New CME Formats: Point of Care and Performance Improvement in Practice

1. New CME Formats: Point of Care and Performance Improvement in Practice SACME Spring Meeting April 16, 2005 Austin, TX

2. Presenters and disclosure Alejandro Aparicio, MD, FACP Director, AMA Division of Continuing Physician Professional Development (CPPD) 312-464-5531, alejandro.aparicio@ama-assn.org Charles Willis, MBA Department Director, AMA PRA Standards and Policy Liaison Activities (CPPD) 312-464-4677, charles.willis@ama-assn.org We have no relevant financial interest to disclose. We are both full time employees of the American Medical Association.

3. AMA PRA Credit, major changes • CME/CPD activities with increasing focus on the learner • CME more directly related to the physician/patient interaction • Credit based on the demonstrated value/impact of the activity and not as directly linked to the time devoted to it

4. Two AMA PRA initiatives with concluded pilot projects • New activities designated for credit • Performance Improvement, concluded September 2004 • Internet Point of Care (PoC) learning, concluded March 2005 • Both linked to practice based activities

5. Performance improvement • AMA Performance measurement [improvement] pilot started in August 2001 • Physicians wanted a mechanism for accruing AMA PRA category 1 credit for performance improvement activities • Five organizations joined as pilot participants

6. Performance improvement 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

7. The questions we had to answer • 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

8. Defined a Performance improvement (PI) activity • 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 • Settled on the idioms from QA and EBM

9. 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)

10. Performance improvement (PI) credit assignment • Time metric could not capture the learning • Encourage engagement with all Stages, with additional credit completing PI activity as a whole (maximum of 20 credits) • Find the full text at: www.ama-assn.org/ama/pub/category/13151.html

11. Performance improvement (PI) credit assignment • 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 be awarded only when the full cycle is completed

12. Our roles will change… • Providers as critical partners, will develop the learning materials • Documentation also critical, requirements to evolve over time • To succeed, we will all have to think differently: a work in progress (SACME leadership opportunity!)

13. What can performance improvement look like? Many models apply: • Systems based education • Improved screening protocols • Community based interventions • Chronic disease management

14. University of Pittsburgh Medical Center (Dr. Barbara Barnes) • Sustained 18 month intervention to improve hand washing rates • Included all members of the health care team • Physician compliance the worst, attitudinal not knowledge problem

15. Demonstrated effectiveness of the PI intervention at UPMC • Web based educational modules focused attention on the problem • Encouraged learners to think about the barriers to compliance • UPMC did improve facilities • Learn more at http://cme.health.pitt.edu

16. Improved screening protocols • VA EES found delay for screening colonoscopies exceeded 24 months • Qualitative evaluation of the process to identify “choke points” (full health team involved) • FOBT+ and other high risk patients identified, wait list assignments revised accordingly • Protocols revised to stratify patients by risk level

17. Community based PI intervention • Traditional medical Spanish CME course, designated for 3 credits, what impact? • Why not construct as a sustained PI intervention tracking pediatric immunization rates for a Hispanic community? • If immunization rates improve, reasonable link to improved communication (health literacy!)

18. Chronic disease management • The pilot experience (Iowa Foundation for Medical Care/Quality Improvement Organizations) • 5000 physicians participated: diabetes and pediatric immunization • Used written flow sheets and billing records, no EMR

19. Chronic disease management • 500 physicians participated in evaluation survey • 95% found it a positive experience • However, 36% found the documentation requirements somewhat to very burdensome • An effective electronic medical record will help

20. Performance improvement as a tool for reducing risk • Illinois State Medical Society insurer doing office certifications • Can address informed consent, follow up on labs, readable scripts, etc. • All of these can have an impact on patient safety (measures documented by third party) • Still need to tie to active physician learner

21. Performance improvement and the ABMS competencies • Could fit with Part 4 of Maintenance of Certification (ABMS): performance in practice • Offers structured way to address requirement, with data and AMA PRA Category 1 credit • ABFM has already accepted AAFP’s METRIC (Measuring, evaluating and translating research in to care) for Part 4/MoC, using PI model

22. All the competencies move through the PI continuum Recognition and Reflection Application Measurement and Evaluation X X X • -- Courtesy of Steven Minnick, MD, pilot chair

23. What makes PI tough… and necessary • Getting and documenting baseline performance data; detail of walking one physician through a PI intervention • Data driven CME that documents a physician’s assessment of practice (personalized physician education) • Recalibrating the CME shop to incorporate and lead on institution wide quality efforts!

24. Internet Point of Care (PoC) CME • AMA Pilots launched in December 2000 • Technology made it possible to capture use of professional literature at or near point of care • Migration to an individual, practice based, needs assessment

25. Internet Point of Care (PoC) CME AMA Pilot • SKOLAR, Inc. • UpToDate, Inc. • American College of Physicians (PIER) • MerckMedicus

26. Internet Point of Care (PoC) CME Questions: • Is there learning associated with searching on a specific topic? • Can it be documented through search criteria? • How do we establish that physicians have adequately engaged this learning activity?

27. Point of Care Learning The Process • Identify the clinical question • Search the evidence for the answer • Impact on the care of the patient

28. Internet Point of Care (PoC) CME • Structured of an educational activity allowing physicians to claim 0.5 credits • describe clinical question • review clinical sources • evaluate application to practice

29. Internet Point of Care (PoC) CME • Asynchronous, could be completed at later time, for example, after the patient encounter (assess practice patterns) • Keep it simple for physicians and providers

30. Internet Point of Care, use patterns • Consistent with use in patient care setting • 1990 and 1991, two studies found physicians averaged thirty minutes for online clinical research • AMA pilot findings (post Internet age): 34 to 37 minutes

31. Internet Point of Care (PoC) CME • Provider driven: awarding, tracking credit • Credibility to outside stakeholders important (licensing boards, public, etc.) • AMA Council on Medical Education approved in March 2005

32. Internet Point of Care (PoC) CME • Content integrity: AMA PRA definition and ACCME content validation guidelines • ACCME commercial support and Internet delivery standards will apply • Support for unbiased content and search engines, high quality evidence base

33. Point of Care The provider: • Establishes a process that oversees content integrity • Provides clear instructions about the process for searching and awarding credit • Verifies physician participation

34. Impact of the new learning platforms • Begin migration to CME tied more directly to patient care activities and outcomes data • Force a rethinking of the credit system in terms of which activities have higher value • Allow for gradual adoption, even as the CME landscape changes

35. Where are we going? • A set of AMA PRA rules for both the physician and provider information booklets (version 4.0) • These must be simple and based on shared values • ACCME will assist through development of companion accreditor guidance

36. Continuing Physician Professional Development • Learning more closely aligned with behavior/systems change • New models for physician learning will complement existing modes of CME (live activities, etc.) • Linking new modes of physician learning (i.e., performance improvement) to AMA PRA Category 1 credit will help meet the demand for transparent, documented and accountable CME

37. Thank You!