesses because they fear it will harm their careers. But even among those who do seek help for PTSD or major depression, only about half receive treatment that researchers consider “minimally adequate” for their illnesses.

“There is a major health crisis facing those men and women who have served our nation in Iraq and Afghanistan,” said Terri Tanielian, the project’s co-leader and a researcher at RAND, a nonprofit research organization. “Unless they receive appropriate and effective care for these mental health conditions, there will be long-term consequences for them and for the nation. Unfortunately, we found there are many barriers preventing them from getting the high-quality treatment they need.”

Researchers concluded that a major national effort is needed to expand and improve the capacity of the mental health system to provide effective care to service members and veterans. The effort must include the military, veteran and civilian health care systems, and should focus on training more providers to use high-quality, evidence-based treatment methods and encouraging service members and veterans to seek needed care.

Researchers found many treatment gaps exist for those with PTSD and depression. Just 53 percent of service members with PTSD or depression sought help from a provider over the past year, and of those who sought care, roughly half got minimally adequate treatment.
Service members report many reasons for not seeking treatment. Many are worried about the side effects of medication or believe that family and friends can provide more help than a mental health professional. Even more reported that they worried seeking care

Researchers also found an urgent need to train more mental health providers throughout the U.S. health care system on delivering evidence-based treatments to service members and veterans

Researchers suggest special training programs are needed to instruct mental health providers in the military, veterans and civilian health systems about the type of evidence-based treatments needed by service members.

The report is titled “Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery.” The full report and several summaries are available at http://veterans.rand.org/.

An example of the need for QI and CME to collaborate.

A recent report suggest cardiac patients admitted during the week are more likely to survive than patients admitted on the weekend. Isn’t this a very real example of the need for the Quality Improvement and Continuing Medical Education departments in hospital settings to work together on an important improvement initiative. QI can surely get at the root cause of this problem by identifying systems and work process issues that could addressed and lead to improvement. CME can surely examine the root cause analysis of the problem done by QI and identify practice gaps amenable to an educational resolution that could lead to improvement. Working together on this issue might demonstrate the real value of QI/CME collaboration.

CME providers clamor for needs assessment data to support education interventions. How does your hospital data compare with the national data? Take a look at your data with your QI department. See what you learn. If there appears to be room for improvement in your setting, perhaps the two departments can identify collaborative initiatives that will significantly change the numbers, reduce morbidity, and save some lives, especially on the weekends.

Just a thought.

Chronically Ill Patients Get More Care, Less Quality

Here is a report every person in CME should at least scan as a source of needs assessment data . What follows is a press release from the Robert Wood Johnson Foundation (4/07/2008). Download the Dartmouth Atlas.

“Medicare pays many hospitals and doctors more than the most efficient and effective health care institutions to treat chronically ill people, yet gets worse results, a new report from the Dartmouth Institute for Health Policy and Clinical Practice finds.

Funded primarily by the Robert Wood Johnson Foundation, the report, Tracking the Care of Patients with Severe Chronic Illness: The Dartmouth Atlas of Health Care 2008 (184 pages, PDF), found that caring for people with chronic diseases accounts for more than 75 percent of all health care spending, due in part to Medicare’s encouragement of the use of acute care hospital services and the proliferation of medical specialists. Indeed, the U.S. healthcare system as a whole lacks efficient ways of caring for people with severe chronic illnesses, the report found.

The report found significant variations in the number of services that patients with severe chronic diseases receive at the end of life, depending on the hospital, region, and state in which the patient is located, rather than how sick a patient is. The report also found that regions and states that use more services per patient do not necessarily have higher quality care — in fact, care in these states is slightly worse.

According to the report, Medicare could save tens of billions of dollars annually if it mirrored the practice patterns of more efficient and effective health care systems such as the Mayo Clinic. With the leading edge of the baby boom generation approaching retirement age, such savings would be realized just as Medicare needs that money most. Medicare spending, like health care spending overall, is expected to double over the next decade, reaching $4 trillion annually by 2017.

“This report demonstrates the need to overhaul the ways in which we care for Americans with chronic illness,” said RWJF president and CEO Risa Lavizzo-Mourey. “The extent of variation in Medicare spending, and the evidence that more care does not result in better outcomes, should lead us to ask if some chronically ill Americans are getting more care than they or their families actually want or need.”

Pharma Interest in CME Outcomes

If you wonder if some pharma are really interested in outcomes from the CME grants they fund listen to my podcast with Jennifer Smith, MS, PhD, Executive Director, PES Department with Wyeth. Dr. Smith is part of a growing number of executives in Pharma very interested in supporting quality CME that can make a difference in patient care.

Pharma Agrees to Disclose Grants to Outside Groups

Under pressure from the federal government a growing number of pharmaceutical companies are volunteering to publicly disclose grants to outside groups in efforts to head off legislation requiring such reporting. Details concerning the grants, including grants in support of CME activities, will be provided on each company’s web site. Many companies will go beyond disclosing grants for continuing medical education and will also disclose payments to patient advocay groups like the American Heart Association, the American Diabetes Association, and accredited CME providers. At least one company, Boston Scientific, is developing a system that discloses certain payments to physicians.

Senators Grassley and Kohl on the Senate Finance Committee have introduced legislation that would require drug and device makers to disclose anything of value given to physicians, such as payments, gifts or travel.

In a few states, such as Vermont and Minnesota, drug companies must disclose certain payments to physicians. Baxter International, Inc. has indicated to Senator Grassley that it could support legislation setting a national disclosure standard, but it’s critical the standard pre-empt state laws.

