Internet Point of Care PoC

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Internet Point of Care (PoC)

• Illinois Alliance for CME
• Stonegate Conference Centre
• June 23, 2006

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Disclosures

• I have no relevant financial interests to
  disclose.
• Charles E. Willis, Vice President
• Education and Training
• American Gastroenterological Association (AGA)
  Institute
• cwillis_at_gastro.org
• 301-941-2604

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Objectives

• Describe the AMA PRA credit system guidelines for
  Internet Point of Care (PoC) CME from a
  providers perspective.
• Outline opportunities and challenges for
  providers to adapt Internet PoC activities.
• Discuss the long term implications for physician
  learners and CME providers.

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Focus on Internet Point of Care (PoC)

• Approved March, 2005
• Pilot Study 2000 - 2004

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Physician directed, interactive Internet (Point
of Care) CME

• How to capture, as learning, use of professional
  literature at or near PoC
• Technology made it possible proliferation of new
  information made it necessary
• Moving to dynamic, practice situated learning

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Internet Point of Care (PoC) CME

• Individual physician learner-driven learning
• Needs assessment just-in-time not just in case
• How do we establish that physicians have
  adequately engaged in this learning activity?

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Internet Point of Care (PoC) CME

• Credit awarded based on engagement with the
  content
• Physicians must complete the following learning
  cycle
• describe clinical question
• review clinical sources
• evaluate application to practice
• Does not have to be done at the same time

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Internet Point of Care (PoC) CME

• Awarding Credit
• 0.5 credits per learning cycle
• Based on completion of process not time!

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Internet Point of Care (PoC) CME

• Provider Responsibilities
• Verifying integrity of clinical resources to be
  used
• Managing access to selected clinical resources
• Verifying physician participation and providing a
  mechanism to document completion of learning
  cycle
• Awarding and recording credit

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What Internet Point of Care is NOT

• Internet PoC is not unstructured online
  research. It is intended to answer a specific
  clinical question within a verified resource
  database.
• Internet PoC is not sources pulled by a
  librarian (or other staff) and provided to
  physicians. Must be completed by the physician
  online.

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Internet Point of Care (PoC) CME

• Opportunities
• Not just large providers smaller providers can
  provide a portal
• Data gathering easy to go beyond AMA guidelines
• Personal learning portfolios?
• Link to patient outcomes?

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Internet Point of Care (PoC) CMEExample Medical
City Hospital (Dallas, TX)

• Introduction Page outlining
• Learning objectives
• Needs assessment information
• Databases to be used
• Directions for access and claiming credit
• Disclosure information
• Required CME language

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Internet Point of Care (PoC) CMEExample Medical
City Hospital (Dallas, TX)

• Describe the Clinical Question
• What is the clinical topic/question? (open
  field)
• Is this question related to (check all that
  apply) 
• - A rare condition - A condition not managed
  recently - A diagnostic dilemma - A need for
  new clinical information - A controversial
  clinical issue - Other (specify)

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Internet Point of Care (PoC) CMEExample Medical
City Hospital (Dallas, TX)

• Review Clinical Sources
• How would you define your findings? 
• - Found clinical information that answered my
  question- Found clinical information that was
  related, but did not directly answer my
  question- Did not find any clinical information
  that addressed my question- Other (specify)
• Please type in 1-3 citations of the most
  relevant articles and the name of the database
  used (open field)

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Internet Point of Care (PoC) CMEExample Medical
City Hospital (Dallas, TX)

• Describe application of findings to practice (1)
•   Describe the application of your findings to
  your practice (Check all that apply and complete
  the statement)
• - Reinforced my clinical decision to (open
  field)
• - Confirmed a diagnosis of (open field)
• - Reviewed the condition of (open field)
• - Applied new clinical guidelines to management
  of (open field)

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Internet Point of Care (PoC) CMEExample Medical
City Hospital (Dallas, TX)

• Describe application of findings to practice (2)
•   Describe the application of your findings to
  your practice (Check all that apply and complete
  the statement)
• - Changed course of management (please detail
  below)
• - Unable to find clinical information that
  addressed my question
•  - Other (specify)

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Internet Point of Care (PoC) CMEExample Medical
City Hospital (Dallas, TX)

• Also included
• Overall evaluation questions (meeting objectives)
• Questions related to barriers for finding
  information
• Beyond the guidelines - combination of checklists
  and open fields
• Allows for physician reflection and detailed
  information
• Allows for standardized data across physicians

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Internet Point of Care (PoC) CMEExample Medical
City Hospital (Dallas, TX)

• To visit this example
• www.medicalcityhospital.com
• Go to physicians, CME, Internet Point of Care

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Rationale

• Provide consistent, reproducible evidence
• Emphasize patient-oriented evidence over
  disease-oriented evidence, but if not there
• Are we missing the information (indexing/librarian
  failure)?
• Is this a missed opportunity to guide the
  clinical research agenda?

