The hype—and concerns—about CME on the Internet

This 'match made in heaven' is convenient, but some worry that commercial interests will bring bias

From the February 1998 ACP Observer, copyright © 1998 by the American College of Physicians.

By Christine Kuehn Kelly

For physicians who want a convenient way to earn continuing medical education (CME) credits, the Internet is shaping up as a practical alternative to medical meetings. But concerns about commercialization of physician CME—and questions about who's controlling the content of many Web sites—may slow its growth.

Educational activities for physicians on the Internet currently range from simple case studies with multiple-choice tests to multimedia sites that offer high-tech patient simulations. A handful of cutting-edge CME sites are even adding audio and video, giving physicians a more functional way to access the latest in medical information.

For most physicians, however, the convenience of online CME—not high-tech features—is the main draw. "The marriage of CME and the Internet is in many ways a match made in heaven," said Michael W. Jacobson, FACP, a New York City internist and creator of Journal Club on the Web, an Internet site for internists (www.journalclub.org/). "The Internet is ideally suited to the mechanics of CME. Nothing can be easier than checking into a Web site at odd hours."

That convenience appears to be leading to a boom in online CME offerings. As of 1996, the most recent year for which data are available, the Accreditation Council for Continuing Medical Education (ACCME) had accredited hundreds of CME providers for a total of more than 5,000 educational activities on the Internet offering more than 2,000 credit hours.

Besides offering convenience, physicians say that online CME provides them with more flexibility than traditional courses. "Online education has the ability to provide better teaching," said David M. Rind, ACP Member, a Harvard Medical School lecturer who is a senior associate at Boston's Center for Clinical Computing. "Physicians can view interactive materials, answer questions and receive instant input on their responses."

A good example of a top-notch CME Web site is The Interactive Patient, which allows medical students and residents to "practice" on patients. (See story, next page, for a list of sites and Web addresses.) The site, run by Marshall University in Huntington, W.Va., allows users to take a medical history, perform a virtual exam and order diagnostic tests. Based on the information they gather, users then submit a diagnosis and treatment plan and earn CME credits.

The Interactive Patient plans to eventually take the learning up a notch by analyzing the questions that users ask and the diagnostic tests that they order. "We are looking at ways to track users individually, said Chris Lehmann, MD, one of the site's developers and a fellow in the division of neonatology at Johns Hopkins University. "Then, using decision analysis, we will provide feedback."

User beware

Despite all the hype about such cutting-edge sites, there are some snags when it comes to online CME.

First, there is the problem of speed in accessing the Internet. For many physicians, a personal computer with a standard telephone connection can make using the Internet an exercise in patience. Images such as ECGs and x-rays may load slowly—or not at all. "Resources are difficult to navigate if you only have a 28.8 or 14.4 modem," said Gary Malet, DO, chair of the American Medical Informatics Association Internet Working Group.

But online CME raises even more serious concerns about the commercialization of physician education. The single biggest sticking point: the presence of industry-sponsored sites.

Because the Internet is such a highly commercialized medium—a trend that promises to intensify—it is inevitable that questions will be raised about the effects of advertisers and sponsors on physician CME. For example, should sites offering CME contain links to drug manufacturers or other vendors?

The AMA has already taken a stand and refuses to provide links to CME sites that direct physicians to commercial sites, according to Mark Evans, PhD, the AMA's director of multimedia continuing education. The concern is that pharmaceutical and medical device companies have the resources to present enticing CME Web sites that may give physicians more than just the facts about a disease or patient condition.

"I worry when I see CME materials filled with advertising," explained John Halamka, MD, senior associate at Harvard Medical School's Center for Clinical Computing, "Some sites don't have peer-reviewed content and can be suspect."

Dr. Jacobson, creator of Journal Club on the Web, acknowledged that the problem of sponsor-associated bias is not exclusive to the online world, but he feels that it is magnified on the Internet. "I have a negative gut reaction about pharmaceutical-sponsored CME," he said. There is a lot of valid information to support both sides of an issue, and you may be getting only one side of the story.

