Succeeding With Cyber-CME Fire up your browser and visit the Web site of Medical Computing Today (www.medicalcomputingtoday.com) for a look at who's doing what in online continuing medical education (CME). There you'll find a list of 172 Web sites (at this writing) where physicians can obtain Category 1 CME credit. Prepared by Marjorie Lazoff, MD, the site's editor, the list includes commentary on the provider, what is presented, and the way it is presented. Sites that are poorly organized, hard to use, or that have gimmicky features are treated mercilessly. Of a site that requires viewers of an online course to periodically click a box to prove they're still watching, Lazoff wonders whether it can detect a Windows solitaire game being played at the same time.

An information delivery system that has been around long enough to be on the receiving end of this kind of hard-nosed criticism is no longer a novelty. It's a business, and one that is evolving (to use an old-technology simile) like a videotape on fast-forward that just keeps on accelerating.

For those who organize medical conferences where CME is offered, the phenomenon of online CME raises some basic questions: 1. What does online CME do for my organization that meetings don't?

2. What kind of collaborative relationships are available?

3. How much control can my organization have? How much should we have? How do we assure quality?

To find answers to these questions--to find out whether they can be answered at all--means looking at online CME from the perspectives of an online provider, an online aggregator (we'll explain this term later), medical associations both large and small, and a medical school. The experiences of Medscape Inc.; Healtheon/WebMD; the American College of Cardiology; the American Association of Diabetes Educators and its online partner CECity.com; and Baylor Medical College are not necessarily generalizable, but they do provide a window into this fast-paced world which is at once intensely competitive and closely cooperative.

Reaching the World "The mission of medical societies and schools is to maximize access to cutting-edge research, so clinicians can use it in their daily practice," says Judith Ribble, PhD, director of CME for Medscape Inc., New York. "If you agree with that as a principle, then a partnership with us is a good thing."

In business since May 1995, Medscape qualifies as the graybeard of online CME. A portal, Medscape offers a broad array of services and resources for physicians. Now, with its merger with Medicalogic Inc., it will also have practice management applications. With more than 350,000 users who register as physicians, it has the largest documented professional audience of any of the sites.

And Medscape is studded with stars of the medical education firmament: George Lundberg, MD, former editor of the Journal of the American Medical Association, is the site's chief editor. Murray Kopelow, MD, executive director of the Accreditation Council for CME, was on Medscape's board for a year. Ribble, who joined the organization in February of this year, was involved with the old Lifetime Medical Television project and is a high-profile member of the Alliance for CME.

For all its CME-establishment cachet, however, Medscape's early ventures in online CME were controversial. Lundberg's approach was to send expert physicians to medical conferences as reporters, who selected the cream of the presentations and wrote informed summaries of them, which appeared shortly thereafter (often the next day) as for-credit materials on the Medscape site. Some CME directors of medical societies took this reporting in stride. Others felt they'd been blindsided, not because of the reporting, but because the summaries were being offered for credit. (Credit was awarded by the Medical Education Collaborative, a nonprofit education company in Freehold, N.J.)

That was a big reason for the arrival of Ribble. With her on board, contact between Medscape and the societies would be through their respective CME counterparts rather than simply through their press offices. "I'm here because CME providers wanted somebody on the inside at Medscape to talk CME with them," Ribble says.

What medical societies get out of their relationship with Medscape--or any of the other major medical Web sites--is exposure to a far wider audience than a single meeting could possibly achieve.

"We're not trying to hurt the meetings business, and we don't think we ever will," says Lundberg. "The vast majority of medical society members don't attend [their annual meetings] anyway. That's the audience we're after."

Ribble also stresses the noncompetitive nature of Medscape's work. "When Medscape comes to your conference, we're bringing in a news organization to showcase your meeting," she says. "We provide a service to your members. And online CME based on annual meetings [has the potential] to not only reach the 80 or 90 percent of members who don't attend, it [can] serve as a debriefing for those who did. And I think it creates more interest for next year's meeting."

Sharing the Cyber-Sandbox At present, Medscape's main collaborative effort centers on reporting on medical society meetings, but, like everything else on the Web, that's changing rapidly. At the moment, Medscape works with 24 accredited providers of CME, including the Medical Education Collaborative, which produces the bulk of the site's Category 1 offerings.

Ribble envisions a new site within Medscape, where CME providers will be able to post their materials in an environment for which Medscape will not be editorially responsible. "Societies will be able to post their CME at our site, for a fee, and get the increased exposure we offer," she says. "They can charge or not charge--they can do anything they want to." There will be options to have Medscape provide as much or as little service as desired. "They can bring us Web-enabled packages that are ready to go, or simply come to us with a concept for which they want commercial or technical support." Or anything in between, Ribble adds.