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Wheres the research?

• Physicians do not seek answers to many of their
  questions, often suspecting a lack of usable
  information. When they do seek information, they
  often cannot find the information they need.
  Clinical resource developers could use the
  recommendations made by practicing physicians to
  provide resources that are more useful for
  answering clinical questions.
• Answering physicians clinical questions
  Obstacles and potential solutions JAMIA, 2005
  12217-224

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Other findings

• This sorry state of affairs has historical roots
• Our findings are consistent with those of Gorman
  and Helfand,4 who found that only two factors
  predicted pursuit of answers the physicians
  belief that definitive answer existed and the
  urgency of the patients problem. In that study,
  only 88 of the 295 questions (30) were pursued,
  and 70 of these 88 were answered.

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Other findings

• Why? Reconciling the basic and clinical research
  literature to clinician needs is very tough
• What are the signs of mesenteric artery
  occlusion and do you test for it? She has end
  stage CAD with stents in her coronary arteries. I
  looked in two textbooks and one Web site. There
  was no listing under mesenteric artery or
  vascular occlusion. I spent over an hour and
  came up with nothing useful.

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Other findings

• We are leaving too much data on the table
• Some recommendations from physicians might be
  considered unrealistic by information resource
  developers. For example, it world be difficult
  for authors to answer practice-generated
  questions without a mechanism for collecting such
  questions and making them available.

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Other findings

• Needs differ based on type of specialty. In this
  case
• General internists, general pediatricians, and
  family physicians were eligible for the study if
  they were younger than 45 years old and practiced
  in the eastern third of Iowa.
• Vertically integrated specialties (or
  subspecialties) may organize in different ways to
  deliver value.

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Additional topics to consider product
developers (AAFP)

• Document how evidence is reviewed and updated
• Describe how strength of evidence is evaluated
• Explicitly rate the strength of evidence
• Technologically dependable

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Some questions to think about

• Can we assign PoC credit for more intensive self
  assessment modules (multiple hours)?
• Any recommended websites for research or can we
  use any evidence-based reference/website?
• For evidence based medicine (EBM), start with the
  American Academy of Family Physicians at
  www.aafp.org

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Sample Sources

• PubMed Clinical Queries (ncbi.nih.gov/entrez/query
  /static/clinical .shtml) a subset of PubMed
  focused on clinically relevant papers
• National Library of Medicines (NLM) Hazardous
  Substances Database
• National Guideline Clearinghouse
  (www.guideline.gov) developed by the Agency for
  Healthcare Research and Quality (AHRQ)
• MerckMedicus (www.merckmedicus.com) non-branded,
  broad educational resource for physicians
• ClinicalEvidence (www.clinicalevidence.com)
  British Medical Journal's (BMJ) compendium of
  evidence based medicine (requires subscription)

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Sample Sources

• Cochrane Database of Systematic Reviews
  (www.cochrane.org) abstracts only
• Genetics Resources on the Web/GROW
  (www.geneticsresources.org)
• Agency for Healthcare Research and Quality/AHRQ
  (www.ahrq.gov) Clinical Guidelines and Evidence
  Reports
• Evidence-Based Medicine (EBM) for Primary Care
  and Internal Medicine (http//ebm.bmjjournals.com)
  BMJ developed abstracts are free, but full
  text access requires a subscription
• CDC Wonder (http//wonder.cdc.gov) a single
  point of access to a wide variety of reports and
  public health data
• Thanks also to RSI Reactive

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Whither Internet PoC?

• Independently developed content, distributed on
  proprietary platforms?
• Or do we focus on the mechanisms for access to
  and retrieval from existing sources?
• And lets talk a moment about content, our shared
  responsibility

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Some other things to think about

• Ease of use!
• Evaluate barriers (log on requirements, speed of
  system, access nodes, etc.)
• Doesnt have to be complex, improve over time

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What I still believe

• Internet PoC learning should integrate
  physicians overall performance (EMR!)
• New models for physician learning already
  complement existing modes of CME (live
  activities, etc.)
• Will help meet the demand for transparent,
  documented and accountable CME

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A closing thought, still

• Internet Point of Care should give us CME that
  is authoritative and adaptively accessible.
• Robert Galbraith, MD
• NBME

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Thank You!Charles E. Willis, Vice
PresidentEducation and TrainingAmerican
Gastroenterological Association (AGA)
Institutecwillis_at_gastro.org301-941-2604