Continuing medical education is at a crossroads. In one direction is CME as it has been for time immemorial; in the other is continuous performance improvement. Which way are you headed?
that continuing medical education is undergoing some fundamental changes is becoming ever more apparent. Fading fast is CME as usual, whose mission is to provide a lecture on a topic of interest and judge an activity's success by asking learners if they liked the coffee and doughnuts. The old version of CME is not-so-slowly, but surely, being reconstituted so that it can become a vital piece of the growing healthcare quality-improvement movement. The new form of CME that will be able to actually help make the QI that physicians, insurers and other payers, healthcare systems, legislators, and patients are increasingly demanding? It's called continuous performance improvement, and it's going to rock the CME world.
So said those who participated in the National Institute for Quality Improvement and Education Fall Conference, held in Chicago in September.
No, it won't be as easy as just changing an acronym, but if you plan to continue educating physicians and other healthcare workers in this increasingly QI-focused healthcare system, NIQIE leaders said you're going to have to erase some old ways of thinking, planning, and conducting it.
While it's easy to think the pendulum is swinging just temporarily to the quality side, all indications are that QI as a fad is one of the first ideas you need to delete from your mind-set. The Institute of Medicine, in its 1999 “To Err Is Human” report, sparked the public interest when it pointed out that up to 98,000 Americans die in the hospital each year from preventable medical errors, the equivalent of a jumbo jet load full of people crashing daily. When IOM followed up two years later with “Crossing the Quality Chasm,” which makes an urgent call for fundamental change to close the quality gap and asks for a redesign of the entire American healthcare system, it was like throwing gas on the fire.
The organizations that regulate, accredit, credential, and license healthcare practitioners have started feeling the QI heat and are putting some of their own on their members. One of the most influential moves so far came when all 24 member boards of the American Board of Medical Specialties began requiring their HCPs to demonstrate their commitment to lifelong learning, engage in a periodic self-assessment process, and show their competence in areas such as patient care and communication skills, as well as medical knowledge, in order to maintain their specialty board certifications.
According to a presentation by Richard Hawkins, MD, senior vice president, professional and scientific affairs, ABMS, Chicago, at NIQIE, recent revisions to Part II of the maintenance of certification, or MOC, standards include requiring 25 CME credits per year, a third of which involve self-assessment. Part IV of the standards, which involves practice performance assessment, now includes practice assessment and QI, including a registry with learning collaborative, a self-administration module, and quality measurement/improvement. This doesn't mean, however, that any CME that qualifies for American Medical Association PI CME credit will automatically satisfy a board's MOC Part IV requirements. Each certifying board has its own criteria for approving activities for MOC Part IV — just being able to offer PI CME credit for an activity that isn't designed specifically to meet that board's criteria may not suffice.
As Hawkins pointed out, there are lots of other parties interested in physician performance improvement as well. Consumers and payers are considering pay-for-performance, physician report cards, and rating systems. Eric Holmboe, MD, senior vice president for quality research and academic affairs with the American Board of Internal Medicine said that ABIM's MOC program has been incorporated into a number of private-sector reward and recognition programs, including those of Aetna, Cigna, and Humana.
Quality organizations such as the Agency for Healthcare Research and Quality, the AQA (formerly known as the Ambulatory Care Quality Alliance), National Quality Forum, and the National Committee for Quality Assurance are also focusing on CPI, as is the federal government in the form of the Centers for Medicare and Medicaid Services. As Atul Grover, MD, PhD, FACP, FCCP, chief advocacy officer, Association of American Medical Colleges, Washington, D.C., showed, the government is beginning to tie reimbursement to the quality, not just the volume, of care provided. A case in point is the CMS Physician Quality Reporting Initiative's recent decision to provide financial incentives to physicians and systems that report on their use of quality metrics.
Of course, the Accreditation Council for CME is making adjustments to this new quality focus as well. In 2006, it revised its accreditation criteria to reflect the growing trend. The aim is to frame CME outcomes in “improvement of competence, performance, and patient outcomes rather than just “'learning,'” said Barbara Barnes, MD, MS, associate vice chancellor, continuing education and industry relationships, University of Pittsburgh; vice president, sponsored programs, research support and CME, University of Pittsburgh Medical Center; and chairwoman, ACCME board of directors, at NIQIE.
For example, Level 2 now asks the provider to incorporate into CME activities the educational needs (knowledge, competence, or performance) that underlie the professional practice gaps of their own learners, where the prior version wasn't specific about the needs, nor did it mention practice gaps. And while the criteria didn't previously ask for more than some kind of evaluation (hence the coffee-and-doughnuts questions), Level 3 now demands that CME activities are designed to change competence, performance, or patient outcomes.
Those who want to achieve “accreditation with commendation (six years) must comply with criteria for mission, educational design, evaluation, and Standards for Commercial Support as well as requirements for engaging with the environment,” Barnes said during her presentation at NIQIE.
