Commercial Interests in Continuing Medical Education: Where Do Electronic Health Record Vendors Fit?

The Accreditation Council for Continuing Medical Education (ACCME) will not accredit an organization that it defines as a commercial interest, that is an entity that produces, markets, resells, or distributes health care goods or services consumed by, or used on, patients. Thus, commercial interests are not eligible to be accredited organizations offering continuing medical education (CME) credit to physicians. This decision is based on the concern that commercial interests may use CME events to market their products or services to physicians, who then might inappropriately prescribe or administer those products or services to patients. Studies have shown that CME events supported by pharmaceutical companies, for example, have influenced physicians' prescribing behaviors.Currently, however, the ACCME does not recognize electronic health record (EHR) vendors, which are part of a multi-billion-dollar business, as commercial interests, and it accredits them to provide or directly influence CME events. 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. Thus, the authors of this Perspective call on the ACCME to recognize EHR vendors as commercial interests and remove them from the list of accredited CME providers.

Consultation's sleight of hand seeks to sugar unpalatable bursaries pill

The Department of Health's consultation on student bursaries has begun and people are being encouraged to take part in it. However, this consultation is not a consultation - it is predictable spin where sleight of hand seeks to sugar an unpalatable pill.

The two (institutional) cultures: a consideration of structural barriers to interdisciplinarity

C. P. Snow's famous Two Cultures essay has become a foil for decades of discussions over the relation between science and the humanities. The problem of the "two cultures" is often framed in terms of how the particular epistemological claims or general intellectual orientations of particular individuals on either side of this purported divide obstruct interdisciplinary dialogue or cooperation. This formulation, however, fails to consider the institutional frameworks within which such debates occur. This article examines the broader structural constraints that provide incentives, erect barriers, or otherwise shape the potential for interdisciplinary research and practice, with particular attention to work involving the life sciences. It argues that in order to understand the nature and scope of the problems facing interdisciplinary work, we must focus on the institutional constraints that shape how individuals frame questions, pursue investigations, develop careers, and collaborate.

Pharmaceutical industry financial support for medical education: benefit, or undue influence?

Presently, the pharmaceutical industry funds about half of the costs of continuing medical education (CME) programs in the U.S. This contributes to the ethical problems that pervade the relationship between medicine and the pharmaceutical industry: trustworthiness and conflicts of interest. The problems are exacerbated by rationalizations prevalent on both sides that deny the ethical concerns. Commercialism and commercial bias are highly visible at large CME gatherings, and available data, while scanty, back up the view that physician attendees' subsequent prescribing practices are influenced by the commercial message. The industry believes that it will recoup $3.56 in increased sales for every dollar that it invests in CME. New guidelines instituted by the Accreditation Council for Continuing Medical Education (ACCME) in 2004 may succeed in reducing excessive commercial influence, especially since the Department of Health and Human Services has also warned the industry of possible anti-kickback violations if firewalls are not erected between CME funding and marketing of drugs. Critics counter that early indicators of improvement are lacking.

Managing conflict of interest in clinical practice

Conflict of interest, even the appearance of potential conflict, has long been a concern for physicians and scientists. Conflict of interest arises when an activity is accompanied by a divergence between personal or institutional benefit when compared to the responsibilities to patients and to society; it arises in the context of research, purchasing, leadership, and investments. Conflict of interest is of concern because it compromises the trust of the patient and of society in the individual physician or the medical center.

A risk stratification tool to assess commercial influences on continuing medical education

INTRODUCTION

Heightened concerns about industry influence on continuing medical education (CME) have prompted tighter controls on the management of commercial funding and conflict of interest. As a result, CME providers must closely monitor their activities and intervene if bias or noncompliance with accreditation standards is likely. Potential for industry influence can be difficult to assess at a stage in the planning process when mitigation strategies can assure balance and content validity. Few tools exist to aid providers in this regard.

METHODS

A 12-item instrument was designed to assess risk for commercial influence on CME. To determine reliability and validity, a cohort of experienced CME professionals applied the tool to standardized "cases" representing CME activities in the early stages of planning. Results were compared with the experts' assignment of the same cases to one of four risk categories. A survey of study participants was conducted to ascertain usefulness and potential applications of the tool.

