Medical providers' and Internet-based education.

Abstract

The purpose of this study was to investigate the attitudes of health care providers towards Internet-based education as a method to meet continuing medical education (CME) requirements. A questionnaire was administered to 111 providers at a large outpatient clinic/inpatient hospital in the southeastern United States; interviews were also conducted. Providers were aware Internet-based CME exists; only 50% reported that useful modules were available. Younger providers were more aware of Internet-based CME than older providers. Provider age and the number of years practicing medicine had no effect on providers' attitudes towards computers, the Internet, and Internet-based CME. Overall, providers had a positive attitude towards Internet-based CME and consider it a viable alternative; however, almost all providers surveyed prefer traditional CME methods such as meetings and seminars. Provider attitudes towards computers and the Internet do not predict attitudes towards Internet-based CME in this population.

Introduction

Continuing medical education (CME) allows providers to maintain credentialing, proficiency, and currency in their field and provides them an opportunity to acquaint themselves with the newest technologies, drug regimens, standards of practice, and methods. In addition, it bridges the gap between research and clinical practice (Peterson, Galvin, Dayton, & D' Alessandro, 1999). Providers must complete 150 units of CME every 3 years to maintain licensure and competency requirements (Marquand, 1998). Traditional seminars and meetings remain the method of choice for providers to obtain required CME (Smith, 1998). However, traditional CME is expensive and in these days of managed health care and cost cutting, it is often the first item cut from the hospital or provider's office budget. Web-based CME is considerably less costly than traditional meetings and seminars (Belfiglio, 1999).

Internet-based Education and Cost Savings

In the mid 1990's, Internet-based education became available for health care providers. The Internet opened up a wide variety of national and international medical educational resources to the provider populace. In health care, investment in instructional technologies, such as Web-based education, is expected to improve communication and accessibility to information, increase efficiencies and reduce costs. When evaluating CME effectiveness, quality patient care and good patient outcomes should be the primary drivers of decisions rather than cost or efficiency. According to the Web-based Training Information Center, 78% of employers consider computer-based training to be extremely cost efficient (Wiesner, 1998). Lee (1999) reports that when companies have a rational mindset and want to save money, the company chooses the first solution that meets the minimum requirements. If a technology is implemented and the providers will not use it, do not know how to use it, or do not learn effectively with a Web-based method, the patients will ultimately suffer. Educating providers with technology that does not enhance the learning processes can result in poor patient outcomes and lead to patient morbidity and even death.

Before health care institutions even consider implementing global policies which affect the way they fund CME for their providers, they must consider all of the implications. This consideration includes assessing the differences between traditional medical education and Internet-based education to see what types of information can be effectively translated into Interact-based self-study modules. In addition, the attitudes of providers toward Internet-based education must also be investigated. This would ensure providers perceive it as a viable alternative that will meet their educational needs since attitudes and perceptions toward educational methods and instruction impact learning (Speier, Morris & Briggs, 2001). Tucker-Ladd (2000) notes that an attitude has three components: (a) cognitive or knowledge, (b) feeling or evaluative, and (c) behavioral where knowledge and feeling are put into action. These three components influence learning a new skill. In 1975, Fishbein and Azjen proposed the theory of reasoned action which suggests that attitudes exhibit a significant relationship with performance.

Impacts of Traditional and Internet-based CME

CME is the recognized standard to obtain educational information after medical school. If medical providers are not current in their field, this can lead to malpractice suits against the providers as well as the medical facility. When providers go to a traditional CME offering, such as a meeting or a seminar, they are unable to care for patients. Most traditional CME must be completed at the offering organization's schedule. In addition to time and response constraints, it is also typically linear learning where the individual needs of learners are not considered (Baum, 1999). In a physician-owned practice, attending traditional CME can result in a direct loss of income (Baum, 1999). If the provider works for a managed care organization, the organization wants the provider to see as many patients as possible (Marquand, 1998). Interact-based CME provides a flexible alternative for providers and the organizations because it can be done at the provider's convenience with minimal impact on patient care (Belfiglio, 1999).

