The Genesis of the 10x10 Course

The 10x10 ("ten by ten") program was launched in 2005 by the American Medical Informatics Association (AMIA) and Oregon Health & Science University (OHSU). The genesis for the program came when then-President of AMIA, Dr. Charles Safran, called for at least one physician and one nurse in each of the 6000 hospitals in the US to have some training in medical informatics. At the same time, AMIA was looking to develop e-learning materials for training in medical informatics, but found that vendors were proposing unaffordable fees.

At that time, the biomedical informatics distance learning program at OHSU was mature and included an introductory course that I had been teaching on-line for nearly a decade. I proposed to AMIA that we re-package this course into a standalone course that included an in-person session at the end (not present in the OHSU course) that brought participants together for interaction and additional learning. Based on Dr. Safran's numbers and my knowledge of the scalable capacity of the distance learning course, I proposed that we name the program 10x10, embodying the aim of training 10,000 individuals in medical informatics by the year 2010.

The training would of course not be limited to physicians and nurses, nor would it be limited to US citizens. AMIA and OHSU negotiated a mutual non-exclusivity agreement, in which AMIA could accredit other educational institutions to offer 10x10 courses and OHSU would continue to own its intellectual property and use it for other initiatives besides 10x10.

The first cohort of 44 students completed the course in 2005. In addition to the "standard" offering of the course being offered to coincide with the in-person session at the end coinciding with an AMIA spring or fall meeting, a number of special offerings have been developed, tailored to specific audiences. These include:

• California Health Care Foundation (2006) - California physicians
• American College of Physicians (2007) - internal medicine physicians
• Scottsdale Institute (2007) - an organization of innovative health care systems
• Mayo Clinic (2007 and 2008) - senior nursing executives, embedded in a larger program centered around health care quality
• Society for Technology in Anesthesiology (2008) - anesthesiologists
• American College of Emergency Physicians (2008) - emergency medicine physicians

In addition, AMIA received a grant from the Centers for Disease Control and Prevention (CDC) in 2008 to organize education for public health professionals in public health informatics in 2008. Part of the grant went to providing the tuition for some of those professionals to enroll in several 10x10 offerings, including OHSU's.

By the end of 2008, a total of 582 people had completed the OHSU offering of the AMIA 10x10 course. While far short of the goal of 10,000, the capacity of course could handle many more people.

Students in 10x10 have come not only from the US, but also from many other countries, including Canada, Argentina, Hong Kong, Kuwait, Pakistan, Israel, and Thailand. One of the original students from Argentina, Dr. Paula Otero, translated the course into Spanish and has delivered it to 380 individuals across Latin America.

The course has also inspired federal legislation in the US, leading to the "10,000 Trained by 2010 Act," introduced by Rep. David Wu (D-OR). The bill was passed by the US House in the 110th Congress (2007-2008) but did not have a Senate sponsor. It has been introduced in the 111th Congress, and elements of it have been incorporated into the American Recovery and Reinvestment Act of 2009, aka, the economic stimulus package.

A demo version of the introductory graduate course from which 10x10 is derived can be accessed at the URL:
http://sakai.ohsu.edu/xsl-portal/site/b6042e92-ea91-442a-af63-d3f882d2e88c
From this page, log in with the following:
Username: bmi_demo
Password: format

More information about 10x10 can be found on the AMIA web site at:
http://www.amia.org/10x10/
Information about the most current OHSU offering is at:
http://www.amia.org/10x10/partners/ohsu/

A number of papers have been written about the 10x10 program:
Hersh, W. and Williamson, J. (2007). Educating 10,000 informaticians by 2010: the AMIA 10×10 program. International Journal of Medical Informatics, 76: 377-382.
Feldman, S. and Hersh, W. (2008). Evaluating the AMIA-OHSU 10x10 program to train healthcare professionals in medical informatics. AMIA Annual Symposium Proceedings, Washington, DC. American Medical Informatics Association. 182-186.
Otero, P., Hersh, W., et al. (2007). Translation, implementation and evaluation of a medical informatics distance learning course for Latin America. MEDINFO 2007 - Proceedings of the Twelfth World Congress on Health (Medical) Informatics, Brisbane, Australia. IOS Press. CD-ROM P421.
Hersh, W. (2007). The full spectrum of biomedical informatics education at Oregon Health & Science University. Methods of Information in Medicine, 46: 80-83.

