Recently, the Center for Continuing Medical Education began a study on attendance at CME activities that are offered annually.  This study looked initially at five activities that have been offered for at least the last five years.  One activity with just a five year history exhibited the dream attendance growth that course directors envision – steadily increasing attendance numbers each year.

In fact all five activities showed similar attendance growth in the first years.  Surprisingly, the three activities with longer histories, 7 years, 9 years, and 10 years, all showed attendance declines after year six.  The two longest running conferences suggest that their attendance may be plateauing.

While it is too early to draw conclusions and more sampling of other annual activities is needed to postulate causes for these findings, some suppositions can be considered:

  1. The target population to which these activities are promoted has been totally reached and no longer needs yearly education. This might be considered a “turn-over” phase in the attendance evolution of an annual activity, whereby, targeted individuals are no longer looking for annual education.  Instead individuals may participate only every other year, or perhaps every three years.
  2. Marketing and promotional plans have not kept up with how the targeted populations prefer to learn about educational opportunities. In the past, printed and mailed brochures were the mainstay of marketing efforts.  However, mailings eventually were received by an office “gatekeeper” who passed along only those mailers that were known to be of interest to the addressee.  Once emailing became a popular marketing tool, the gatekeeper was temporarily removed, only to be re-established when given responsibility for the addressee’s emails as well as the incoming mail.
  3. Other factors may be affecting attendance, such as content, faculty selection, costs, and activity location. These are all considerations that an individual weighs when deciding to attend an activity.  Changing just one may impact attendance.
  4. Competition cannot be ruled out. There is nothing like success to breed competition.
  5. Two other considerations that may play a role are: Exhaustion, whereby, the target audience has “maxed out” on the activity; or a “natural” limit in attendance has been reached relative to the size of the target audience.

It is anticipated that definitive conclusions may be offered when more annual activities are studied.  More data and an opportunity to discuss marketing methods with course coordinators will also help to focus conclusions.



Several years ago the Center for Continuing Medical Education (CCME) instituted the CME Activity Proposal for Consideration (i.e., Proposal) as a means by which planners could articulate the information vital to an educational activity for physicians allowing it to be certified for Category 1 PRA AMA credit.  While the Proposal is often regarded as a substitute for a CCME staff member participating directly with the planners, it does not replace the guidance that an involved CCME staff person can provide.

The objective of the Proposal is to organize the planning process by responding to an outline of inquiry that results in an orderly development of a CME activity.  All too often planners layout the activity agenda before assessing the educational need, practice gaps, and expected results for the proposed activity.  Or these needs, gaps and results have been recognized but not formalized as part of the planning process.  Among the first steps in planning is to define the intended audience and describe why this audience needs the proposed education – that is, what is their “professional practice gap(s)”.   And by outlining the educational deficits – gaps – of the audience, planners are better able to assess the educational needs and define their expectations – objectives – for the activity.

We recommend following in order the steps listed below to insure a well-planned CME activity:

  1. Recognize a known practice gap or need for educational intervention among a specific group of healthcare practitioners.
  2. Organize a group of planners that can expand and expound on this practice gap.
  3. Insure through the conflict of interest process that all planners can contribute to the planning process without implications of potential bias by setting limits to the contribution of planners with relevant commercial relationships.
  4. Define the audience that is known to have the practice gaps being considered.
  5. List and use respected resources to define the educational needs of the target audience – the personal observations of the planners are not sufficient verification of educational needs.
  6. Determine what the learner should accomplish by participating in the educational activity.
  7. Using these resources and the planned results, begin to outline topics that will help learners to overcome their practice gaps by improving their medical knowledge, describing methods for developing their competence, and/or demonstrating how patient care may be improved.

The ultimate goal of a Category 1 CME activity is to improve patient outcomes and this may happen when a well-planned activity improves physician knowledge, competence, and/or performance.


As an accredited provider The Ohio State University Wexner Medical Center must have mechanisms in place to record and verify participation for six years from the date of the CME activity.  The Center for Continuing Medical Education has the responsibility of determining the process to fulfill this requirement of recording and verifying learner participation.  This responsibility is often delegated to activity coordinators, but the coordinators are limited in the choice of processes that may be used in order to achieve uniformity in attendance documentation.   The processes that CCME uses to fulfill this requirement are sign in sheets, signed attendance forms, posttests, and/or signed evaluation forms.  Occasionally two or more of these options may be used to document attendance.

