AMA Update and Overview of the AMA PRA Credit System

Missouri State Medical Association and Kansas Medical Society 2013 Continuing Medical Education Conference AMA Update and Overview of the AMA PRA Credit System Mary Kelly Program Administrator, AMA PRA Standards and Policy 312.464.4668 mary.kelly@ama-assn.org October 4, 2013

Session Objectives At the end of this presentation the participants should be able to: Cite the status of the AMA Council on Ethical and Judicial Affair’s ethical opinions related to continuing medical education Utilize the AMA credit designation statement and the phrase AMA PRA Category 1 Credit™ appropriately Discuss the requirements for each of the seven (7) approved AMA learning formats to assure that CME providers comply with changes to the AMA PRA credit system. Describe and apply knowledge of the format specific requirements to case examples to illustrate best practices when designating AMA PRA Category 1 Credit™.

CEJA Opinions Update • Three CEJA opinions relevant to CME • E-8.061 Gifts to Physicians from Industry • E-9.011 Continuing Medical Education • E-9.0115 Financial Relationships with Industry in Continuing Medical Education (issued November 2011) • E-9.011 Updated June 2013 • Guidelines for physician attendees edited for clarity • Guidelines for faculty and sponsors removed due to overlap with requirements established in other policy, including E-9.0115 • E-8.061 Proposed Update for Interim Meeting • Streamlined (removed overlap) and updated • Guidelines related to pharmaceutical samples will be separated out • Guidelines related to scholarships retained

CEJA Opinion 9.011 Continuing Medical Education • Physicians should strive to further their medical education throughout their careers, to ensure that they serve patients to the best of their abilities and live up to professional standards of excellence • Participating in certified CME activities is critical to fulfilling this professional commitment to lifelong learning. As attendees of CME activities, physicians should • Select activities that are of high quality and are appropriate for the physician’s educational needs • Choose activities that are carried out in keeping with ethical guidelines and applicable professional standards • Claim only the credit commensurate with the extent of participation in the CME activity • Decline any subsidy offered by a commercial entity other than the physician’s employer to compensate the physician for time spent or expenses of participating in a CME activity

What is the AMA PRA Credit System? The AMA Physician’s Recognition Award (PRA) was established by the AMA House of Delegates in 1968 to recognize physicians who regularly participate in continuing medical education at a significant level The AMA PRA CME credit system was established as a metric to be used for the PRA The AMA owns the AMA PRA credit system The AMA Council on Medical Education determines the requirements and eligible learning formats for earning AMA PRA credit All states with mandatory CME requirements accept AMA PRA Category 1 Credit™, and in some cases AMA PRA Category 2 Credit™, as meeting CME requirements for licensure renewal

What is the Relationship between the AMA and the ACCME/SMS? In 1981, the AMA and six other national organizations (ABMS, AHA, AHME, AAMC, CMSS, FSMB) formed the Accreditation Council for Continuing Education (ACCME) Within the US, the AMA only authorizes organizations accredited by the ACCME or a recognized state medical society to designate and award AMA PRA Category 1 Credit™ to physicians The AMA reserves the right to withdraw the authorization to designate AMA PRA Category 1 Credit™ if an organization violates AMA requirements, regardless of accreditation status PRA Booklet Pages 1, 3

What is the process for awarding AMA PRA Credit? Organizations may certify an educational activity for AMA PRA Category 1 Credit™ if: The activity complies with all AMA PRA requirements, and The organization is accredited by either the ACCME or a recognized state medical society The AMA does not charge either the accreditors, the accredited CME providers, or physicians for this privilege The AMA does not review CME activities

Who may be awarded AMA PRA Credit? AMA PRA credit is only awarded to physicians, defined as: MDs DOs Equivalent medical degree from another country(http://www.ecfmg.org/certification/reference-guide.html) 3