Certification in Informatics

The current issue of Journal of the American Medical Informatics Association (JAMIA, March-April, 2009) contains several papers related to a process the American Medical Informatics Association (AMIA) is spearheading to establish a medical board sub-certification in clinical informatics (Detmer et al., 2009). I myself was involved in the training requirements paper that will be submitted (Gardner et al., 2009), along with the core curriculum (Safran et al., 2009), to the American Board of Medical Specialties. I note that the core curriculum looks a great deal like the OHSU medical informatics track curriculum of our biomedical informatics graduate program.

As AMIA is not a physician-only organization, another process is underway to establish certification for non-physician doctoral-level certification in clinical informatics. This will include doctoral-level health care professionals (e.g., those with PharmD, DNP, DPT, etc. degrees) as well as those with PhD degrees. At the same time, the Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM), which certifies health information management professionals, has announced plans to establish a master's-level credential in health informatics.

What does all of this mean? First, it is important to understand the terminology. Certification applies to individuals, who obtain a credential that certifies their knowledge and skills to perform certain professional tasks, e.g., board certification of physicians, nurses, and other health care professionals as well as in other fields, such as a certified professional accountant (CPA). This is different from accreditation, which applies to educational programs and declares them capable of providing the training of individuals to attain certification. Sometimes programs are accredited without a corresponding formal certification, such as academic programs in public health and computer science.

Certification is usually applied to people in professional positions. It is not usually applied to those who are in academic or research settings. So while a Department of Medicine in a medical school may have its clinical faculty certified to practice medicine, it does not have corresponding certification for its research faculty (or for the non-practicing portion of the jobs of clinical faculty). Certification usually indicates that one has a competency to carry out a professional task, such as practicing medicine. In the case of informatics would most likely apply to those who work in operational settings, such as hospitals, clinics, health centers, and the like.

Certification would add some order to a field now where anyone can call themselves an informatician or offer an academic program. Indeed, there are a growing number of four-year colleges and even community colleges that are beginning to offer baccalaureate and associate degrees in the field. Of course, without a formal certification in informatics, there is no reason why they cannot. However, my own view is that informatics is the synergistic and unique intersection of health sciences, computer sciences, and management sciences, and as such, is difficult to impart with just a baccalaureate or associate degree. This does not mean that those individuals cannot work in health care settings, but rather that to truly do informatics professionally requires a level of training that combines expertise in multiple disciplines, and it is difficult to see how it can be imparted without some amount of graduate study.

Another challenge with certification will depend on how the training requirements are implemented. As many reading this know, I direct one of the largest academic informatics programs in the country, and its distance learning option has been extremely popular and successful. While I do believe that informatics expertise requires real-world experience, we have been able to provide that for those who have sought it in their education. Whatever on-site training requirements emerge, I do hope the educational and/or fellowship experience will allow sufficient flexibility for didactic coursework to be on-line and for hands-on training experience to be available in diverse settings and not necessarily just the sites of academic programs.

The implementation of certification and accreditation will bring a new level of maturity to our field. It will allow informatics professionals to gain the recognition of the important role they play in health and health care organizations. But hopefully it will be implemented in a way that maintains the intellectual, geographical, and other forms of diversity that exist in our field.

References

Detmer, D., Lumpkin, J., et al. (2009). Defining the medical subspecialty of clinical informatics. Journal of the American Medical Informatics Association, 16: 167-168.
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.