Sign in sheets should only be used as the sole documentation of attendance when the CME activity is two hours or less.  For longer CME activities sign in sheets should only be used with a second means of documentation – attendance forms or posttests are suggested.   Attendance forms may more accurately support attendance because these require the participant to indicate the sessions that were attended.  Properly designed posttests take the place of sign in sheets or attendance forms since a successful score on the test indicates that objectives for the participant were achieved.  Signed evaluation sheets are less reliable as a documentation of attendance and should not be used alone.

Whichever method of attendance documentation is used, the activity coordinator remains an essential part of the documentation process.  Short of “clocking” participants in and out of the CME activity, coordinators or other staff should purposefully oversee the documentation process.  Setting out unattended sign in sheets is unacceptable.  Screening attendance forms as participants leave the CME activity is a necessary responsibility.  While the Accreditation Council for Continuing Medical Education (ACCME) requires attendance documentation, CCME procedures go beyond attendance documents to include prudent observation as part of that process.

Information should be included in syllabus material or in introductory remarks about attendance documentation and how this documentation relates to awarding CME credits.


In 2009 the Sunshine Act, also known as the National Physician Payment Transparency Program or Open Payments Program, was signed into law as part of the Affordable Care Act (Obamacare).  Its primary purpose is to make more transparent the relationships between physicians (also dentists, podiatrists, optometrists, chiropractors) and pharmaceutical companies and medical device manufacturers by requiring these commercial interests to report payments and other “transfers of value” made to “covered recipients”, i.e., physicians and teaching hospitals, into a federal database operated by the Centers for Medicare and Medicaid Services (CMS).

The Sunshine Act does have consequences for CME providers and their activities since reportable payments, or transfers of value, include travel, honoraria, and meals. – items which are prominent in CME activity budgets.  Since many CME budgets are underwritten by educational grants from commercial interests, these interests may require as a condition of their approval that activity coordinators provide lists of physician participants receiving payments or transfers of value.

CMS recently clarified this reporting requirement to indicate that it only applies to “direct or indirect payments to covered recipients”.  Since CME guidelines prohibit direct payments to physicians by commercial interests, the concern for CME is what constitutes an indirect payment.  CMS states that if a manufacturer “requires, instructs, directs, or otherwise causes” a CME provider to make a payment or payments to a known covered recipient, this would constitute a reportable indirect payment.  However, as long as the covered recipient is unknown to the commercial interest – and this should always be the case for Category 1 certified CME activities – there is no requirement for reporting to the federal database.

Lastly, for some participants at CME activities the Sunshine Act requirement for reporting transfers of value, say for meals, may unfairly distort their relationship with the grantor.  Therefore, before providing any information on physician participants, it is recommended that activity coordinators contact the CME office or their compliance or legal officer for advice.



Last April the Centers for Medicare and Medicaid Services (CMS) issued their final guidelines for implementing the Sunshine Act.  In the initial version of the CMS guidance CME was exempted from the Sunshine Act reporting requirements.  However, in the final guidelines the specific CME exemption was removed, ostensibly subjecting CME activities underwritten by commercial interests to the reporting requirements for direct or indirect payments or transfers of value to physicians for travel, honoraria, or meals, etc.  Critics of the CME exemption argued that CMS appeared to be validating commercial sponsorship of CME activities, and the new guidance perhaps may be seen as eliminating the appearance of endorsing corporate support of CME.

Nevertheless, despite exclusion of specific language exempting commercial support of CME activities in the final guidelines, CME activities still have options that may avoid providing physician lists to corporate sponsors.  Most prominent of these options is CMS’ clarification of indirect payments.  The Accreditation Council for Continuing Medical Education (ACCME) requires that all commercial grants be made to the CME Provider or the CME Provider’s Institution which, under the CMS guidelines, constitutes an indirect payment or subsidy.   However, with CMS’s clarification, commercial grants will not be considered indirect payments as long as the grants meet established criteria, including that CME Providers, not the commercial interests, have control over the content of their CME activities and commercial interests do not “require, instruct, direct, or otherwise cause” the CME Providers to direct the payment to a specific physician(s).


