By Barbara E. Barnes, M.D., M.S.
As the health care environment continues to evolve, physicians’ continuing education needs are changing. Although the traditional formal program remains a valuable resource, practitioners are finding that they have less and less time to leave their practices in order to attend CME programs, necessitating the delivery of content in a variety of independent learning formats.
Even when formal educational activities are available, research has demonstrated that, in order for significant learning to occur, other resources such as consultation with a colleague and independent study are usually required. In addition, provider networks are increasingly interested in offering education which is specific to established guidelines of care, outcomes indicators (such as HEDIS), and issues identified through the quality improvement process. This requires that standardized information be delivered to widely dispersed sites of care (not only locally and regionally but also internationally) in an efficient and effective manner. Information and telecommunications systems technologies are becoming important means for supporting the medical education requirements of the managed care environment. This article will describe some of the modalities available and their potential application to CME.
Interactive Video Conferencing
Satellite technology has traditionally offered a mechanism for transmitting educational programming over great distances. The common standard features a one-way audio-video signal sent from a central hub (such as a university) to multiple down linked receiving locations. Question and answer periods are often conducted by speaker phone. This modality can be cost effective when a large number of locations wish to receive the same conference simultaneously. However, the venue is very expensive when just a few sites are involved. New geocentric satellites can now offer two-way video but this format is expensive and is not widely available.
Interactive video conferencing technology (IAVC) provides real time, almost full motion two way audio and video. Analog video signals are digitized, compressed, transmitted through telephone or other telecommunications lines, and reconverted to an analog signal at the remote end. This technology was traditionally limited to large centers or to sites funded by grants due to the high capital and operating costs and the need for sophisticated telecommunications support.
However, advances in data compression and telecommunications infrastructure (such as ISDN) have improved signal quality, decreased equipment costs and offered access, even in many geographically remote sites. The availability of PC-based, desk top units now makes it feasible to implement this technology in the office setting and video conference bridges permit the connection of multiple sites simultaneously.
Initial interest in IAVC applications in health care focused on clinical consultation, particularly involving the provision of specialty services to rural areas with the intent of improving the access to care and decreasing health care costs by keeping patients in community settings.
Although the technology has been useful in offering tertiary services to underserved areas, many telemedicine networks have been poorly utilized, creating interest in developing additional applications. A survey of rural and small town physicians performed by the University of Pittsburgh Medical Center in 1994 demonstrated high levels of interest in utilizing IAVC for CME. These providers work in institutions which are not accredited to provide Category 1 credit and they must take time away from their practices and communities in order to access educational programs.
Through the Commonwealth of Pennsylvania’s HealthNet telemedicine system, the UPMC has broadcast educational programs to seven rural hospitals and clinics. Some of these conferences are ongoing activities such as medical grand rounds. These activities are broadcast through the use of video cameras in the lecture hall, with transmission through coaxial cable to the IAVC unit. Other CME programs are directly broadcast from the telemedicine suite. The remote participants not only have the opportunity to listen to the presentations but they can also interact with the speakers, just as if they were on the university campus, as well as earning Category 1 CME credits. In the last three years, over 1000 practitioners from rural areas have participated in these programs.
The experiences of the voluntary, publicly funded telemedicine networks with IAVC is now being built upon by the emerging integrated delivery networks which are using telecommunications systems to support clinical care, education, and administrative conferencing. The modality has been quite useful in supporting inter-institutional case conferences, quality improvement committee meetings, and clinical pathway development in addition to more traditional forms of CME. The implementation of such telecommunications systems not only promotes time-efficiency but also allows providers who are working in very disparate sites to maintain collegiality, fulfill medical staff responsibilities and pursue academic interests.
The Internet provides opportunities to offer a multitude of resources to a wide audiences at very low cost. Formal CME is being provided as self-study activities. Early programs were largely text-based, reformatting written monographs onto the world wide web, but more recent activities are interactive and utilize multi-media materials. The University of Pittsburgh Department of Pathology’s web site (http://www.path.upmc.edu/) includes Category 1 certified case studies featuring a variety of images as well as audio broadcasts of recent conferences. Some other sites offering CME include Marshall University (http://ruralnet.marsahall.edu) and MedConnect (http://www.medconnect.com/). On-line chat sessions such as those being offered through America Online permit providers to interactively discuss cases. Integrated networks are developing Intranets which contain educational programs specific to local practice issues, practice guidelines and quality improvement initiatives.
Although the Internet offers a very efficient mechanism for providing CME to large audiences and increasing numbers of activities are emerging, this is not as yet a major source of continuing education. For one thing, the plethora of web resources makes it difficult to locate specific items of interest. In order to make CME accessible for busy practitioners, indexing and cataloguing services will be necessary. In addition, the development of interactive multi-media programs can be very labor intensive, and programs will need to be financially supported either through grants, institutional funding or program tuitions.
Video conferencing can be accomplished through the Internet but the capabilities for data compression and transmission capabilities still limit the amount of material which may be conveyed. It is anticipated that this technology will steadily improve, and that the Internet may eventually become the primary modality for video conferencing.
Knowledge bases are also becoming available through the Internet. Literature searching services, such as Medline, have been utilized for a number of year to identify resources in the literature, including journal abstracts. However, providers needing full text materials have had to access them through a library or other traditional resources. Systems such as OVID now permit authorized users to search the literature and to access appropriate full text journal articles directly on their PC. Even more advanced systems in development will permit physicians to query and retrieve a wider variety of resources, including textbooks.
The Integrated Work Station
Telecommunications and information systems are allowing practitioners to communicate through a variety of modalities and to access a wide diversity of resources from home, office and hospital. Technological strides in the last several years have permitted the development of a variety of educational options which enhance efficiency and access.
However, end users are still faced with utilizing different technologies and non-integrated systems. For example, practitioners may need to go to the hospital to attend a teleconference, go to the library to access primary information sources and log out of the clinical information system in order to participate in on-line CME. The Internet offers the opportunity to integrate diverse modalities and data bases into a common interface accessed through a personal computer. Informaticians and continuing educators are working collaboratively to develop work stations which will allow physicians to access library resources and CME activities during the process of care delivery (“just-in-time” education), obtain specialty consultation through the electronic transfer of data and images or through video conferencing, and participate in formal and ongoing life long learning activities.
This approach will foster the integration of education into everyday practice, improving physician efficiency, promoting educational effectiveness and, most importantly, supporting the delivery of high quality patient care.
Barbara Barnes, M.D., is Associate Dean, Center for Continuing Education in the Health Sciences University of Pittsburgh Medical Center