RESULTS

Analysis demonstrated strong intraclass correlation across cases (0.90), interrater reliability (94%), and correlation between assessment of risk with and without the tool (Spearman coefficient, 0.93, p < 0.01; weighted kappa, 0.59). Participants found the tool easy to use and of potential benefit to their CME office.

DISCUSSION

The Consortium for Academic Continuing Medical Education (CACME) risk stratification tool can help CME providers identify activities that must be closely monitored for potential industry influence, remain aware of factors that place programming at risk for noncompliance with accreditation standards, and substantiate the allocation of resources by the CME office.

The relationship between paediatricians and commerce

The interaction between doctors and commerce, particularly the pharmaceutical industry, has recently been subject to increasing scrutiny. Doctors are now exposed to mounting influence from industry as it spends large amounts of money on marketing, is heavily involved with continuing medical education and sponsors a major proportion of research. Conflicts of interest may exist on both sides of the relationship: doctors can be manipulated and companies need to be profitable. Paediatricians are just as open to this influence as are other members of the medical profession. There is evidence that clinical practice is altered by interaction with industry, although doctors appear to deny the likelihood of being influenced. There are significant concerns over the increasing involvement of the pharmaceutical industry with research, although the regulation of the industry continues to be strengthened and the process of research is becoming more transparent. Disclosure of conflicts of interest involving authorship is now common practice and should extend to all facets of the relationship. However, collaboration continues to be necessary in order to develop new therapies, maximise research and particularly in paediatrics, to test medications in children. Paediatricians need to be aware of the sources of influence and understand current guidelines so that interactions with industry continue to be appropriate.

Commercialization of dental education: have we gone too far?

Early U.S. dental training involved a closer relationship between commercialism and education, which was strongly counteracted by university affiliations at the beginning of the twentieth century. With recent decreases in public support for higher education, schools have become increasingly dependent on private revenue sources, including corporate support. There are ethical risks as well as benefits from dental schools establishing business partnerships with corporations. In 2002, a private, for-profit company was responsible for the inception and direct funding of an orthodontic postgraduate program at a private U.S. university. In the last four years, this company has begun funding two additional orthodontic programs, both associated with U.S. public dental schools. Such partnerships with academic institutions represent unique corporate relationships with dental education that are fraught with ethical risks. The dental profession needs to preserve the appropriate autonomy of dental education from commercial influences in order to prevent erosion of academic and ethical standards that are critical to professional integrity and public trust.

Educational governance for the regulation of industry sponsored continuing medical education in interventional and device based therapies

The relationship between industry and clinicians in educational programmes needs to be regulated. Industry may be best placed to deliver educational programmes in "craft" related specialties and particularly in areas where device implantation/technology based therapy has a major clinical role. The authors supervise industry sponsored clinical teaching at a purpose built independent teaching facility, and have developed the concept of educational governance to regulate their relationship with their industry sponsor and that concept is presented.

G.A.T.S. and universities: implications for research

The likely impact of applying the General Agreement on Trade in Services (GATS) to higher education are examined. GATS aims to "open up" services to competition: no preference can be shown to national or government providers. The consequences for teaching are likely to be that private companies, with degree-awarding powers, would be eligible for the same subsidies as public providers. Appealing to the inadequate recently introduced "benchmark" statements as proof of quality, they would provide a "bare bones" service at lower cost. Public subsidies would go: education being reduced to that minimum which could be packaged in terms of verifiable "learning outcomes". The loss of "higher" aspirations, such education of critically-minded citizens of a democratic and civilized society would impoverish the university's research culture which demands honesty and openness to public scrutiny. Most university research is substantially supported by public subsidy. Under GATS discipline, commercial providers of research services could be entitled to similar public subsidies. Publicly funded fundamental research would fade, leaving university research totally dependent for funds upon the good will of industry and commerce. Present problems, such as the suppression of unwelcome results and the use of questionable results to manipulate public opinion, would considerably increase. The public would lose a prime source of trustworthy knowledge, needed in political discourse, legal disputation, consumer protection and in many other contexts.