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Tuesday, October 23, 2012

Challenges for building capacity of the clinical informatics subspecialty

The new clinical informatics subspecialty promises to provide professional recognition to the increasing number of physicians who work in the specialty of combining information with their medical expertise to improve quality and safety while lowering the cost of health care. The American Board of Preventive Medicine (ABPM), the administrative home for the subspecialty, is currently defining the criteria for those who will be eligible to take the certification exam without formal training (i.e., "grandfathering" by virtue of previous work in the field, whether by the "practice pathway" or prior training, which will be allowed for the first five years of the subspecialty's existence), developing the first board certification exam, and defining criteria for future fellowship training.

The new subspecialty will provide a great opportunity for professional recognition of physicians who work in clinical informatics. One concern, however, is how our field will build capacity to train the critical mass of those who wish to become trained and certified in the subspecialty. There are a number of unique aspects of this discipline that will make this task challenging. In this posting, I will speak to these from my position as a program director of one of the largest clinical informatics educational programs in the United States.

There will be challenges both during the grandfathering era as well as when formal fellowship training is required. For the former, there will likely be exclusion of some who have the knowledge or the experience, but not both, to be deemed clinical informatics subspecialists. For the latter, if this field follows a "traditional" path of requiring all entrants to the field to obtain training only in 1-2 year, on-site fellowships, then we may be unlikely to match the need for these specialists or the aspirations of those who often enter the field in middle of their careers.

Data and Perspectives

Our informatics educational program at Oregon Health & Science University (OHSU) has been an extremely popular approach for all, including physicians, to receive training in clinical informatics. The program is available both on-campus and via distance learning, with the asynchronous nature of courses in the on-line program allowing students to train without having to move or leave their current jobs. A total of 1,359 individuals have enrolled in the OHSU informatics program since its inception in 1996. During that time, 441 people have received a total of 12 PhD degrees, 184 master's degrees, and 278 graduate certificates. (The graduate certificate is a subset of the master's degree program covering the core content of the field. While it has been in existence for over a decade, its numbers increased significantly from funding by the Office of the National Coordinator for Health IT [ONC] University-Based Training [UBT] Program for "short-term training," especially in the workforce role of "clinician leader.")

There are currently 291 students actively enrolled in the OHSU informatics program, 95 (32%) of whom are physicians. A similar proportion of our graduates are physicians, many of whom have gone on to leadership roles in clinical informatics, such as that of Chief Medical Informatics Officer (CMIO). A not-insignificant number of them were already CMIOs or other leaders upon entering the program, and some of those negotiated enrollment in the program or at least some courses within it as a condition of employment. Our data and experience clearly show that informatics via distance learning is a credible pathway for physicians and others to become clinical informatics professionals.

Our experience has also shown that essentially all types of informatics experiential learning can take place in a distance learning program. One concern we have always had in our program is the ability to gain experience through a practicum or internship. We have been able to institute such programs that allow students to carry out a mentored experience in "real-world" settings of health care organizations, companies, government agencies, and others. Our process tracks deliverables of the documentation of experiences and includes faculty monitoring of progress. It has even sometimes led to employment in those settings.

Some additional data from our program is relevant to the following discussion of challenges for building clinical informatics capacity of physicians. One is the median age of our students, which is about 41.5 years at matriculation into the program. The following chart shows the average age of physicians currently enrolled in the program. These data clearly show that most physicians in our program pursue informatics training and positions in the middle of their careers, i.e., do not follow the traditional contiguous progression from medical school to residency to subspecialty training and employment.


Another data point concerns the mapping of our curriculum to the core content of the new subspecialty, as laid out by Garnder et al. (2009) and included in the proposal for the subspecialty approved by the American Board of Medical Specialties (ABMS). We recently mapped the core content to our existing curriculum and found the material spread over 23 academic-quarter courses. Clearly the core content of clinical informatics will need to be consolidated into many fewer courses, but it is unlikely that any course of study will require the equivalent of a master's degree or at least a graduate certificate.