Bell, Fonarow, Hays, and Magione (2000) studied the learning efficacy of 162 family practice and internal medicine residents at four universities utilizing an Internet-based tutorial system. A control group received the material via traditional printed materials, and the experimental group utilized the Internet-based tutorial. Post test scores for both groups were similar, but the experimental group spent less time studying and had greater learning efficacy and satisfaction. Peterson et al. (1999) measured the frequency of use and satisfaction of providers who utilized the University of Iowa's online CME program over an 18-month period. Only 5% of the participants had ever used Internet-based education; 88% said they would use it again. Mamary and Charles (2000) surveyed 1,120 providers in Nevada to assess their preferences for CME delivery methods. They concluded that a lack of computer skills discouraged the use of computer-based CME methods since many respondents reported that they did not know how to use Internet-based training.

Purpose of the Study

The purpose of this study was to investigate the attitudes of health care providers towards Internet-based education as a method for CME. This study had five objectives. The first was to assess if medical providers were aware that Interact-based CME was available. The second objective was to determine if providers felt Internet-based CME was a viable alternative that would meet their educational needs. Three additional objectives were to assess providers' attitudes towards computers, the Internet, and Internet-based education to see if they were affected by their age or the providers' number of years practicing medicine. The last objective was to determine if providers' attitudes towards computers and the Internet influenced their attitudes towards Internet-based CME.

Theoretical Framework

The theoretical framework was based upon two major hypotheses formulated from a current literature review. First, in order for Internet-based CME to be a successful educational method for health care providers, they must have a positive perception or attitude toward this method. If providers do not like this method, they will not use it. If they are forced to use it, they will not learn effectively. In order for providers to develop a positive or negative attitude towards Internet-based CME, it must first be ascertained if they even are aware of it. In some populations, age plays a role in perceptions/attitudes toward computer technology (Liaw, Ugoni & Cairns, 2000). Since Internet-based education is a method that utilizes computer technology, younger providers may have a more positive attitude toward Internet-based continuing education modules than older providers. This hypothesis was based on the premise that younger physicians have been exposed to computers during their medical education, while older physicians have not. Since some people enter medical school after they have worked several years in another profession, the number of years practicing medicine was also considered since older providers who have only been practicing medicine a short time may have been exposed to computers in medical school.

Methods

A population of 111 credentialed medical providers at a large outpatient clinic/inpatient hospital was examined. The facility serves a population of approximately 50,000 beneficiaries. The medical facility employed approximately 1,000 staff and averages 1,005 outpatient visits per day. The facility has a $100,000,000 annual budget, and fills 2,300 prescriptions and performs 3,500 laboratory procedures per day. This facility has a centralized computerized health care network which was utilized by all providers to order and review laboratory and other types of diagnostic testing, order prescriptions, and order patient consults. Providers also had e-mail capability through the computerized health care network and through Microsoft Outlook. All providers also had Internet access (Facility Resource, 2000). A five-part, 70-item questionnaire was administered to the entire provider population; no sampling techniques were employed. Five members of the population were then randomly selected through simple random sampling to participate in a semi-structured interview.

The closed-end questionnaire focused on assessing the attitudes of providers towards computers, the Internet, and Internet-based education. Nineteen items were extracted from the General Attitudes Towards Computers (GATCS-C) and the Personal Technostress Inventory (PTSI), two research instruments that were validated by Rosen and Well (2000). The remainder of the questions were formulated and analyzed for validity and reliability (Cronbach alpha 0.83). Except for demographic information, all questions were 5-part Likert-type scale items which were designed to measure positive and negative attitudes and perceptions.

The second instrument used in this research was a 5-item, standardized, open-ended interview. Information about fifteen demographic variables was also collected. Five participants were selected using simple random sampling from the population to participate in the telephone interviews.

Results

In this study population, 54.3% of the providers had been practicing for 5 years or less; 28.6% had been practicing medicine 11 or more years. Providers were somewhat aware that Internet-based CME is available. In general, younger providers were more aware of the availability of this type of CME than older providers. Providers in different age categories answered the questions concerning their awareness of the availability of Internet-based CME differently. This difference was statistically significant, Chi square (1, N = 35) = 24.08, p = .02. Only 28.6% of the respondents had previously taken an Internet-based CME course. This supports Jack Kues statement that few providers are applying for online CME credit as reported by Belfiglio (1999).

