AT PRESS TIME, the American Medical Association's Task Force on Self-Directed/Self-Initiated Learning was in the midst of a pilot project to examine the feasibility of incorporating a point-of-care, Web-based clinical support tool into the AMA Physician's Recognition Award credit system to keep it in line with the changing educational needs of physicians. Some of these tools, which incorporate huge medical databases from which physicians can receive practice recommendations, are strictly Web-based, while others can be accessed using a hand-held PDA, or even incorporated into a healthcare organization's electronic medical records (EMR) system.

While official spokespersons from the AMA's task force were unavailable at press time, others involved in related point-of-care pilot projects being conducted under the AMA umbrella say there may be big news on this front coming in early 2004. The AMA task force was scheduled to meet on the topic in February, and the Leawood, Kan.-based American Academy of Family Physicians, which is also considering point-of-care tools for its CME accreditation program, had a related meeting scheduled for January. But there still is much work to be done.

Action, Not Hours

“This is the ultimate in CME,” says Nancy Davis, PhD, AAFP's director of CME. “These are practice-based, evidence-based tools that physicians can use to get practice recommendations they can apply to the patient right in their offices. The question is: How do you award CME credit for it?”

That's something that AAFP is struggling with in working with Charlottesville, Va.-based InfoRetriever, whose clinical-care tool of the same name is being used in a pilot project AAFP is conducting in conjunction with the University of Florida College of Medicine in Gainesville. According to Davis, the issue is how to get the software programming to award credit based on something other than a time concept.

Some of the other products involved in the AMA project, such as UpToDate, developed under the auspices of Burton Rose, MD, a clinical professor of medicine at Harvard Medical School in Cambridge, Mass., award one hour of Category 1 credit for one hour using the system. But Davis disagrees with that approach: “I don't think it matters if it takes you five minutes or two hours to find the answers to your clinical question,” she says. “The amount of time you spend researching the database doesn't reflect how much you learned — there are so many other factors involved, such as the physician's searching skills.”

Instead, AAFP is looking for a way to award credit based on a physician documenting the clinical question they want answered, the evidence source they use, and the application of the practice recommendation. “We don't want to make them write a book on what they did to get credit,” says Davis, “so we're still looking at ways to document their evidence search.”

Once the wrinkles get ironed out, though, hopes are high that the outcome of the AAFP-UFCM pilot project will lead to real progress. “This approach is consistent with what we know about adult learners,” says Floyd Pennington, PhD, associate director of CME at UFCM. “Adults learn to get answers to specific questions. They want valid information in small bites. They want to get answers just in time.” It also is consistent with what's required for Category 1 credit, he says. “There is a [learning] need, there is a plan for how to address that need, there is a learning activity, and there is a mechanism in place to evaluate whether the need was met. This is Category 1 CME credit at its best.”

Another pilot project under the AMA umbrella, the American College of Physicians' Physician Information and Education Resource system, is facing similar issues. While the physicians who currently use PIER can't get CME credit for their efforts, “that's changing,” says Michael Strange, vice president of Medical Knowledge and Education Division, ACP, Philadelphia.

Phase 1 of a new pilot project, scheduled to begin in January in partnership with Libertyville, Ill.-based Allscripts Healthcare Solutions, links PIER's database to Allscript's wireless EMR to track physician behavior at the point of interaction. PIER aims to have CME awarded on the basis of action, not time. But Strange agrees with Davis that it's not easy.

“The tough part of the work we're doing with AMA is to create an algorithm that can translate the 10 seconds spent searching for a clinical recommendation into the value of a CME credit.

“We can't upset the apple cart of a billion-dollar industry” whose gold standard is hourly CME credit, he says. “However, I have full faith, having done this in other industries, that we'll come up with a clinical algorithm that'll pass clinical muster.” Phase 2 of PIER's pilot project, which will explore changes in patient outcomes as a result of physician behavioral changes, is further down the road.

Ultimately, Strange believes the integration of clinical decision-making into EMRs will be the wave of the future. “The EMR companies don't have the staff to do it. But the College has the intellectual horsepower for the original authoring and constant updating needed to keep the ‘living organism’ of a database valid.

“If you make the system more effective, then everyone benefits. Other industries do it, and the healthcare industry has to catch up,” he says. “The key is whether it happens in six months or six years.”