With this will surely come additional government queries directed to grant recipients asking for an accounting of how the funds were spent. Are you ready for that?

Click here to see letters to Grassley from pharma.

Pharma Free CME – Oregon Academy of Family Physicians

I was surfing some blogs recently and found this post.

Pharma-Free CME Activities: Is This the Right Approach?

The author, Bruce Freidman, posts this notice:

The Oregon Academy of Family Physicians (OAFP)…is hosting its 61st Annual CME Weekend at Salishan Spa and Golf Resort in Glendale Beach, OR this May. There’ll be plenty of golf, tennis, beach activities, spa rejuvenation, wining and dining, kiting, and shopping at this “pet friendly” lodge, but pharmaceutical companies are verbotin!…As the program guide says, this event is “Pharma Free: The OAFP is 100% free of any pharmaceutical company funding or support. Consequently, this CME conference has dispensed with a traditional exhibit hall.” …”We’re still putting on CME seminars, of course {said the OAFP executive director], but …not taking any unrestricted grants, so we’re looking for other financial support….We’re attracting interest from some health plans and hospital systems, people we’ve not traditionally approached in the past. It’s more work to get those sources, but there are also electronic medical records companies and insurance companies. So it’s possible.”

Here is an experiment we may want to watch. With an increasing number of people in CME suggesting that pharma support be phased out and ultimately eliminated, looking for other sources of funding to support CME activities is going to increase. Will the elimination of pharma support for CME activities remove the concern over bias in our CME activities or will it introduce other sources of bias? I suggest the later.
What do you think?

Firewalls Proposal or Other Important Issues?

Perhaps Ms. Beales and her colleagues at Lowell General Hospital might want to consider more important issues than railing against ACCME, MECCS, pharma, and suggesting the intervention of the federal government in vetting speakers for CME activities. (Medical Meetings/March April.2008 p 32ff.) A recent report indicates that medicine mix-up, accidental overdoses and bad drug reactions harm roughly one out of 15 hospitalized children. 7.3 percent of hospitalized children or about 540,000 kids each year are affected. (Glenn S. Takata, MD, et. al. PEDIATRICS Vol. 121 No. 4 April 2008, p. e927-e935 (doi:10.1542/peds.2007-1779). Add this to the other published estimates about errors in hospitals and ask yourself if firewalls related to support for CME or changes in the ACCME will solve these problems? I suggest hospital CME departments establish strong relationships with their QI department and initiate effective performance improvement CME activities that have the real potential to make a difference in the care provided in their settings. The other concerns pale in comparison to this important work.

Certification Examination for CME Providers Close

In January of this year I let you know about the development of a certification examination for people working in CME. Well it is about to happen. For a status report, including some important timelines, you might want to listen to my podcast with Dr. Judy Ribble, Executive Director of the National Commission for Certification of CME Professionals, Inc. (NC-CME). If you are interested in learning more be sure to visit the NC-CME website to find some important information.

Institute for CME

In a recent editorial in the CMAJ, (March 25 2008;178(7):805-806), the Editor in Chief, Paul C, Hebert, MD MHSC, joined a growing number of people calling for establishing an Institute of Continuing Health Education. He argues that continuing medical eduction is driven by the pharmaceutical industry and that physicians seemed to think they are entitled to the benefits of that involvement.

The editorial then asserts:

“To arrive in a healthier place, we need to disentitle physicians and adopt a more principled approach. The only way out is to take ownership and reinvent the system. Most importantly, given that the provision of efficacious continuing education is a quality-of-care and patient-safety issue, its focus must be on improving clinical knowledge, skills and attitudes as a means of improving clinical outcomes and quality of care by enhancing a practitioner’s performance. In addition, continuing education activities must provide accurate information free from real or perceived biases. They should focus on themes and topics based on the needs of patients or health professionals; make greater use of a broad range of proven, effective adult learning techniques; include all health professionals; and be affordable, accessible and, where possible, integrated into clinical practice. Finally, all these initiatives should be easily implemented, monitored and accredited so that public trust is maintained. We might even consider publicly posting every physician’s dossier of continuing medical education activities in the interest of optimal transparency.”

We probably all agree with these proposed attributes for CME. But will an Institute for CME adequately address the concerns underlying the argument for establishing an Institute for CME. The Editorial suggests that mandate for the Institute would be to:

• Set guidelines and standards for efficacious and unbiased continuing education.
• Develop, support and promote interprofessional educational opportunities.
• Monitor sources of all funds and set accreditation standards for continuing education providers.
• Provide continuing education grants to accredited institutions.
• Identify education and treatment gaps.
• Develop more effective ways to educate health professionals.
• Find new ways to integrate education into clinical practice.
• Help health care professionals overcome barriers to lifelong learning.
• Act as a central clearinghouse for continuing education for all health professionals

It is my contention that, at least in the US, some, not all, of these mandates are being addressed by the current CME system. There is room for improvement. The question is whether a central focus for the continuing education of health care professionals will make any difference at all. Perhaps, but I am a skeptic at least as far as CE in the US is concerned. So someone step up to the plate and try it. Not as the sole way to do CME but as a competitive model in the mix of what is already happening.

It is my guess that funds for such an Institute would still need to come from pharma. Would an Institute be able to attract adequate funding to give the idea a good test? Maybe so. Maybe not. Pharma will think very carefully about providing funds to such an enterprise. What is in it for them. Will an Institute be seen as a value by industry and thus an attractive alternative to how they currently allocate money to the CME enterprise?

The idea of an Institute deserves debate and perhaps a test. I am not convinced it is the panacea that some think it will be.

What do you think?