Pulse
Credit for Change
Performance improvement CME has been touted as the future of continuing medical education. But will a good idea succumb to the burden of process?
As physicians at HealthPartners Roseville and Lino Lakes clinics were preparing to roll out a statewide initiative to improve depression care in primary care practices, the organization’s continuing medical education staff saw a perfect opportunity to test out a format that was being hailed by the American Medical Association (AMA) as the “core of the new CME.” Designed to be more relevant to practice than listening to lectures or reading journal articles and answering questions, this new format, called performance improvement CME (PI CME), awards physicians credit for actually changing the way they practice medicine. “We [wanted] to take a topic that was front and center and see if there might be an application for PI CME,” says Deb Curran, director of continuing professional development for HealthPartners Institute for Medical Education.
Approved for credit by the AMA in 2004, PI CME is a three-stage process. First, the physician uses data to assess his or her practice on a specific health issue such as depression, blood pressure, or diabetes management. The physician then sets a goal for improvement and implements one or more interventions to achieve that goal. Finally, he or she assesses outcomes data to determine the extent to which the goal was achieved and reflects on what was learned from the experience. Physicians can earn CME credit for completing each of the three stages.
“It puts the responsibility into the hands of individual physicians to help them identify areas of their performance that need improvement,” Curran says.
Depression care seemed to be a good candidate for a PI CME initiative, she says, because many of the components of each stage were already in place. For instance, the goals were to have patients with a PHQ 9 score of 10 or greater see their score decrease by at least half—indicating they are improving—after six months, and then to achieve remission (a score of less than five) within another six months. The interventions included having a care manager (often a nurse or social worker at a participating clinic) call patients between appointments to make sure they’re taking their medications, discuss side effects, and offer encouragement. Physicians could then use the follow-up PHQ 9 scores to see how patients were faring six and 12 months later.
Physicians such as Karen Mackenzie, M.D., a HealthPartners Medical Group family physician at the Roseville Clinic who participated in the PI CME initiative, took the intervention a step further. In addition to working with a nurse and social worker to follow up with patients, she took part in formal and informal educational sessions with a psychiatrist to learn how to better manage patients with depression. “Psychiatrists may be a little more aggressive with increasing medications more rapidly than we had been accustomed to doing, but we also saw that by doing that, people got their depression under control faster,” she says. Mackenzie says she also learned how to use combinations of medications and to recognize when a patient needs to be referred to a psychiatrist.
“Performance improvement initiatives are a wonderful way for us to learn,” she says. “A lot of what we learn as physicians is what we learn from consults. It’s different from sitting in a lecture or reading.”
But the challenge has been translating that type of learning into CME credit. Only half of the 10 physicians and two nurse practitioners who took part in PI CME program completed the final stage.
In some cases, Curran notes, physicians didn’t need the additional credit that went along with completing the final stage (they could earn five CME credits for each stage plus five bonus credits for completing all three stages). Others chose not to take the time to document their final analyses. In addition, some physicians didn’t quite know what to do when asked to reflect on how their practice changed.
A Cumbersome Process
Figuring out how to get physicians to view continuing education differently has been another challenge in getting PI CME off the ground. In 2007, Joan Bissen, now executive director of the Park Nicollet Institute, invited physicians to participate in a PI CME pilot project related to blood pressure management. “Our physicians routinely get performance data on clinical outcomes and process measures, and we have a fairly robust quality improvement initiative that’s ongoing. So we thought this would be an excellent way to give them credit for this activity at the same time,” she says.
Bissen says physicians were given a choice of taking part in lectures and a group activity or doing a PI CME activity specific to their practice. “We found there was a lot more interest in the group activity,” she says. “It’s something physicians are comfortable with.”
Bissen says the two physicians who did take part in the PI CME found it onerous. “It was very time-consuming to document the various steps, and some of what they did was difficult to document,” she says, adding that the physicians only took part in the first stage—evaluating what they were currently doing in regard to screening for and managing high blood pressure.
She says the problem with the current format for PI CME lies in the requirements for awarding credit. “We’re all working on continuous improvement, so even defining what is a stage, according to the criteria, is difficult.” Plus there’s the issue of time—both that of the CME staff who develop the modules and the physicians who participate. “Physicians are all working hard at this, and we’re seeing improvements across the board in community measures,” she says. “What they’re doing is working. Asking them to do additional steps for credit doesn’t necessarily seem like the right direction to go.”
Giving Credit Where It’s Due
For that reason, CME providers are trying to find ways to award physicians credit for taking part in quality and performance-improvement activities other than having them go through a formal three-stage process. For example, instead of looking at individual physicians’ data on managing depression the way HealthPartners did, Mayo Clinic took a broader approach. “We needed to know how Mayo Clinic was going to do this collectively, not just through individual physicians,” says Kelly Nowicki, administrator of Mayo’s School of Continuous Professional Development. She says they helped the clinics establish a framework that enables physicians to engage in quality improvement activities that can be completed individually or as part of a team. Physicians can earn educational credit after successfully completing the project and writing about what they learned.
Nowicki says that since January 2010, Mayo has awarded physicians AMA PRA Category 1 credits for taking part in approximately 20 quality-improvement projects including one designed to get glucose measurements under 200 in postoperative cardiovascular patients, another to reduce the overall incidence of broncopulmonary dysplasia in neonates, and others that address autism, breast cancer, and osteoporosis screening. Bissen says Park Nicollet has awarded physicians credit for participating in discussions and workshops in which they reviewed clinical outcomes data and medical evidence in order to develop strategies to improve patient care.
At HealthPartners, Curran says they’re applying what they learned from the depression care project to their next PI CME initiative, which will focus on reducing disparities in care among people from different cultures served by its clinics. She says the project will include training physicians in quality improvement. “What CME providers recognize is that many physicians have had no formal training in quality improvement, so we’re working to help them understand that process,” she explains. “Once physicians have that QI background and understand what it is, and what performance improvement is, PI CME will have a promising future.”
That future may be here sooner than expected. According to Bissen, more and more physicians will need to do this type of work in order to maintain their board certification. “It’s going to come down to whether physicians can get credit for something that’s meaningful and that they’re already doing as part of their practice,” she says.—Kim Kiser