Like it or not, the participants at the NIQIE conference emphasized, the healthcare quality movement is gaining momentum, as is the concomitant shift from CME to continuous performance improvement.
As NIQIE board member Jack Kues, PhD, assistant senior vice president for continuous professional development, University of Cincinnati Academic Health Center, said after the conference: “Quality is going to be the focus of healthcare reform; CME will not survive if it cannot adapt.”
People have been talking for years about the need to get out of the CME silo and collaborate with others. It may be cozy, but silos get the red pencil. As Don Moore, PhD, director, division of CME; director of education and evaluation, graduate medical education; faculty associate, Office of Teaching and Learning in Medicine; and professor of medical education and administration, Vanderbilt University School of Medicine, Nashville, said, “It's about coordinating a different set of resources than it has been in the past.” That means coordinating with quality-improvement professionals and instructional designers to develop effective continual performance-improvement approaches. To receive AMA PRA Category 1 credit for a CPI activity, physicians must complete three phases: They must compare their performance to national benchmarks, identify gaps and improve practice, and measure their performance over time. They get five credits for each phase they complete, and another five for completing the whole set.
“Clearly the most important, and most difficult, part is to develop a collaborative relationship with whomever is doing quality improvement in your organization, or in the case of a medical education company, the organization you're working with,” he said.
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What makes it difficult is that people in the quality field don't necessarily understand what a CME program can contribute — they tend to believe that all that's needed to get people to change their behavior is to show them that they're not meeting some sort of quality standard. “Everyone needs help to change,” Moore said. “And not just doctors. Just telling a patient to lose weight doesn't mean that the patient will do it.
That's where the CME office can come in, not just to provide the knowledge source, but to provide the opportunity to practice how that knowledge translates into a clinical setting. The point of PI CME isn't to just find another education avenue or one-off activity that physicians can take to get their credits, but to change practice, Nancy Davis, PhD, NIQIE's executive director, pointed out. To do that, you need to find out what quality approach the organization you're working with is using, and what its goals are, then integrate evidence-based CME that's planned for impact on physician performance and is assessed based on the actual change that occurs.
No longer is it enough to start at the beginning and go on from there; now you need to start with outcomes, said Moore. Because the MOC standards move from the seat-time requirements of the old CME to assessment-based, interactive, practice-focused CME; and performance measurements that are linked to quality improvement, the activities you design have to be based on a recognized gap between actual performance in the clinical setting and an externally acknowledged standard of care. “Planning for and assessing outcomes must go together,” Moore said, adding that you should start with the outcome in mind and reassess throughout the activity to ensure that what you're doing is still leading toward the desired outcome. “Plan backward: Start with outcomes.”
It also has to be designed to engage learners, let them reflect on and practice what they learn in the educational activity, and provide feedback that is encouraging, rather than discouraging, both during the activity and in follow-up. In other words, it has to be designed so that learners will actually become not just knowledgeable in the subject matter, but also able to understand how to put that knowledge into action in their own specific clinical settings, be able to practice doing just that during the activity, and be given ongoing support to encourage them to bring their new skills back to their practices.
Performance-improvement CME also includes reinforcing activities, such as reminders, post-course materials, and commitment-to-change forms. Throughout the process, the HCP will be continually reassessing to ensure that he is still on target to reach the outcomes the PI program was designed to reach. And if the outcome isn't reached, he reassesses and starts the cycle again. “Think of assessment as a continuum, from initial gap analysis through the learning activity to outcomes,” he said.
For a full discussion of this approach, see “Achieving Desired Results and Improved Outcomes: Integrating Planning and Assessment throughout Learning Activities,” an article Moore and coauthors Joseph Green, PhD, and Harry Gallis, MD, published in The Journal of Continuing Education in the Health Professions, 29(1):1-15.
While you still won't just stumble across the data you need, you do need to delete the dearth of data from your list of reasons for not doing CPI, because the data you need to establish best practices, to compare and identify gaps between the standards of care and actual performance, and to measure the outcomes achieved can be found.
One resource you may learn to love is the AMA's Physician Consortium for Performance Improvement performance measures. As explained by Cary Sennett, MD, PhD, who served as PCPI's vice chair at the time of the NIQIE conference and is chief medical officer with Bowie, Md.-based MedAssurant Inc., PCPI currently has performance measures available for 43 clinical topics or conditions, including measures for patient-centered, team-based care transitions performance.
The best data for the second and third parts of the equation — practice gap comparisons and outcomes measurement — however, is by necessity homegrown. While electronic medical records, or EMRs, can be mined for performance information, their purpose really is to record patient-care transactions, not to measure and compare different patient populations, and EMRs are limited to one practice instead of going across different practices to gather data, said Thomas Dent, CEO of ICLOPS, a Chicago-based patient safety and quality company, during his NIQIE presentation.