Core Requirements for all Learning Formats Conform to AMA’s definition of CME Address demonstrated educational needs Communicate to participants a clearly identified educational purpose/objectives Designed using appropriate AMA approved learning formats; credit based on the format Content appropriate in depth and scope for intended physician audience 4

Core Requirements for all Learning Formats Planned in accordance with relevant CEJA ethical opinions and ACCME Standards for Commercial Support; nonpromotional (www.ama-assn.org/go/ceja) Evaluate effectiveness in achieving purpose/objectives Document credits claimed by physicians Certified for AMA PRA Category 1 Credit™ in advance of activity Include the AMA PRA Credit Designation Statement in activity materials 4

AMA Credit Designation Statement and Credit Phrase • Must be used as is, you may not change the AMA wording • Must be listed separately; do not combine in the same paragraph as other statements • Learning format must be the AMA format as listed on page 7 of the AMA PRA booklet • If you put the number of credits, you must include the full credit designation statement • AMA PRA Category 1 Credit™ must always be used in full, and italicized with trademark symbol 7-8

AMA Approved Learning Formats Live activity Enduring material Journal-based CME activity Test-item writing activity Manuscript review activity PI CME activity Internet Point of Care activity 4-7

Live Activities Occur at specified time Learner and faculty real-time interaction 4-5

Live Activities 4-5 • Participation in person or remotely • Clear identification of certified segments • Wide variety of delivery mechanisms • Multi-day or single day conferences • Workshops, seminars, live Internet webinars, regularly scheduled conferences • Journal clubs • Structured learning presented during committee meetings

Live Activities Credit Designation Simultaneous certified sessions can only be counted once toward the designated maximum Credit calculation based on time 60 minutes = 1 AMA PRA Category 1 Credit™ Credit is designated in 15 min or 0.25 credit increments; round to nearest quarter hour The Provider XYZ designates this live activity for a maximum of [number] AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. 4-5

Live Activity – Faculty Credit New! • Faculty credit is a type of live activity • There are two categories of faculty credit • Faculty preparing and presenting an original presentation at a live activity certified for AMA PRA Category 1 Credit™ (2006) • Faculty preparing for and teaching medical students and residents in LCME and/or ACGME accredited programs (2013) • Both recognize the learning that occurs in preparation for teaching, but the credit is calculated based on presentation time (2:1 ratio) 4-5

Live Activity – Teaching at a Live AMA PRA Category 1 Credit™ Activity • Must be an original presentation • Physician only awarded credit once, regardless of how many times the presentation is given • Presentation itself must be certified for credit • Credit calculated on 2:1 ratio of speaker’s presentation time • Physician can get credit in one of two ways • Accredited CME providers may certify this as a live activity • Meet all AMA requirements for a live activity • Contact your accreditor regarding the accreditation requirements for “learning from teaching” • Physician can claim credit directly from the AMA 4-5

Live Activity – Teaching Medical Studentsand Residents New! • Approved by AMA Council on Medical Education in March, 2013 • Institution must be ACCME/SMS accredited and LCME and/or ACGME accredited • Provide clear instructions to learner that define the educational process of the activity • Teaching must be verified by UME and/or GME office

Live Activity – Teaching Medical Studentsand Residents New! • Awarding AMA PRA Category 1 Credit™ for teaching medical students and residents • Recognizes the learning that occurs as physicians prepare to teach • Calculated using a 2:1 ratio based on teaching time that uses what physicians learned in preparation For more information contact Mary Kelly mary.kelly@ama-assn.org 312.464.4668

Credit Designation Statement for Teaching Medical Students & Residents Credit designation statement needed adjustment as you will not know the number of credits in advance This credit designation statement is to be used only for this type of live activity: The Provider XYZ designates this live activity for a maximum of 2 AMA PRA Category 1 Credits™ per 1 hour of interaction with medical students and/or residents/fellows. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Use the standard credit designation statement for all other activities New!

