Demand rises for CME linked to physician quality improvement

As physicians face increasing pressure to demonstrate performance improvement, more are utilizing a model of continuing medical education that gives them tools to assess the care they provide patients, and make measurable enhancements.

The concept of Performance Improvement Continuing Medical Education was introduced in the early 2000s, and the model has expanded significantly since then. In 2011, 44,275 physicians and 7,492 nonphysician health professionals participated in 502 PI CME activities offered in the U.S., according to the Accrediting Council for Continuing Medical Education. That’s a steep increase from the 744 physicians and 175 nonphysician health professionals who participated in 22 PI CME activities offered just six years earlier.

The model makes up a small fraction — less than 1% — of the more than 132,000 CME activities offered nationwide. But demand for PI CME is expected to grow as the country shifts to a pay-for-performance system of care that emphasizes quality over volume.

“This is a model that is trying to bridge the gap to continuous improvement,” said Laura Lee Hall, PhD, director of the American College of Physicians’ Center for Quality. “Physicians increasingly are going to be required to look at their practice and find ways to improve it. PI CME is a way to help busy physicians approach this whole science of quality improvement.”

Measurable progress shown

Under the traditional CME model, a physician may get credit for completing a short quiz after attending a lecture, watching a video or taking an online tutorial. The concept for PI CME evolved out of a desire to integrate that instruction into the practice setting and show measurable results, said Norman B. Kahn Jr., MD, executive vice president and CEO of the Council of Medical Specialty Societies.

The American Medical Association and the American Academy of Family Physicians approved the standards for PI CME in 2004. The effort followed widespread calls for increased emphasis on patient safety and quality of care, Dr. Kahn said. The Institute of Medicine released two related reports, “To Err is Human” in 1999 and “Crossing the Quality Chasm” in 2001. Like other CME models, ACCME accredits organizations offering PI CME. The organizations determine how physicians are assessed and credited.

PI CME involves three basic steps: an assessment of the physician’s practice using identified evidence-based performance measures, implementation of an intervention, and re-evaluation of those performance measures to gauge improvement, according to the AMA.

A major advantage of the model is that it allows physicians to compare patient outcomes with national benchmarks, said Mindi McKenna, PhD, director of the AAFP’s CME division.

“It’s evidence-based, and it’s giving individualized measurements and data in the context of a broader sample,” she said.

For example, family physicians can use PI CME to help improve the care they provide to patients with chronic conditions such as diabetes, asthma and chronic obstructive pulmonary disease. In the case of diabetes, doctors can evaluate patient outcomes and compare the results to national data. To reduce diabetes-related complications among their patients, physicians might develop an intervention to address the problem, such as doing routine hemoglobin A1c checks and foot exams.

“The patient is going to be the beneficiary,” McKenna said. “For a patient whose physician is engaging in PI CME, it ensures more systematic, evidence-based care.”

For osteopathic physicians, the equivalent of PI CME is the American Osteopathic Assn.’s Clinical Assessment Program. Also known as CAP, the program was developed in the late 1990s as a way to assess the performance of resident physicians, said Richard Snow, DO, MPH, an AOA consultant to the program. The CAP model, which has the same three-step structure as PI CME, was first offered as CME in 2005.

The challenge of multiple mandates

Demand for PI CME is expected to grow with increased focus from payers, hospitals and certifying boards on improving quality of care through health system reform and implementation of more rigorous maintenance-of-certification and licensure requirements, McKenna said.

Numerous entities require physicians to participate in CME. Doctors have to complete a certain number of credits to maintain hospital credentials, specialty board certification and state medical licenses, said Nancy Davis, PhD, director of practice-based learning and improvement with the Assn. of American Medical Colleges. She was director of CME at AAFP when the PI CME standards were developed.

As part of maintenance-of-certification requirements implemented by the American Board of Medical Specialties about 12 years ago, doctors have to demonstrate continuous practice assessment and improvement to be board certified. Many specialty boards have approved PI CME activities as a way to meet that requirement, Davis said. PI CME also serves as a way for physicians to meet quality improvement requirements set forth by the Centers for Medicare & Medicaid Services and many private insurers.

Because the model is relatively new, the FSMB is not asking its member boards to mandate PI CME, but its guidelines encourage boards to consider it as part of the new requirements, said Humayun Chaudhry, DO, president and CEO of the Federation of State Medical Boards.

PI CME programs take longer than a traditional CME activity, but physicians have the opportunity to earn more credits for their efforts, said Dr. Kahn, of the Council of Medical Specialty Societies. For example, a physician may get one credit for attending a one-hour lecture with traditional CME, but 20 credits for completing all three steps of PI CME. Drs. Kahn and Davis served on an AMA task force that developed the original PI CME standards.

One major challenge physicians face is synchronizing electronic health records in their individual offices with national registries to compare data, Dr. Snow said.

“We’re all investing a lot into different [EHRs] and clinical informatics, so we hope to get past that barrier,” he said.

Although PI CME may allow physicians to meet multiple quality reporting requirements, they still have to report those credits to each individual agency, Davis said. That is expected to change. Medical licensing boards and specialty certification boards are working together to align their reporting requirements.