A more hands-off approach is taken by Healtheon/WebMD in Atlanta, according to Ricardo Martinez, MD, senior vice president of health affairs. At WebMD, online continuing medical education has been outsourced to HealthStream, a company that aggregates (there's that word) CME from other sources--mostly medical schools and medical centers. HealthStream pays a royalty to WebMD to have its material available from the WebMD site. WebMD in turn has purchased a big block of HealthStream stock, and each company co-markets the other's online products.

"We're trying to get a strong partner to provide best-of-breed CME, which is why we're moving into the relationship with HealthStream," says Martinez. His greater interest is in developing strong collaborative relationships with national medical societies. "We want to put their news, their advocacy efforts, and their calendar out to a broader audience."

Just-in-Time CME Martinez stresses the importance of timeliness in online CME. "Information is a perishable commodity," he says. "Timeliness, quality of information, usability, and credentials are the qualities that draw audiences. The top universities, medical centers, and associations are the credible sources for this information."

In fact, WebMD offers something called Just-In-Time CME: WebMD editors post news stories that in their judgment are particularly useful in the practice of medicine. After reading such a story, a physician can click to a quiz that asks a few questions about the material just read. In an arrangement with the University of Alabama at Birmingham Medical School, a quarter-hour of CME credit can be earned this way. WebMD keeps a database of credits awarded. Physicans can use those credits to meet their state's licensure requirements as well as their specialty societies' requirements for membership.

How Much Control? "We do what we do best; they do what they do best." Everyone in the online CME world repeats this like a mantra. Yet there are varying approaches to taking responsibility--and therefore control--over what appears on a physician's browser. Medscape touts its hands-on editorial strength as an assurance of quality. At WebMD, Martinez stresses the relationship with HealthStream and HealthStream's relationship with such CME providers as Vanderbilt University Medical Center, Duke University Medical Center, the Cleveland Clinic, and Scripps Clinic. Medscape promotes editorial rectitude; WebMD promotes quality partners.

For CME providers on the other end of the relationship, the bottom-line question is whether their quality education will receive a quality presentation on the Web. This in turn raises a more fundamental question: How much control can you maintain over information once it has been presented? Is there such a thing as too much control?

"Our philosophy has always been that we know our meeting is public, that members of the press attend, that all sorts of stories are written," says Marcia Jackson, PhD, senior associate executive vice president, education, American College of Cardiology, Bethesda, Md. "We feel [putting our information on other sites] extends the reach of our program to audiences that would not typically find it on our Web site. The only thing that would disturb us is that if it somehow appeared that [CME] was ours when in fact we had no input into it. We certainly like to be credited when material is taken from our meetings."

In fact, in the interest of spreading the ACC's message far and wide in the medical community, the organization has relationships with both Medscape and HealthStream, proving that multiple relationships are not the exclusive province of the big medical sites.

Some medical societies and hospitals put up CME especially for their members or credentialed physicians, and don't seem to care whether or not they reach larger audiences. Medscape's Lundberg doesn't understand why they bother. "If they want to limit themselves to an audience of their members or staff, that's fine. But why do that when the whole world is out there?"

Meanwhile, Under the Radar Somewhere in between the global reach of Medscape and a community hospital site that is meant to reach its own staff lies the American Association of Diabetes Educators in Chicago. Just like the ACC, the AADE wants to be a source for information in its specialty and wants to increase its members' access to educational programs. Unlike the ACC, or Medscape or WebMD, for that matter, its informational ambitions are modest, and it must work within a limited budget.

"We know of our 11,000 members, we may see only 1,000 at our live conferences," says Lois Book, PhD, director of education. "For us, using the Web is truly an access and cost issue."

When her association decided to investigate distance learning, Book shopped around (see sidebar, page 40) and eventually entered into a partnership with CECity.com, a Pittsburgh-based Internet company. "We're not a technology company trying to build something we think health care professionals need," says co-founder Simone Karp. "We were two pharmacists who had trouble getting our CE credits who thought it would be good to automate the process on the Internet." The AADE's needs were relatively straightforward--to offer a series of online texts and then allow an online test for CE credit. No on-the-scene reporting, no streaming video.

"We try to keep everything at the lowest common denominator. We don't let the technology run ahead of the user's capabilities," says Karp, whose nickname at the company is "The Crash Dummy" in honor of her lack of technical expertise on the Web. CECity.com's strategy is to provide a quick, painless way for a medical organization to get up on the Web. "We don't want CECity to be a destination," she says. "When you visit the AADE site, the only way you know you're at CECity is by looking at the URL. We have their name up throughout the program."

The business model is simple: AADE charges a fee for its education; CECity shares a portion of the revenue. AADE concentrates on providing content; CECity concentrates on putting the material up on the Web in an easy-to-use format. Why, we seem to be back at doing what everyone does best!

Flying Solo--Sort of So far we've talked about Internet companies and education providers as separate species. Clearly, online CME can increase the audience for a CME activity, and far from cannibalizing attendance, it can actually promote interest. Methods of collaboration vary from the close attention of Medscape to the broad sweep of WebMD to the almost cottage-industry approach of CECity.com. But as we know, life is unfair, and there is always an example out there to explode our assumptions about what is possible. Down in the Lone Star State, Baylor College of Medicine in Houston is showing that with creative organization and a lot of grant money, a single organization can indeed score big on the Internet without any outside partners at all.