Case Study ABC Community Hospital has a group of physicians who meet once a month to review and discuss journal articles. The articles are all from peer-reviewed journals and are disseminated ahead of time to participants. The group convenes to discuss the salient points of the articles and how any clinical recommendations may affect their current practice. Each physician completes a form at the end of the session to document how the review and discussion will affect their practice. • What is the learning format for the activity? • Journal-based CME • Live activity • Journal club Red Yellow Green

Case Study ABC Community Hospital has a group of physicians who meet once a month to review and discuss journal articles. The articles are all from peer-reviewed journals and are disseminated ahead of time to participants. The group convenes to discuss the salient points of the articles and how any clinical recommendations may affect their current practice. Each physician completes a form at the end of the session to document how the review and discussion will affect their practice. • How is the credit determined? • One credit per article • Good faith estimate • Time based Red Yellow Green

Case Study ABC Community Hospital has a group of physicians who meet once a month to review and discuss journal articles. The articles are all from peer-reviewed journals and are disseminated ahead of time to participants. The group convenes to discuss the salient points of the articles and how any clinical recommendations may affect their current practice. Each physician completes a form at the end of the session to document how the review and discussion will affect their practice. • If a physician reads the articles but does not attend the meeting, can he/she claim AMA PRA Category 1 Credit™? • Yes • No • I’m not sure Red Yellow Green

Case Study ABC Community Hospital is accredited by the ACGME. One of its GME programs, a Family Medicine residency program, has had teaching its residents certified as a live activity. One of the physician faculty members has a one hour session with a resident to teach how to appropriately perform a physical exam, and will give feedback to the resident after observing the resident in action. The faculty member has taught how to perform the physical exam many times, and doesn’t need to do any additional preparation for that part of the session, but seeks out information about effective methods for giving feedback. The physician then spends 15 minutes of the one hour session giving feedback to the resident, utilizing the skills learned during the preparation. . • How many AMA PRA Category 1 Credits™ can the physician claim for this session? • Twice the amount of time spent preparing for the session • 2 AMA PRA Category 1 Credits™ (twice the time of the session) • 0.5 AMA PRA Category 1 Credit™ (twice the time spent giving feedback) Red Yellow Green

Enduring Materials Certified activity that endures over a specified period of time 5

Enduring Materials 5 • No real-time interaction • Includes variety of media: • Print, e.g. monographs • Audio, e.g. tapes, podcasts, CDs • Video, e.g. DVDs • Internet materials, e.g. archived webinars, internet videos

Enduring Materials Requirements Provide clear instructions to learner on completion of activity Provide an assessment of learner that measures achievement of purpose/objectives with established minimum performance level Rationale - Brings consistency to what was already a frequent practice; strengthens confidence that physicians have assimilated the content and met the objectives. Communicate the minimum performance level for successful completion Provide access to bibliographic sources 5

Enduring Materials Credit Designation • Credit calculation based on good faith estimate of time physician will take to complete • 15 min or 0.25 credit increments; round to nearest quarter hour The Provider XYZ designates this enduring material for a maximum of [number] AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. 5

Case Study Accredited CME provider XYZ, Inc. has a certified enduring material that was released on November 15, 2010 and will expire soon. The activity has been popular with the target audience of physicians, and it is planned to update and renew it. The amount of credit was determined by having two physicians who are part of the target audience complete the activity and averaging their times. In addition to the activity meeting all AMA core requirements, the CME provider gives clear instructions on how to complete the activity and provides access to appropriate bibliographic sources. However, there is no assessment of the learner and it is not required for physicians to achieve a minimum performance level in order to be awarded AMA PRA Category 1 Credit™, and this was not required when the activity was originally released. • What changes must provider XYZ, Inc. make in order to renew the activity for AMA PRA Category 1 Credit™? • Develop an assessment of the learner that measures achievement of the educational objectives and/or purpose; Establish a minimum performance level for the assessment that must be met by physicians in order to be awarded AMA PRA Category 1 Credit™; and Communicate that minimum performance level to participants • No changes need to be made because the activity was originally certified prior to July 1, 2011 • I don’t have enough information Red Yellow Green