Providing vendor displays at CME activities is an important source of revenue typically used to support these activities.  CME coordinators need to be aware of several provisions concerning displays before soliciting them.  Most important among these – arrangements for commercial exhibits are not permitted to influence planning, interfere with presentations, or be a provision of commercial support (i.e., an educational grant) for the activity.  For live CME activities vendor displays may not set up within the same space or meeting room as the CME activity.  CME coordinators must avoid creating an “obligate” pathway for CME participants when providing vendor display space outside of the meeting room.  That is, participants should not have to pass through a gauntlet of displays to get to the meeting space.

With education being the emphasis of a CME activity, vendors should be encouraged to display educational materials and coordinators should prohibit advertisement materials.  No direct sales may be conducted in the immediate area of the CME meeting or the display area.

When determining appropriate fees for vendor displays, CME coordinators must take into consideration two factors: The actual cost of providing the display (rental of space and furniture, set up costs, electrical access, security, etc.); and the market value for a display.  Market value is determined by evaluating the fees that all vendors for all CME activities have paid to display over a period of time – usually a year – taking into consideration such variables as the site of the CME activity; the profession and size of the CME audience; the relative premium of the display space; and the prestige of The Ohio State University Wexner Medical Center.  Display pricing may not consider counter offers by vendors; discounts for multiple displays; whether the displaying company has also approved an educational grant; or personal relationships between CME planners and vendors.

While many applicants for vendor displays use CCME’s Application for Displaying at a CME Activity, some companies submit their own display agreement.  Many of these have specific clauses requiring market value pricing.  Activity coordinators should be aware that it takes only one such display agreement to affect the display pricing for all vendors.  Because most vendor display agreements require a legal review and execution, a single such agreement obligates activity coordinators to apply justifiable pricing for all display applications.

One other key variable that should be avoided when setting the vendor display fee is the budget for the CME activity.  Setting display fees at prices that best balance the budget, whether well below or above the market value acts to depress the market value and eventually depressing revenue for other CME activities.  CME coordinators should consult with staff at the Center for Continuing Medical Education for the latest market valuations.


Regardless of the subject or the sponsor, coordinators for CME conferences very often follow the same procedures for recruiting participants to their activities. There is the conference brochure with a conference registration form attached.   This brochure is often printed, but digital versions that are emailed to prospects are becoming more and more popular.  Included on the form are instructions for paying the registration fee.  Acceptable forms of payments are checks, money orders, and credit cards.

Did you know that The Ohio State University has a policy that applies to individuals that handle or manage credit card transactions? The University’s Payment Card Compliance Policy ( is intended to protect customer cardholder data and the University from a cardholder breach (think Target, American Express, Home Depot, or Citibank).

Compliance with the Payment Card Policy means more than locking up payment card information. Compliance requires making major changes in the way credit card payments are accepted.  The first step may be redesigning that registration form and limiting the number of individuals who handle that form once it is received.  You never want that registration form to be a self-mailer, especially if it will have payment card information on it.  And you never want that form to be faxed or emailed back to you with payment information.  The simple reason for these restrictions is the potential for too many other individuals to access this information.

The ideal solution is for the cardholder to conduct the entire transaction without needing to reveal account numbers and PINs to an intermediate party. The Center for Continuing Medical Education has such a solution with its online registration and payment website, and all CME conference coordinators are encouraged to use this system.  Still, mailed registration forms remain very common as are registrations received by telephone.  And these both obligate the cardholder to provide payment card account information to that intermediate party – the individual or organization between the cardholder and the processing bank.

The University’s Payment Card Policy has requirements for individuals and organizations that act in this intermediate manner. This policy sets the requirements for the use of payment card terminals, including virtual terminals; requires individuals that conduct payment card transactions to complete the PCI Compliance computer based learning module; and defines how, and by whom, payment card information may be managed.  If you are managing credit card payments, you must complete the PCI CBL and submit to an audit of your procedures for handling and securing credit card information.  In addition, if you will be sending credit card information to the CCME office to conduct the transaction, you will need to submit an attestation document to CCME that confirms you have completed the PCI CBL requirement and have procedures in place to secure card information.  CCME may not agree to conduct your credit card transactions without clear indication of your compliance.

In short, the Payment Card Policy should make CCME’s conference registration system a far more practical means of collecting payments from your registrants.