According to the Alliance for CME's history book, the organization's early annual conferences consisted of roundtable discussions. As part of the Alliance's 25th anniversary conference this January in New Orleans, MM brought together 14 CME leaders from across the industry for a roundtable over lunch. Participants work in a range of settings, both for-profit and nonprofit, from national specialty societies to community hospitals, from HMOs to the American Medical Association to Procter & Gamble.

We asked each person to identify the key two or three issues presenting the greatest challenge to his or her CME field in the near future. Not surprisingly, there were issues raised particular to certain settings, but participants also discovered they shared a common ground--almost everyone had something to say about the explosion of online CME. Once we identified that topic, we spent the remainder of our time brainstorming. How will e-CME change the industry? How can providers capitalize on its benefits, while avoiding the pitfalls? And, finally, what leadership role should organizations such as the Alliance play in the evolution of online medical education?

Funding for Online CME What many providers have feared is coming true--commercial support for traditional CME is declining, in part because of the Internet, according to Frederic Wilson, director, professional relations, The Procter & Gamble Company, Cincinnati.

"I hate to be a wet blanket, but the one key issue I see coming up is that the business of CME is getting smaller...because distance learning techniques on a cost-per-learner basis cost less. The solution I would suggest would be to embrace the notion that online learning will become the prevailing practice for continuing professional development in the future. If I were a CME provider, I would ensure that I had information technology expertise in my staff."

On the other hand, Wilson noted that commercial supporters do get more exposure with live activities. "With online learning, it's impersonal. There is a disclosure statement, of course, but it's at the end, it might not be seen." Even if a CME provider offers adequate visibility either in live or in online offerings, there's no way to guarantee what will happen to content once it's on the Internet, said roundtable participants.

Whose CME Is It? Portions of the 1999 American Academy of Pediatrics annual meeting later appeared on a major medical Web site. "Completely unbeknownst to us, reviewers were sitting in our meeting rooms, writing up summaries of sessions," said Suzanne Ziemnik, director, division of CME, American Academy of Pediatrics, Elk Grove Village, Ill. Not only did photos of AAP faculty and write-ups of their talks appear on the Web site, but the company offered their own CME credit for activities originated by the AAP. "Our attorneys said we have no legal recourse," Ziemnik reported.

When educational activities are "re-purposed," the potential problems are mind-boggling. For one thing, the original commercial supporter may lose visibility. And, critically important--if content is taken out of context, it may no longer be balanced. For instance, a paragraph may be picked out from a lecture, or one lecture offered alone online, when originally it was one piece or part of a multiple-lecture presentation.

Another problem is "framing," participants said--where an accredited activity is taken from an association's site and put on another site, where it's framed by ads. Then physicians call the association wanting credit for an activity that may no longer be compliant with Accreditation Council for CME rules on commercial support, which stipulate the separation of promotion and education. Providers need to find ways to protect their integrity, participants said.

Byte-Sized CME Under the current credit system as administered by the American Medical Association, credit is allocated based on education hours or half-hours. But in the new world of online CME, physicians log on for 15 minutes at a time. The value of CME is in how the doctor applies it, participants said. Physicians can access education about a particular patient's problem on a computer, right before they see the patient. It would be great, participants said, to recognize chunks of just-in-time learning that are linked to a potential patient outcome.

Any chance the AMA will revisit its credit structure? "We're not averse to that," answered Dennis K. Wentz, MD, director, division of continuing physician professional development, AMA.

The Big Picture While the AMA and ACCME are discussing specific guidelines for online CME, the wider CME community needs to step back, look at the big picture, and take responsibility for content, participants contended. Big dotcom companies are paying organizations to repurpose grand rounds, for instance, that may not be worth putting on the Web at all, pointed out Joseph S. Green, PhD, associate dean for CME, Duke University Medical Center, Durham, N.C. Providers need to concentrate on quality of content and apply what they know about how physicians learn when developing online education. Web curricula should be evidence-based, for example.

Focus on quality, said David Davis, MD, assistant dean, CME, University of Toronto, so that "what we market becomes the best, most research-oriented, most practical. I think we'll survive if we do that."

Another role for the CME community is to help physicians find that high-quality education amidst the fast-multiplying myriad of Web sites. "Perhaps among our goals should be that we train physicians to be not only self-directed learners, but real critical appraisers, so they can [sort] out the wheat from the chaff," Davis said.

At Kaiser Permanente in Richmond, Calif., a staff person surfs the Web once a week to scout out and evaluate new Web sites, and then sends that information to member physicians, said K.M. Tan, MD, assistant physician-in-chief.

Perhaps the Alliance could develop a committee to look at the Internet from the point of view of education methodology and content, suggested Green, and develop a set of criteria for physicians. By the end of the roundtable, it was decided that Green would take that idea to the Alliance for CME. We'll keep you posted.

Thank You We are very grateful to the CME leaders who shared their expertise at MM's Roundtable. We will bring you more of their ideas in future issues. In addition to those quoted in the article, the following people participated: Barbara B. Huffman, manager, CME, Carle Foundation Hospital, Urbana, Ill.; Judith G. Ribble, PhD, president, Institute of Genetics Education, Santa Fe, N.M.; Sue Ann Capizzi, COO, American Board of Psychiatry & Neurology, Inc., Deerfield, Ill.; Robert Orsetti, vice president, Medical Education Collaborative, Freehold, N.J.; Kathleen Regnier, assistant executive director, Accreditation Council for CME, Chicago; Richard F. Tischler, Jr., PhD, president, RF Tischler Jr & Associates, Inc., Mt. Airy, Md.; Carolyn Darrow, director, CME, New York Medical College, Valhalla, N.Y.; Joan Sondag Taylor, president, Taylor & Associates, Kansas City, Mo.; and Jeanette Harmon, director, department of administration, Louisiana State Medical Society, Baton Rouge.

Dotcom Dilemmas When is it time to bring in a dotcom company to produce your online CME? Will online associations such as take your members away and drain your meeting attendance? For strategies on those and other online education questions, watch for our June cover story,