But clear unlike most other medical subspecialties, the knowledge base of clinical informatics is not a refinement of what the physician learned in medical school and built upon in residency. Consider, for example, a trainee in the area of critical care medicine. A future intensivist physician will have learned the basics of the diseases, treatments, tests, etc. starting in medical school. In medical school, the student will have started in basic science courses with the fundamentals of the cardiovascular system, the pulmonary system, and other applicable biomedical areas. As a clinical student, he or she will see their first cases of conditions such as sepsis, heart failure, and severe pulmonary disease in critical care units and other areas of the hospital. If interested in a career in critical care medicine, that medical student may then pursue a residency in internal medicine, surgery, anesthesiology, or other areas, but will continue to build upon the foundation of diseases and treatments learned in medical school. He or she will complete their training in a clinical fellowship, where more detailed knowledge emanating from the basics started in medical school will be mastered. Those who aspire to train in clinical informatics, however, will enter a new world of knowledge. While clinical expertise certainly will provide a partial foundation to the knowledge he or she must master, entire new areas of study will be brought into the equation. These include topics such as clinical decision support, organizational behavior and management, health information exchange, and standards and interoperability.

Challenges in the Grandfathering Era

The ABPM will soon be announcing what will qualify as "already working in the field," which will determine who will be eligible to sit for the certification exam in the first five years of the subspecialty. The proposal submitted to the American Board of Medical Specialties (ABMS) suggested that working in the field be defined as either having worked in the field at 25% or more effort for at least three years or by having completed a "non-accredited fellowship" of at least 24 months duration. What exactly is meant by the latter is unclear, especially since many who have entered the field have done so through graduate-level educational programs, such as the OHSU program described above, that meet or exceed the depth of a fellowship program, even if they are not pursued in a full-time manner.

I have concerns that there will be disappointment with the criteria, both from those who are not eligible and could likely pass the exam as well as those who will be eligible but find the knowledge content of the exam overwhelming despite their substantial experience working in the field. I know this is true of all new medical specialties that become formalized, and that it takes some time for a field to synchronize its training and its practice knowledge base. But as noted above, clinical informatics has some unique differences, especially with regards to a knowledge base that is not just a refinement of what is learned starting in medical school.

There will likely be many in the category of physicians who are deemed not to meet the grandfathering requirements for experience yet could likely pass the test. This may include those who have completed educational programs such as a master's degree or graduate certificate, either in informatics or a related discipline. Depending on how many of these programs qualify as a "non-accredited fellowship," there could be many physicians who pursued formal training in the field only to not be eligible under the initial certification process.

By the same token, there will also likely be many physicians who have been working in CMIO or other clinical informatics positions, thus meeting the practice requirements, but whom have little or no formal training in the field and lack mastery of the knowledge base to be able to pass the certification exam. Clearly there must be some bar set for knowledge in the field, but many experienced clinical informaticians will require substantial education to achieve the level of knowledge required to pass the exam. Some challenges will include where to set the bar and how to help those who fall below it achieve the knowledge to move above it.

Challenges in the Clinical Fellowship Era

There will be additional challenges for building capacity after the grandfathering era has ended and formal fellowship training is required. These challenges will likely be more daunting, especially if we want to broadly expand the capacity of the field to meet perceived needs for individuals trained and certificated in clinical informatics. Depending on how stringent the requirements are for full-time, in-residence fellowship training, it could be quite difficult to build the needed capacity.

The first challenge for clinical informatics training will be how new trainees learn the core content. Clearly a subspecialty fellowship in clinical informatics will require a more formal educational program than the usual half-day per week of lectures by local subject experts in a typical clinical fellowship. This point is driven home by an analysis of the core content mapped to courses in the OHSU biomedical informatics graduate program described above, where we found the material to be mapped over 23 academic-quarter courses. Certainly a course of study will need to be consolidated into many fewer courses, but the mastery of this knowledge will not be provided the usual half-day per week of lectures provided in a conventional clinical fellowship. Organizations that offer clinical informatics fellowships will need to provide this educational activity, or at least partner with others who can do so.

A second challenge for building the capacity is that many physicians (and others) enter the field of informatics in the middle of their careers. This is not a negative for the field, as many clinicians come to realization that some of the biggest challenges in health care involve managing and making best use of data and information. As such, they decide to pursue careers in informatics that will allow them to do that. This pursuit of informatics in mid-career is one of the major reasons for the popularity of distance learning programs. We have found that despite the large numbers of students in our program, one of our biggest challenges is filling classrooms on our campus. Even "local" students in the Portland area want to take "distance" classes due to convenience and/or daytime working constraints.