Health IT provisions of American Recovery and Reinvestment Act of 2009

There is a great deal of excitement in the biomedical informatics field due to the health IT provisions of American Recovery and Reinvestment Act of 2009, also known as the economic stimulus package. There are two main health IT provisions in the economic stimulus package: incentives for “meaningful use” of electronic health records (EHRs) by physicians and hospitals ($17B) and direct grants administered by federal agencies ($2B). No grant programs have been announced yet, but an encouraging sign is the recent appointment of a new National Coordinator for HIT, Dr. David Blumenthal. The are also provisions in other areas of legislation that pertinent to health IT in other areas of the stimulus package, including comparative effectiveness research, NIH and other science funding, and broadband and other infrastructure funding.

The incentives for “meaningful use” of EHRs will be implemented through increased Medicare or Medicaid reimbursement starting in 2011. Non-hospital-based physicians will receive incentives based on Medicare or Medicaid charges, up to $64K. Hospitals will have an incentive base amount of $2M, which is adjusted by the hospital’s number of discharges, Medicare/Medicaid patient mix, up to $9M, and phased down over four years. After 2016, physicians and hospitals begin to have reimbursement penalties for not using EHRs.“Meaningful use” is likely to include CCHIT certification, e-prescribing capability, interoperability standards, and other features.

There are opportunities in this space for software vendors, consultants, health care organizations with existing EHR systems. There are also opportunities for educational programs to train users, implementers, and others.

The stimulus package contains a variety of other funding initiatives that will be led by the Office of National Coordinator for Health IT (ONC) now under the leadership of Dr. Blumenthal. A total of $2B will be distributed to a variety of programs. The legislation does not allocate specific dollar amounts of the specific programs. The ones most pertinent to our program include:

• Sec. 13201 – Establishment of multidisciplinary Centers for Health Care Information Enterprise Integration, led by NIST, but involving other federal agencies, and funding research projects
• Sec. 3012 – Health Information Technology Implementation Assistance, providing matching funds for Regional Health IT Extension Centers
• Sec. 3013 – State Grants to Promote Health Information Technology, providing funding to states to facilitate and expand health information exchange
• Sec. 3015 – Demonstration Program to Integrate IT into Clinical Education, providing grants to develop academic curricula integrating EHRs into clinical education of health professionals
• Sec. 3016 – Information Technology Professionals on Health Care, providing funding for short-term (re-)training in informatics for IT and health care professionals in established educational programs

(A disclaimer about 3016: I wrote some of the words in it, and can honestly claim to have inserted the word "informatics" into the stimulus bill. Thanks to the staffs of Rep. David Wu and Sen. Ron Wyden for allowing me to help them draft the text. Naturally, OHSU's educational program is "shovel-ready" to train and re-train people for the jobs in health IT!)

The legislation provides other monies for health IT, some of which will fund biomedical research. There is $8.4 billion for National Institutes of Health for biomedical research. Some of this money is already being allocated, such as the newly announced NIH Challenge Grants program. Most of the money will be funneled to the 30 or so Institutes of the NIH, including the National Library of Medicine (NLM), which funds research and education in biomedical informatics. OHSU is already seeing some of this money in the expansion of our biomedical informatics training grant that will also provide funding for summer internships for both college students and non-research college faculty (e.g., community college and high school teachers).

The legislation also allocates $1.1B for comparative effectiveness research, which it defines as “research studies that compare one or more diagnostic or treatment options to evaluate effectiveness, safety or outcomes.” This money will be distributed by a variety of agencies, not only NIH but also the Agency for Healthcare Research & Quality and the Department of Health & Human Services. This is another area of key strength for OHSU.

These are exciting times for Biomedical Informatics!

These are exciting times for the field of biomedical informatics. On the clinical side, the health care field is taking seriously the impact that information technology can have on health care quality, safety, and cost. Patients are increasingly empowered by increased access to information to maintain and improve their health. On the biomedical research side, advances in genomics and proteomics are revolutionizing approaches to health and disease. The world of biomedical research has fundamentally changed. Biological experiments now generate mass amounts of data, and researchers are required to interact with databases and other information resources. Biomedical informatics plays a key role in clinical and research areas. There is a great need both for informatics researchers to conceptualize and develop new applications and for informatics professionals to implement and disseminate them.

