If You Want to Change
perceptions about continuing medical education on Capitol Hill, Robert Meinzer, senior director, national CME, New Jersey Academy of Family Physicians, Trenton, has a pretty straightforward solution. “The government is looking at CME as part of the problem, not as part of the solution,” he says. “The only way we are going to change that perception is to get on the same page as the government.” If CME is targeted at healthcare gaps the government has identified, and improves physician performance, then CME providers — and industry — will be seen as part of the solution, not the problem.
Meinzer put his philosophy into action when developing the $1 million Global Initiative for Chronic Obstructive Pulmonary Disease, a CME program that launches this month through AAFP chapters in 15 states, funded by Pfizer and Boehringer Ingelheim.
Finding the Fed's Priorities
In developing the COPD program, Meinzer mined his knowledge of government sources and connections. First, he checked the Centers for Medicare & Medicaid Services' Statement of Work report, which is aCMS signs every three years with the Quality Improvement Organization Program. The SOW report outlines areas where CMS wants quality improvements in healthcare. Meinzer learned about the SOW about eight years ago. “Up until that point, I had no idea that there was a parallel universe of government people who were trying to change physician behavior,” he says. Among the areas listed on the most recent report, the 8th SOW, was COPD. So Meinzer thought that might be an area to pursue for CME.
Next, he contacted his local Quality Improvement Organization representative in New Jersey to learn more about how they were approaching COPD. NJAFP has had a relationship with the QIO for years, since QIOs, charged with improving physician performance, have access to all government data about diseases. In fact, the academy recently hired someone from the New Jersey QIO, further strengthening the connection. Regarding COPD, the QIO was interested in reducing the number of bounce-back patients, those patients who were going back to the hospital after initially being treated for COPD at home, a problem that was highlighted in the SOW report.
Armed with that information, Meinzer consulted the annual Health Plan Employer Data and Information Set or HEDIS measures, which the National Committee for Quality Assurance issues annually. It outlines ways to measure the quality of care in a variety of areas. The 2007 report caught Meinzer's eye because it called for the use of spirometry testing — the process of testing breathing through the use of a spirometer — to diagnose COPD.
Pursuing that avenue, Meinzer did a focus group with area doctors to discover educational gaps around spirometry. He found that many physicians don't use spirometers. “Family doctors pretty much know they're supposed to use spirometry, but they have a lot of barriers to using them, not the least of which is they don't have them in their offices,” he explains. Some doctors don't think they need one to diagnose COPD, or they don't have the time and resources to use them. Since assistants often conduct the tests, doctors not only need to learn how to use spirometers themselves, but also have to learn how to train someone else — another barrier.
However, since spirometry use became a HEDIS measure in 2006, there is incentive for doctors to use them — otherwise, they will jeopardize their status as preferred providers with managed care organizations, who are judged on HEDIS measures.
Based on that feedback, Meinzer and NJAFP Executive Director Ray Saputelli decided to develop an interactive workshop to show physicians how to use spirometers. The centerpiece of the program is a video presentation featuring doctor-patient simulations performed by actors. The workshop participants, limited to 25, interact with the video. Two live instructors stop the video at various points and ask the attendees to respond via audience response technology to questions on what should be done next. The attendees each have spirometers on their desks so they can handle the equipment as they are learning. The video also shows doctors how to bill for spirometry, how to chart it, and addresses other practical matters that might be barriers to its use.
Does it Work?
NJAFP brought in AXDEV Group International, Brossard, Québec, to conduct outcomes evaluations. Given the focus of the program, Suzanne Murray, president, AXDEV Group, is primarily looking to measure physicians' confidence levels or attitudes toward using spirometry, as well as their skill and performance. “Attitudes and confidence frequently interfere with physicians' willingness to take the next step after the knowledge transfer, that is, to develop the skill,” she says.
Evaluations will take place pre-, post- and three months after the workshops, all using mixed methodologies including focus groups and surveys. The evaluations will also include patient interviews. They will ask the doctors to identify several patients with COPD that meet AXDEV's selection criteria. “We don't want physicians to choose their best patients, so we go through a selection criterion,” Murray says. Then AXDEV will get permission to follow up with the patients in three months to ask them about their treatments. AXDEV will also ask the physicians if they changed the way they treat patients with COPD.
The findings will be published by AXDEV in a peer-reviewed medical journal. Publication, says Murray, not only brings added credibility to NJAFP, it also advances the discipline of CME by bringing this type of evidence and methodology to the public domain.
Through NJAFP's connections with other AAFP chapters, the two-hour COPD workshop will run in 15 states. Also, through Meinzer's relationship with the New Jersey QIO, there is a possibility that the online video will be distributed through the various QIOs (there are 53 in the U.S.) to home healthcare professionals, who treat COPD patients. The QIOs have to review the video package to make sure it meets their stringent requirements before signing on. In addition, Meinzer is in talks with two other large national distribution platforms, but details were not available at press time.
“If I didn't understand the HEDIS measures, if I didn't understand how QIOs worked or what the 8th SOW is, none of this could have happened because I wouldn't have spoken the language,” says Meinzer.
It's that kind of approach that can improve CME's perception with the government, Meinzer and Murray say. “We talk about evidence-based medicine, but we sure don't talk enough about evidenced-based education,” says Murray. “The more evidence you have, the more you can defend the results and mitigate the risks around bias and conflict of interest.”
Adds Meinzer: “If commercial interests fund programs that fill a void that's outlined by government agencies and focus on addressing and improving the HEDIS measures, it's going to be hard to criticize them. I would like to think that, instead of criticism, we could get some positive feedback from the government.”
Start Your Research
CME providers should develop CME activities based on healthcare gaps the government has identified, says Robert Meinzer, senior director, national CME, New Jersey Academy of Family Physicians, Trenton. He suggests you check out the following:
Centers for Medicare & Medicaid Services' Statement of Work report, cms.hhs.gov
State of Healthcare Quality Report, issued annually by the National Committee for Quality Assurance, ncqa.org
Health Plan Employer Data and Information Set or HEDIS measures, issued by the National Committee for Quality Assurance, ncqa.org
Follow the Need
Taking it a step further, CME providers should also focus activities on the parts of the country where the need is greatest. “If you are doing programs on obesity in Colorado and San Diego — get real,” says Meinzer. “If I'm the government, I'm saying, ‘Wait a minute, guys. This is a good thing you're doing, in theory, but why do it here with all these people who jog and are vegetarians? Get down to Mississippi or Alabama.'”
The U.S. Centers for Disease Control and Prevention (www.cdc.gov) breaks out the prevalence of medical problems — whether it's obesity, diabetes, smoking, or hypertension — by state, right down to the county, says Meinzer. It also has information on the occurrences of various maladies by ethnic background.