To cite an example, Dr. Jacobson said that even the choice of topics presented on a site is subject to bias. "Pharmaceutical-sponsored CME courses are more likely to focus on topics like the primary prevention of coronary heart disease by cholesterol- lowering drugs rather than the use of beta-blockers post-MI, which is just as important but frequently involves generic medication," he said.

Sorting the good from the bad

Another concern is the validity of CME testing and the rigor of the testing method used. There are worries that some sites may refrain from asking the really tough questions on their test. As Dr. Jacobson explained, "If you are trying to sell CME and you make the questions too difficult, you cut down on your user base."

While the majority of CME sites currently use multiple-choice questions, interactive test taking will become more common as providers become more technologically sophisticated. In the future, physicians may only need to browse an educational site and perhaps answer a minimum percentage of test questions to earn CME credits.

When it comes to grappling with these issues—and sorting the good online CME from the bad—physicians can look for ACCME accreditation, which is often viewed as the gold standard. "A lot of work goes into accreditation, and it's important that doctors look for providers who have received it," said Murray Kopelow, MD, executive director of the ACCME. Once a CME provider is accredited, the ACCME monitors it through a periodic re-accreditation process that includes responses to inquiries and complaints from users. (To report a problem you're having with a CME provider, call the ACCME at 312-464-2500.)

One easy way to make sure that the content of online CME is current is to check the date the material was put on the site. "In some areas such as HIV treatment, the protocols are changing rapidly," said the AMA's Dr. Evans. "Physicians need to be aware of how current the information is in a particular CME course."

Some issues facing the future of online CME won't be as easy to resolve, however. Experts say that the medical community may simply have to get more comfortable with the idea of commercial interests supplying online CME.

And will doctors be willing to pay for CME online, when much of the other content on the Internet is free, asks Howard Groveman, MD, medical director of San Diego-based Continuing Medical Education Associates. His company produces CME in the form of live seminars, videos and CD-ROMs.

Add the fact that providing sophisticated CME is an expensive proposition for private companies, and it's possible that the presence of commercial interests may be required for online CME to grow and mature. "Top-notch medical content on the Web won't expand if entrepreneurial companies aren't involved," he said.

Christine Kuehn Kelly is a Philadelphia-based freelance writer specializing in health care.

To find online CME, try these search engines, Web sites

To find online CME, try using search engines that allow you to enter a term you want to locate and then add the modifier "AND CME online." Even better, check out medicine-specific sites like Medical Matrix (www.medmatrix.org/), which uses peer reviewers to analyze Web sites and provides links to the best online CME. Finally, the AMA's Web site has a browser that allows physicians to access information on more than 2,000 AMA Physician's Recognition Award activities. The AMA is considering linking to those programs offered online that pass its peer review.

Here is a partial list of CME sites on the Internet recommended by physicians and medical informatics experts:

• www.ama-assn.org/cgi-bin/cme-redir
  AMA's CME locator is an online database that contains more than 2,000 AMA category 1 educational activities. These activities are either sponsored by credible CME providers, accredited by the Accreditation Council for Continuing Medical Education (ACCME) or approved by the AMA.
• www.cmeweb.com/
  This site offers tests approved by a variety of organizations worth 1.5 category 1 credits.
• www.healthgate.com/
  Topics from Boston University School of Medicine include myocardial infarction therapy, primary angioplasty vs. thrombolysis, and vitamins and lipid lowering. AMA category 1 credits are offered.
• medicus.marshall.edu/medicus.htm
  The Interactive Patient from Marshall University offers patient simulations that use sound, video and graphics. Users take a history, perform a physical exam, order radiologic and laboratory tests and offer a diagnosis and treatment plan. Category 1 credits are offered.
• www.medmatrix.org/SPages/Internet_CME_Accredited_Sites.asp
  This site contains an annotated list of accredited CME sites from the Medical Matrix, a well-known listing of medical sites.
• www.medscape.com/home/CME center/CMECenter.html
  Medscape lists accredited CME courses on its Web site, including online courses.
• bio-3.bsd.uchicago.edu/home/u1/rita/Hhs/Lead/Lead-toxicity.html
  This University of Chicago site provides CME on lead poisoning through a case study. The site includes a pre-test, challenge questions and a post-test, all for category 1 credit.

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