Biomedical informatics is the field devoted to improving human health, health care, and biomedical research through optimal use of information, usually with the aid of information technology (IT). As government, health care, and biomedical research leaders recognize its value, there are growing opportunities for careers in a diverse array of jobs, some of which are highly technical and others that focus on people and organizational issues insuring its most effective use.

President Barack Obama has made the use acceleration of health IT a key part of his “Reinvestment and Recovery Act of 2009,” stating, “To improve the quality of our health care while lowering its cost, we will make the immediate investments necessary to ensure that within five years, all of America’s medical records are computerized … It just won’t save billions of dollars and thousands of jobs – it will save lives by reducing the deadly but preventable medical errors that pervade our health care system.” (http://www.whitehouse.gov/agenda/economy/)

In biomedical research, the role in informatics in the discovery of new tests and treatments to improve health is equally acclaimed. The Web site of the National Institutes of Health, the US government agency that funds biomedical research, notes, “Modern biomedical scientists use computers and robots to separate molecules in solution, read genetic information, reveal the three-dimensional shapes of natural molecules like proteins, and take pictures of the brain in action. All of these techniques generate large amounts of data, and biology is changing fast into a science of information management. There is no way to manage these data by hand. What researchers need are computer programs and other tools to evaluate, combine, and visualize these data.” (http://nihroadmap.nih.gov/bioinformatics/)

These statements, and the growing commitment by the government, health care institutions, and research funding agencies, show that the future is bright for the high-skill, high-paying jobs available in biomedical informatics. There is an extreme diversity of jobs available, such as:

• Using electronic health records and other sources of data to measure and improve the quality of health care and to facilitate the conduct of biomedical research
• Serving as the bridge between the IT and clinical professionals in health care settings to insure IT systems are easy to use and provide the most useful data to clinicians, administrators, and researchers
• Analysis of genomic and clinical data to determine the role of genes in human health, to ascertain the risk of developing disease, and to predict the response to different treatments
• Deploying telemedicine and telehealth systems to bring medical expertise to the point of need
• Coordinating the information systems and data within them for state and local public health agencies

Oregon is a leader in health IT. Not only do many its major health systems have advanced health IT and biomedical informatics infrastructures, but it is also a leader in the education and training of biomedical informatics professionals. The Biomedical Informatics Education Program at Oregon Health & Science University (OHSU) is one of the largest in the country. Its graduate programs feature master’s and PhD degrees with the opportunity to focus on bioinformatics (informatics in bioscience and genomics) or medical informatics (informatics in health care). Its 200+ alumni have obtained jobs in a wide variety of industry, academic, and health care settings. The program’s faculty are leading researchers and thought leaders in the field.

Although students in the OHSU biomedical informatics program most commonly have backgrounds in computational/mathematical or life/health sciences, there are opportunities for virtually all types of students who are motivated to learn and contribute to working in and advancing the field. Students can pursue a tailored course of study commensurate with their interests and background while having access to cutting-edge research and/or experiences in local industry, health care settings, or biomedical research labs.

For more information, visit our Web site at:
http://www.ohsu.edu/dmice/

Or contact me:
William Hersh, MD
Professor and Chair
Department of Medical Informatics & Clinical Epidemiology
Oregon Health & Science University
hersh@ohsu.edu
www.billhersh.info

I look forward to your thought and comments on my postings!

Bill

Welcome to the Informatics Professor Blog

I am Professor and Chair of the Department of Medical Informatics & Clinical Epidemiology (DMICE) at Oregon Health & Science University (OHSU). These are exciting times for our field, with the increased attention to electronic health records by the new Obama administration. Of course, there are exciting things in other areas of the field as well, such as bioinformatics, clinical research informatics, and public health informatics. I hope to use this blog to raise attention to various issues in the field and look forward to your feedback.

William Hersh, MD
www.billhersh.info