A third challenge for developing capacity concerns the ability of organizations to stand up on-site training programs to handle building overall capacity. In order to maintain a clinical informatics fellowship program, according to the training requirements laid out by Safran et al. (2009), organizations will need to provide not only practical, hands-on training under supervised certified clinical informatics subspecialists, but also a robust educational experience. A scan of existing informatics training programs shows that some have strong hands-on components and others have well-developed educational programs but few have both. While the quantity of clinical informatics subspecialists needed is not precisely known, it is clear that only a small number of programs would be able to stand up programs that could meet the requirements spelled out by Safran et al. in contrast to the potentially hundreds if not thousands of hospitals and other clinical settings that could benefit from these specialists. This necessitates a more efficient approach to training, a contribution of which distance learning approaches could provide.

A fourth challenge is who will bear the cost of fellowship training. While most educational programs are funded by tuition, clinical fellowships are usually paid positions where the cost is covered by a combination of graduate medical education subsidy through Medicare as well as patient care services provided by the trainee. While both of these traditional sources of fellowship funding might work in some settings, it is not clear in this era of reduced federal funding for medical training and squeezed hospital budgets that paid fellowships will be viable in many places.

A final challenge could be the accreditation of fellowship sites by the Accreditation Council for Graduate Medical Education (ACGME). This challenge is not limited to the clinical informatics subspecialty. While the ACGME has accredited some programs that allow elements of remote learning, e.g., (Emmett and Green-McKenzie, 2001), its view, like most of medicine, is that subspecialty training is mostly an activity that takes place in a full-time fellowship at one or more physical sites.

Road Ahead

The need for clinical informatics subspecialists is clear, and the aggregate capacity to train adequate numbers is probably available. However, the traditional fellowship where experiential and didactic learning takes place in a single organization is likely impractical, certainly for the numbers that most estimate are needed for the subspecialty. Based on our experience in training physicians and others for careers in informatics, we believe the approach that is most effective and scalable will be to combine the online curricular delivery with practical experience on the ground augmented with additional interactions among trainees, including in-person or virtual approaches.

There are likely creative ways to build the capacity of clinical informatics training programs. One would be to allow institutions that could offer up robust experiential training to partner with those can provide the education, with the latter in a remote manner. Our program is already in discussion with two organizations that are considering melding our educational programs with their on-site training. Not only will we provide "out-sourcing" of coursework to these institutions, but we will also engage with their faculty in faculty development. We also plan to make use of telecommunications modalities to allow interaction among their trainees, our faculty, and even our local trainees.

There are other reasons why clinical informatics fellowship training should be more distributed. The world of clinical informatics is very different in high-resource academic centers compared to community hospitals and other clinical settings. The latter types of organizations are less likely to achieve "meaningful use" of information technology (Desroches, Worzala et al., 2012). A robust training experience should include these types of settings as well. Distributed training experiences will also allow for more interaction among trainees. As a single health care organization is likely to only be able to accommodate a few trainees, an integrated multisite program will allow more trainees to interact and share knowledge and experiences.

Clinical subspecialty training has historically been provided at one or a small number of sites, with educational activities also provided at those locations. However, with the growing proliferation of specializations that physicians can undertake today (Cassel and Reuben, 2011), many of which did not exist during their initial training, clinical informatics will not only benefit from novel approaches but could also provide an opportunity for medicine to reconsider how physicians train in many other specialties. Regulatory bodies will need to recognize these problems and authorize training programs that achieve their educational goals, even if in non-traditional ways. Just as the rest of education has adapted to and embraced the use of technology, medicine must do likewise.

References

Cassel, C. and Reuben, D. (2011). Specialization, subspecialization, and subsubspecialization in internal medicine. New England Journal of Medicine, 364: 1169-1173.
Desroches, C., Worzala, C., et al. (2012). Small, nonteaching, and rural hospitals continue to be slow in adopting electronic health record systems. Health Affairs, 31: 1092-1099.
Emmett, E. and Green-McKenzie, J. (2001). External practicum-year residency training in occupational and environmental medicine: the University of Pennsylvania Medical Center Program. Journal of Occupational and Environmental Medicine, 43: 501-511.
Gardner, R., Overhage, J., et al. (2009). Core content for the subspecialty of clinical informatics. Journal of the American Medical Informatics Association, 16: 153-157.
Safran, C., Shabot, M., et al. (2009). ACGME program requirements for fellowship education in the subspecialty of clinical informatics. Journal of the American Medical Informatics Association, 16: 158-166.

This post by William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, appeared on his blog Informatics Professor, where he posts his thoughts on various topics related to biomedical and health informatics.

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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

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Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

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Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

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Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

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Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

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Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

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Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

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Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

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Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

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Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

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Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

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Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

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American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
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PLoS Blog
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White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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