Curbside Consult with Dr. Jayne 2/17/20

It was a wild and crazy weekend, as I got to experience what it was like to get rained on with 100,000 of my closest NASCAR friends. The race was postponed, so I get to do it again Monday, minus the presidential visit and military flyover since I doubt they’re going to send Air Force One and the Thunderbirds again.

I’ll be spending a lot of time in airports trying to get home due to the changes. When I fly, I usually try to catch up on continuing education or read something for my book club, because it doesn’t matter as much if I get distracted versus trying to do actual work. Most of my continuing ed journals are in the realm of emergency medicine or primary care, so I was happy to run across an interesting read in the healthcare IT arena.

A couple of days ago, a “published ahead of print” manuscript authored by some prominent clinical informaticists made some waves. Appearing in the online version of the journal Academic Medicine, it addresses the idea of commercial interests in continuing medical education, and how electronic health record vendors play a role.

Looking back 20 years, there was a great deal of continuing education that was sponsored either directly or indirectly by pharmaceutical companies. During medical school, pharmaceutical representatives would bring breakfast to a session with the not-so-subtle title of “Drugs and Donuts.” They would talk about their products and when they should be used, and I don’t doubt this led to heavy prescribing of the products.

A few years later, this evolved to a more subtle sponsorship of our Grand Rounds lunchtime lectures, where it was obvious who was paying for the steaming pans of sweet and sour chicken and what drug they sold. The reps no longer addressed the crowd, but were available to detail folks afterwards and hand out promotional items. At my school, some of these sessions were accredited for formal continuing education credits and the objectivity of the program was addressed, but others were much looser.

As the authors note, the Accreditation Council for Continuing Medical Education (ACCME) won’t give accreditation to commercial entities that produce, market, resell, or distribute health care goods or services used by or on patients. However, they will accredit academic institutions and other bodies who want to provide credit for courses they sponsor, and those institutions can accept pharmaceutical funding.

For now, ACCME doesn’t categorize EHR vendors as commercial interests and thus provides them accreditation to deliver continuing medical education. The authors note, “Like pharmaceutical company-sponsored CME events, EHR vendor activities, which inherently only focus on use of the sponsoring vendor’s EHR system despite its potential intrinsic limitations, can lead to physician reciprocity. Such events also may inappropriately influence EHR system purchases, upgrades, and implementation decisions. These actions can negatively influence patient safety and care.” They continue to “call on the ACCME to recognize EHR vendors as commercial interests and remove them from the list of accredited CME providers.”

I’ve had the opportunity to attend CME sessions put on by multiple vendors. They vary greatly in their content and how much general education is given versus how much it is really just a veiled training session. Some of the best sessions I’ve been to revolve around newer models of care delivery such as Patient-Centered Medical Home, Chronic Care Management, or Transitional Care Management. A good session will include an in-depth discussion of how the programs benefit patients, what they entail, how to bill for them, and what outcomes you might be able to glean from using them. Only a small percentage of the session is actually learning how to document the program in a given EHR. Bad sessions are little more than click-by-click directions for how to use the EHR, with CME provided to entice providers to attend when they otherwise didn’t participate in training.

I fully agree that being able to execute a workflow well in the EHR is beneficial to patients, as their data is more likely to be documented accurately and comprehensively. That doesn’t necessarily make a class worthy of continuing education credits, but I’ve seen it done.

The authors go on to explain why EHR vendors should be considered commercial entities. They note, “Even though the 21st Century Cures Act excluded EHR systems from the Food and Drug Administration’s (FDA’s) oversight they should be considered medical devices similar to pacemakers, insulin pumps, and CT scanners, which are all under the purview of the FDA. No other commercial device or technology is used more often by physicians and other health care professionals than EHRs.”

One of their major points is that when EHR vendors sponsor CME sessions, they focus only on the vendor’s system and its benefits without mentioning competitor options. “Because every EHR system has intrinsic limitations, attendees are not adequately trained on alternate ways to solve problems… Instead of learning best clinical informatics practices and challenging the vendor to improve its product, attendees are presented with only the vendor’s worldview, which may result in their suboptimal or inappropriate use of EHR products or services on patients.”

One of their comments particularly resonated with me: “EHR vendors focus physicians’ attention on future enhancements to their systems so physicians may miss opportunities to implement available solutions that are more congruent with the needs of their patients, organizations, and the community.” I’m still waiting for an enhancement I requested back in 2006, despite the fact that other vendors include the request in their core functionality. Because the vendor kept promising it, there was no way my employer was going to fund an alternative solution.

The authors made some outstanding points, which was to be expected since several of them are leaders in the American Medical Informatics Association. This fact prompted a statement from AMIA noting that the article wasn’t reviewed or endorsed by the AMIA board of directors. Regardless, the AMIA statement calls on the ACCME to “recognize and consider the potential for bias when HIT vendors offer education to health care professionals” and goes further to urge ACCME to define EHR vendors as “commercial interests” in the same way that pharmaceutical or device manufacturers fit the definition.

AMIA states that although education on the use of EHR products is appropriate and relevant, it may not be appropriate for continuing education credit. The AMIA board asks CME organizations to “establish rules and processes by which they may support certified CME in a manner that is independent and unbiased,” just like drug and device companies must.

Knowing what I know about the ACCME, it will likely be some time before they respond to these calls to action. I’ll be curious whether they make a decision or whether they take it under advisement for further review. For many physicians who stay current in their specialties, it’s not hard to accrue all your required CME hours without relying on vendor-sponsored hours. Many of my colleagues have two to three times the number of mandatory hours simply but doing what they’re already doing to further their knowledge for patient care. I’ve got a couple of friends on vendor CME committees, and I’ll reach out and report back on what they have to say.

What do you think about EHR vendor-sponsored continuing medical education credits? Leave a comment or email me.

Email Dr. Jayne.