Computerized CME makes strides with new features
High-end products feature patient simulations and instant feedback
From the March 1996 ACP Observer, copyright © 1996 by the American College of Physicians.
By Edward Doyle
When the College releases its first CD-ROM version of MKSAP later this year, many internists will find themselves part of medical education's newest trend: computer-based education.
In addition to hundreds of color images and video clips, MKSAP 10 Electronic will give physicians a chance to interact with the computer in a way that will change how they get their CME credits. When internists work through their MKSAP questions, they will have access to instant feedback from the computer. By hitting a key, for example, they will immediately know if their answer was correct. If it was not, the computer will explain why the answer was wrong--and provide additional materials to back up its point.
In its move to embrace computerized CME, the College is not alone. Dozens of products have recently begun offering physicians CME credits via computer, and several specialty societies already have released or are in the process of introducing computer-based CME programs.
Not surprisingly, physicians are beginning to take note. Despite initial uncertainty about how physicians would respond, the American College of Cardiology (ACC) sold more than 3,500 copies of its first self-assessment CD-ROM in just over a year. (The paper version sold 5,000 in just over three years.) Plus, AMA officials estimate that the number of physicians earning CME credits through AMA-accredited computer programs has increased fourfold over the last year.
Why the sudden interest in electronic CME? In part, it is due to the ability of CD-ROM to store and deliver high-resolution images such as diagnostic images and video. The ACC's CD-ROM, the Adult Clinical Cardiology Self-Assessment Program (ACCSAP), for example, contains more than 600 echocardiograms, X-rays, EKGs and other images.
Richard P. Lewis, FACP, editor-in-chief of ACC's self-assessment program and the association's president-elect, says that CD-ROM's ability to store images and video gives computerized CME its biggest advantage over its paper-based counterpart. "You can show moving visuals like angiograms and ECGs that are impossible to show in the paper version," he explained. "You can take users through a case where they have to interpret an ECG rather than just answer a question about it. They have to know that that's an acute myocardial infarction and that the person needs a thrombolytic agent or a cardiac cath."
But the ability of CD-ROMs to store and play images is only part of the reason for the growing popularity of computer-based CME. Electronic CME also provides users with instant feedback and test scores, something that time-strapped physicians value. "When you look at something where you have to check off answers and mail it in and then wait to get your score back, it's much less attractive then getting an immediate answer," explained Edward P. Hoffer, FACP, assistant director of the Laboratory of Computer Science at Massachusetts General Hospital and author of the chapter on computerized CME in ACP's book, "Computers in Clinical Practice."
The CD-ROM version of the College's MKSAP 10, currently being developed, will allow internists to apply for CME credits by simply printing out a form and sending it to the College. But, as with many of today's CME products, that is only the beginning.
At a glance, internists will be able to see how many questions they have answered and how many of those answers are correct. And to help physicians with the questions they answered incorrectly, the program will provide critiques that explain the rationale behind the questions and answers. Finally, physicians will be able to search all 17 sections of the program for more information.
More interaction
This type of interaction between user and computer is a sign of how sophisticated computerized CME is becoming. Many high-end CME products feature patient simulations where users interact directly with the computer, asking questions and giving orders. In products like RxDx, an electronic CME program that Dr. Hoffer helped create, users are given a patient history, lab data and the results of diagnostic tests and asked to choose the necessary tests and procedures to treat the patient.
Experts agree that this interaction between humans and machines makes electronic CME more powerful than conventional sources of CME like textbooks and publications. "It's much easier to assimilate facts if they're put in context instead of just reading a descriptive article," Dr. Hoffer said. "If you have a patient either real or simulated who you can use to focus your thinking and learning, it helps you retain material."
According to the ACC's Dr. Lewis, practicing physicians who already know the basics of medicine are looking for exactly this level of interactivity to get information specific to their practice. "They're after concise, up-to-date, state-of-the-art summaries that are clinically oriented," he said. "Texts just give you general statements. But through the questions we're asking we can deal with real-life issues, real-life clinical problems."
Even interacting with other physicians in person can sometimes pale in comparison to computerized CME, explained Dr. Hoffer. "The problem with going to weekly grand rounds is that they are aimed at a general common denominator," he said. A lot of speakers are not very interesting, while others may be interesting but may not give you any new information, he said. With electronic formats, you can pick the subject of interest to you and go through it at an appropriate level.
The next step: online
CD-ROM-based CME may offer physicians information that is specific to their practice, but the next generation of CME products--offered on the Internet--promises to offer even more convenience.
A big benefit of Internet-based CME is that it is accessible from a variety of locations. "As a general practitioner, I won't spend an evening or a weekend going to a seminar about lead poisoning," explained Julian Zelingher, ACP Associate, a fellow in clinical computing at Boston's Center for Clinical Computing. "But online CME materials go directly to your home or office."
And while CME programs on CD-ROM usually cost hundreds of dollars, many of the CME sources on the Internet are either free or very inexpensive. Dr. Zelingher likes one site run by the National Institutes of Health that is free and a site that allows users to work through patient simulations for $15 per use. (See "Software, Internet sources for electronic CME credits" for more details.) Another advantage of online CME: Applications for CME credits are usually submitted automatically when the user finishes the program--no need to mail an application.
But because Internet-based CME services are still relatively new, they face considerable challenges. First, there is the issue of speed. Viewing images on the Internet can be a painfully slow process, particularly for users who don't have a special high-speed connection to the Internet. In addition, the Internet is growing so fast that it can be difficult for physicians to know about all the CME sites.
It is worth noting that CD-ROM-based CME products face their own problems. While the general caliber of CD-ROM products has been improving, Dr. Hoffer noted that many products still rely too heavily on text from paper-based sources and lack the interactivity that makes computer programs truly unique. In addition, he said, there are few products geared for subspecialists. Several products may focus on a subspecialty, but they are typically designed for generalists.
Until they improve even more, the experts say, electronic CME products probably will not be for everyone. And even when electronic CME becomes more sophisticated, there is some doubt as to whether physicians will ever want to get all of their credits via computer. Some things, after all, cannot be replaced by computers.
"You get some things with grand rounds that you can't get with computers," Dr. Hoffer noted. "You know you're going to bump into Dr. Smith at grand rounds because that's where everybody goes. You show up more so you can see him and discuss something and not because you're interested in the lecture."
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