Registries can be a good option because they can integrate more points of data than EMRs, go across practices, and include external, third-party laboratory data from hospitals, radiology, and even patient-entered data and surveys. Physician participation can be required by the quality initiatives of their hospitals or other physician organizations; they also have to use them if they want to participate in Medicare's Physician Quality Reporting Initiative.
While not without problems — such as a variability in reporting and accuracy, and having too few docs in a particular specialty to make a viable comparison — local, regional, and national registries can have their place in CPI. For example, said Dent, they can help measure specific areas of quality so that residents can see their performance, show variation in physician behavior and outcomes, and help to identify problems, be they knowledge-based, behavioral, or just the result of bad data entry. They also can help to provide the big picture needed to assess outcomes.
To meet the needs of CPI, you need to blow up the CME office, said Davis — and for good reason. As CME increasingly transforms into CPI, workplace learning, or point-of-care learning, also likely will increase. Physicians are redesigning their practices to transform them into “medical homes,” as described by Bruce Bagley, MD, director, medical quality with the American Academy of Family Physicians, Leawood, Kan., in his NIQIE presentation. Fortunately, CPI will fit right in because these medical homes are being built with continuous performance improvement in mind. In addition to improved patient support and practice organization, this practice model includes quality measures that foster a culture of improvement that includes staff education and performance measures, Bagley said. It also includes health information technology that entails, among other things, clinical data analysis and representation, including all-patient, all-condition registry, quality measurement collection and analysis, and reporting to third parties.
The clinical reporting measures are key both for getting a baseline on the practice, and for finding areas ripe for performance-improvement CME. “Measurement is fundamental to any change strategy,” he said, adding that systematic changes for the better are what the medical home model is designed to facilitate. CPI, he said, could help with systematic changes — develop a team approach to care, say, or train staff to provide patient self-management support — as well as with changes in individual behavior.
NIQIE's Davis pointed to Improving Performance in Practice, or IPIP, a state-based, nationally led QI initiative administered by ABMS and funded largely by the Robert Wood Johnson Foundation, as a peek into what may well be the future of CME as it morphs into CPI. She said, “A basic hallmark of the IPIP initiative is for a designated quality-improvement consultant to work on-site with the practice leadership team to develop a practice-specific redesign plan utilizing the resources of collaborating experts.” That means that future CPI providers could end up being more like coaches, education brokers, or consultants who provide real-time learning at the point of care that is based on performance improvement.
And a team approach is becoming more necessary than ever. As several NIQIE presenters discussed, these medical homes are nothing if not team-based, where the interconnected actions of everyone involved in that patient's care can change what actions others in the system take, even though what exactly they'll do isn't always easy to predict. What's needed, according to those who presented at NIQIE, is workplace learning that addresses how the individuals on a patient's team respond to challenges by acquiring, interpreting, reorganizing, changing, or assimilating information and skills.
It'd be nice to be able to cross off this most stubborn challenge CME providers face when moving from CME to CPI, but you still need to keep it on the board. For now, anyway.
The consensus from NIQIE participants was that, now more than ever, it pays to pay attention to what Big Pharma is doing with its grants. For example, while GlaxoSmithKline announced this fall that the number of programs it plans to support will shrink, it also will be providing grants only to those with a decidedly CPI bent. According to a statement released in September, funding levels for each grant will depend on the quality, scope, and complexity in closing the clinical gap identified by the provider, and must include plans to assess the impact of the educational program on healthcare professional competence, performance, and improved patient health. Pfizer announced a similar plan for its CME granting last year. However, while pharma companies are making it known that they want to fund these types of programs, they don't always understand what PI CME should look like in terms of scope — number of measures, types of interventions, costs, etc. — which can make it difficult for them to review, evaluate, and compare across proposals, Davis said. As Kues noted, “The future of funding for CME is probably going to be tied to its ability to show improved patient care and corresponding cost savings.”
For more information about the Homestead, Pa.-based National Institute for Quality Improvement and Education, the annual conference, and other educational offerings, go to www.niqie.org.
Elizabeth Gifford-Drury, program manager,
Boston University School of Medicine Continuing Medical Education, outlined a chronic obstructive pulmonary disease activity the school launched last year for participants at the National Institute for Quality Improvement and Education Fall Conference, held in Chicago in September. It started as a mostly Web-based module that let clinicians enter chart review data, select interventions, and enter follow-up chart review data.
Then they added more elements to help keep participants supported and motivated, including live teleconferences, one-on-one coaching calls, a discussion board, live regional meetings, and two local practice initiatives that include on-site meetings at each practice.
So far, more than 250 providers are enrolled, and improvements in some areas are way up (e.g., repeat spirometry: up 129 percent).
The key things her office has learned, she said, are to use fewer measures, keep interventions simple, be flexible with deadlines, and start small.
Then there's the role of medical education and communication companies in PI CME. Read more here, and feel free to add your two cents.