The CME Transformation
In November 2018 Vanderbilt University Medical Center physicians and other clinical team members gathered from specialty services that see patients who are more apt to be gravely ill — trauma, cardiology, gerontology and so on. The occasion was an intensive training session spread over three consecutive days, called Difficult Conversations with Seriously Ill Patients. In this pilot version of the training, participants learned basic principles of how to approach such conversations and together practiced having those conversations.
“It’s another thing to think about how do I actually embed this in my workflow, where I’m really busy, how do I make this work in the context of what I actually do? To help accomplish that we needed to have the team there,” said Bonnie Miller, MD, Senior Associate Dean for Health Sciences Education at Vanderbilt University School of Medicine, and Executive Vice President for Educational Affairs for VUMC.
For their participation, physicians in the group happened to earn continuing medical education (CME) credits, a requisite for licensure and maintenance of specialty board certification. Miller points to this pilot session as an example of CME that has direct bearing on day-to-day clinical practice.
“Basically, a lot of traditional CME has been very passive. You can call it seat-based time in lecture halls and conferences, and it may or may not relate to actual physician practice needs or practice gaps — as in ‘here’s my current level of practice based on some measurable outcome, this is where I should be, there’s a gap, what am I doing to close that gap?’ Ideally, that’s what continuing education should help people do.”
At Vanderbilt and beyond, efforts are afoot to transform CME.
“We want CME to bear more directly on health outcomes and individual and group performance, including performance in non-technical areas such as social competency and communication. We also are seeking to bring CME more in line with well-established principles of effective adult learning,” said Donald Brady, MD, Senior Associate Dean for Graduate Medical Education and Continuing Professional Development.
In the vanguard of these efforts is the Accreditation Council for Continuing Medical Education (ACCME), and its President and CEO, Graham McMahon, MD, MMSc.
“One of our strategic goals is to accelerate the evolution of CME. A lot of people think CME is about box-checking and credit-seeking, but from our perspective CME is about performance management for professionals; it’s about integrating learning into practice,” McMahon said.
It appears that the stars are starting to align for more meaningful and targeted CME. For example, through the efforts of the ACCME, it’s now possible with a single clinical improvement project for physicians to earn CME credits, participate in the Centers for Medicare & Medicaid Services Merit-Based Incentive Payment System, and satisfy the American Board of Medical Specialties Maintenance of Certification Part II (Lifelong Learning and Self-Assessment) and Part IV (Improvement in Medical Practice). According to McMahon, the ACCME and the American Medical Association have in recent years made it easy for CME providers to award credits to physicians for all manner of practice improvement activity. He said CME providers — hospitals, specialty societies, for-profit CME companies, medical schools — are beginning to respond to a call for innovation and transformation, seizing opportunities to go beyond lectures and other one-and-done type activities.
CME providers still have a long way to go, according to Geoffrey Fleming, MD, associate professor of Pediatrics and Anesthesiology. Two years ago Fleming was named to the new role of vice president of Continuous Professional Development at VUMC, making him the institution’s first official clinician-champion for CME.
“My role is to really embed principles of adult learning in operational change. People are trying to move the education moment out of the lecture hall and into the practice of the individual. In an institution like ours, education really needs to be tied to operations. I want us to get to the next phase, and I think there’s a richer phase ahead,” he said.
VUMC efforts to transform CME come in the wake of thoroughgoing changes to the undergraduate experience at the School of Medicine, launched in 2013 under a program called Curriculum 2.0.
“The idea is to help physicians become self-evaluating, self-correcting professionals. So, for that, we need to design a learning environment that first of all gets them to that level, and then provides the support they need to do that throughout their careers,” said leading CME expert Don Moore, PhD, professor of Medical Education and Administration and director of the Office for Continuing Professional Development at VUMC. Moore works on education design and evaluation for med students, trainees and practicing physicians. He and Fleming are a team.
“There are people like Don who know everything there is to know about adult learning theory,” Fleming said, “and then we have the operations people who understand clinical processes and what makes or breaks a clinical outcome. We have to connect those two pieces, and I believe clinicians like me who want to change the system have a role, because we can be the link between operations and education.”
To ease this burden of documenting CME participation, VUMC is participating in an ACCME pilot program whereby CME providers, with the consent of participants, report credits earned by physicians directly to state licensure boards. Also, VUMC has a system that allows clinicians to easily document their participation in live CME events via text message.
Information Technology and CME
Fleming and Moore see a new role for information technology in CME.
“Information technology is the big change afoot in CME, taking the education out of the lecture hall and putting it in the hands of physicians a little more on their own time scale,” Fleming said.
Last year VUMC introduced QuizTime, a learning and assessment application using text messaging and email, created by Toufeeq Ahmed, PhD, assistant professor of Biomedical Informatics and executive director of Education Informatics. A VUMC team has adapted QuizTime for use in CME, beginning with modules on the use of opioid and non-opioid therapies in managing pain. The app sends questions daily to clinicians by text message or email, and once they submit their answers, they receive immediate feedback about the topic. Recently offered to physicians at VUMC, the pain management module will also be offered to clinicians across Tennessee.
A year ago, VUMC installed an electronic health record (EHR) system and related software from Epic Systems Corp., a major health care systems vendor based in Verona, Wisconsin.
“I’m trying to figure out how we can use the power of the EHR system to help physicians identify where they need to concentrate their learning, and then help them get that learning,” Moore said.
This is top of mind for Fleming as well.
The intention to transform CME raises some issues. How can more meaningful CME be delivered without undue disruption to clinical workflow? Physicians are busier than ever, and improving their practice is going to require more effort from them than listening to an occasional lecture. Can electronic medical records systems be yoked to CME? How will physicians take to individual clinical reporting as a focus of CME?
“If I could wave my wand, tomorrow I would start a grassroots quality improvement initiative among every clinician in the institution, with each looking at their own practice data and deciding for themselves where they want to begin to work on any problems. Collectively, all those tiny little problems that they identify are going to help the system,” Fleming said.