Journal-Based CME Within a peer-reviewed professional journal Certification prior to publication 5

Journal-based CME Requirements Peer-reviewed Provides assessment of learner that measures achievement of purpose/objectives with minimum performance level Rationale - Brings consistency to what was already a frequent practice; strengthens confidence that physicians have assimilated the content and met the objectives. Communicate the minimum performance level for successful completion 5

Journal-based CME Credit Designation • Individual articles are certified for one (1) AMA PRA Category 1 Credit™ (not time-based) • The Provider XYZ designates this journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. 5

Case Study A specialty society publishes a monthly journal that includes peer reviewed articles. One of these peer reviewed articles in each issue is certified for AMA PRA Category 1 Credit™. One month the CME article is particularly long, and the specialty society would like to certify it for 1.5 AMA PRA Category 1 Credits™. • What options does the specialty society have? • Certify the article as journal-based CME for one (1) AMA PRA Category 1 Credit™, as journal-based CME is not a time-based activity • Certify the article as an enduring material for the amount of credit determined by a good faith estimate of the amount of time it will take a physician to complete the activity and satisfy its purpose and/or objectives, being sure that all other requirements for an enduring material have been met • Either a or b Red Yellow Green

Test Item Writing Added in 2006 Physicians learn through contributions to the development of high-stakes examinations or certain peer-reviewed self-assessment activities Involves researching, drafting and defending potential questions 5-6

Test Item Writing Requirements Be developed only for: NBME examinations ABMS member board certification examinations National specialty society peer-reviewed, published, self-assessment examinations Depth and scope that requires review of literature and knowledge of evidence base Includes participation in a group peer review process Document that guidance was given on how to use evidence for writing quality questions 5-6

Test Item Writing Credit Designation • Each test writing activity should be certified for ten (10) AMA PRA Category 1 Credits™ (not time-based) • The Provider XYZ designates this test-item writing activity for a maximum of 10 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. 5-6

Case Study A state specialty society has developed a self-assessment activity for its members. The physicians who wrote the questions have asked if they can get credit for the question writing process. • Can the state specialty society certify this as a test item writing activity and award AMA PRA Category 1 Credit™ to physician participants? • Yes • No • I don’t have enough information Red Yellow Green

2012 Continuing Physician Professional Development Manuscript Review Added in 2006 Physicians learn through the critical review of an assigned journal manuscript 6

Manuscript Review Requirements Reviewed article must be submitted to a journal indexed in MEDLINE Manuscript must be original article requiring multiple reviewers Provide clear instructions for completion Depth and scope that requires review of literature and knowledge of the evidence base Have oversight mechanism to evaluate the quality of reviews submitted Rationale - Provides consistency that credit is awarded to physicians that fully participate in the activity in a meaningful way 6

Manuscript Review Credit Designation • Credit only awarded for review deemed acceptable by editor • Certified for three (3) AMA PRA Category 1 Credits™ (not time-based) The Provider XYZ designates this manuscript review activity for a maximum of 3 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. 6

Case Study A national specialty society that publishes a journal included in MEDLINE certifies manuscript review as a CME activity. Dr. John Doe is one of the participants, but his review was not deemed acceptable by the journal editor. He has asked if he can receive partial credit for the time he spent in the process. • Is this possible? • Yes • No • I’m not sure Red Yellow Green

2012 Continuing Physician Professional Development Performance Improvement (PI CME) First pilot tested in 2000-2005 Added to the PRA in 2006 Collaborative project with AAFP Intent to create more meaningful link for physicians between patient care, quality and education 6-7

AMA Update and Overview of the AMA PRA Credit System

AMA Update and Overview of the AMA PRA Credit System

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