One of the Internet's most sophisticated CME Web sites is called www.lipidsonline.org, and it was created by the Center for Collaborative and Interactive Technologies at Baylor. The Center has three components: a tech applications and development group, the Office of Continuing Education, and the Center for Educational Outreach. "So, we have individuals with expertise in Internet technologies and databases, we host our own sites, and we also have folks with expertise in curriculum and instructional design and education," says Michael Fordis, MD, associate dean for CME at Baylor College of Medicine and director of the Center. In short, he's got everything it takes to produce online CME under one roof.

"Being able to use technology has allowed us to control the quality of what we're developing, and the opportunity to marry the technology with the educational aspects of design much more seamlessly than we might have done otherwise," he says.

The Lipids Online site, produced with an unrestricted grant from Merck, is a model of what is possible on the Internet. Its rapidly loading pages offer CME in the form of a streaming video showing a speaker, with the speaker's text scrolling beneath it, while slides are shown to the right side of the screen.

At another site designed for pediatricians and nurses who provide care for children with cancer, placing your cursor over a highlighted technical term produces a definition of the term on a screen just below the main text.

Yet even Baylor doesn't really work in isolation; partnership is still the name of the game. "We've worked with other academic centers where they may actually be providing the CME credit [the lipids program Category 1 credit comes from the University of Michigan, for example]; we're doing the development," says Fordis. "It has surprised some folks, but it makes sense to us. If in fact you can have strategic partnerships and alliances on projects where everybody is bringing something to the table, those partnerships allow you to do things more efficiently, maintain control of quality, and also be more cost-effective. That's what's important."

Fordis says Baylor has had successful partnerships not only with other academic institutions, but with for-profit CME providers. The main goal is to propagate quality information to the largest audience possible. "In one partnership we've developed pieces that were accredited by a sister institution and not only is it on their Web site, it's on our Web site, and it's on a very large portal that's a commercial site. And we've achieved our goal, which is to provide quality education and information that meets the needs of our professional community."

e-Equalizer? "In researching online CME for my list, I didn't find a strong correlation between quality content and type of accrediting institution," says Medical Computing Today's Lazoff. "Both medical education companies and academic institutions create quality CME. It depends more on their threshold for excellence, on the expertise of the authors, and on whether the content undergoes serious peer review and editing." In other words, in the online world, it's what you do that counts, not your pedigree. Maybe the Web will be the place where medical communications companies and medical associations can bury the hatchet and work together to produce great CME.

Lazoff's findings also seem to question the legitimacy of "Just-In-Time" CME as offered by WebMD and Medscape's "next-day" reporting on medical society presentations. Yet Lazoff recognizes, with some reservation, that this can be good education: "As long as it is thoroughly researched and well-presented, there is certainly a place for non-scholarly CME of this type on the Web."

Ribble defends the quality of Medscape's CME offerings. "Does doing summaries of presentations that just happened make the quality of the research less?" she counters. "Medscape's next-day reports are not little news items but 1,500 to 3,000 word, referenced-round-ups written by top authorities."

Looking to the future, Marcia Jackson of the ACC wonders whether there will someday be a shift in the role associations have traditionally played for experts.

"Before the Internet, what medical associations did was bring experts together in a single place, to give members access to them. Now one of our members could do something on our Web site, and because of that be asked to do something on someone else's Web site, and so on," she says. "I find myself wondering if at some point experts will decide to have their own Web sites, where they'll post their own studies and charge royalties for access to them. I don't know if that will actually happen, but it could."

Choosing the Right Specialist When Lois Book, PhD, director of education for the American Association of Diabetes Educators (AADE), Chicago, Ill., started her search for an online partner, she began by looking in professional journals in the training and development field; she also went to a meeting. "I met Simone Karp [of CECity.com] at a meeting of the American Consortium of Pharmaceutical Education. I went there looking for vendors." She also contacted the Association Forum, a local Chicago organization with lists of vendor contacts that also sponsors a convention of education and association vendors.

When she started talking in earnest with online vendors, she made a number of observations. One of these was that everyone offers a different level of service, and that prices for services and revenue sharing percentages are negotiable.

Here are Lois Book's top tips: If you provide digital audio with a cue for slide changes, don't expect to be charged for synchronizing because you've provided a product that's ready to go.

Pick a vendor whose systems are not radically different from yours, otherwise you won't save anything from providing formatted files.

Therefore, know your own systems well enough to know where the synergies that can save you money will arise.

Anticipate the repurposing of material recorded at your meetings. If you want to webcast a presentation, record it digitally, because analog won't be good enough for the Web.

"Knowing in advance what outcome you want means you can put the bits and pieces together and save yourself some money," says Book.