Only 31.4% of all respondents reported that Internet-based education is available "when and where I need it." This also validates Smith's (1998) assertion that many providers are not aware of the types of CME that exist. In this group, only 48.6% of all respondents surveyed agreed or strongly agreed that Internet-based education met their needs; this supports Zimitat's (2001) theory that many Internet-based CME courses were not built using sound educational principles.

In this study, 71.4% of the providers agreed/strongly agreed that Internet-based CME is a viable alternative to meet some of their CME requirements. However, only 2.9% of respondents believed it to be as effective as traditional methods such as meetings and seminars; only 8.6% reported that they believe Internet-based CME meets their educational needs. There were no statistically significant differences in perception of viability by age Chi square (1, N = 35) = 15.15, p = .23, or years of practice Chi square (1, N = 35) = 14.20, p = .29. This result supports Mehta, Sinha, Kanwar, Inman, Albanese, and Fahl's (1998) findings where providers reported that although Web-based education was valuable, it could not replace traditional educational methods. Respondents indicated that they learn better with face-to-face interaction (85.7%); only 14.5% reported they learned better with self-study methods such as Internet-based CME. Only 42.0% of respondents agreed that Internet-based CME was effective. Almost one-half (42.8%) of the respondents preferred not to use Internet-based CME. These findings validate Mamary and Charles' (2000) and Reddy, Harris, Galle, and Seaquist (2001) conclusions that providers prefer traditional CME programs.

This research also explored the attitudes of providers towards computers to see if these attitudes impacted providers' attitudes towards Internet-based CME. The attitudes towards computers of both younger and older providers were compared; age was not found to affect providers' attitudes. There was no statistically significant differences in attitudes towards computers and technology in the analysis by age (F =.08, p > .05), or by years of practice (F =.96, p >.05). There was a statistically significant difference in provider attitudes towards the Internet by age (F=.03, p<.05), but not by years of practice (F-.92, p>.05) in the univariate analysis. The multivariate analysis showed no statistically significant differences (F=.20, p>.05).

Attitudes of providers towards the Internet were also explored to determine if these attitudes may impact provider's attitudes towards Internet-based CME. Overall, providers of all ages and experience groups had a somewhat positive attitude toward the Internet (M = 3.50). The attitudes towards the Internet of both younger and older providers were compared; age was not found to affect providers' attitudes towards the Internet. The attitudes and perceptions of these providers towards Internet-based CME was also explored. There were no statistically significant differences in attitudes of providers towards Internet-based CME by age (F =. 17, p > .05), or by years of practice (F = .39, p> .05). Only 37.2% of the survey respondents agreed when asked the question, "I know how to access Internet-based CME." All providers, regardless of age and experience, had a somewhat positive attitude (M - 3.20) toward Internet-based CME. They did not perceive it as difficult to use. Overwhelmingly, although providers noted the merit of Internet-based education, they reported a definitive preference for face-to-face interaction.

Attitudes towards computers in this provider group do not predict attitudes towards Internet-based CME (r = -0.01, p > .05). Attitudes towards the Internet also do not predict attitudes towards Internet-based CME (r = 0.25, p > .05). This again leads to the conclusion that other factors besides technological skills affect provider preferences and attitudes in this group because most of the providers surveyed agreed that they had sufficient knowledge and skills to access Interact-based CME. These other factors include a definite preference for traditional CME delivery methods.

Conclusions

Most providers were aware that Internet-based CME is available. Younger providers were more likely to know about the availability of Internet-based CME than older providers. Provider age and the number of years practicing medicine had no effect on providers' attitudes towards computers, the Internet, or Internet-based CME. Overall, providers had a positive attitude towards Internet-based CME and considered it a viable alternative; however, almost all providers surveyed prefer traditional CME methods such as meetings and seminars. Providers felt that Internet-based CME modules were not as effective as traditional CME instruction. Provider attitudes towards computers and the Internet did not predict attitudes towards Internet-based CME in this population.

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Halupa, M.Sc Ph.D. is the Educational Program Director of the United States Air Force Medical Laboratory Programs and adjunct faculty at St Joseph's College of Maine.