Sunday, June 26, 2011

National Library of Medicine: An Informatics and Government Agency Exemplar

This week I am off to another meeting I attend every year, which is the National Library of Medicine (NLM) Informatics Training Conference, the annual meeting held for all trainees funded under the NLM Biomedical Informatics Training Grant Program. Also in attendance are program directors and faculty, NLM staff, VA informatics trainees, and a variety of other people. The meeting varies between being held at the NLM and the various sites; OHSU hosted the meeting in 2009.

At a time when Americans increasingly question the function and value of their government and its agencies,  the NLM is a shining testament to the good that the public sector can perform. It is hard to imagine a private entity carrying out the mission of NLM, especially as successfully as it has done so.

The NLM is the world's medical librarian, providing an entry way into the biomedical literature for anyone on the planet who types into a browser. (The Pubmed system provides access to the MEDLINE bibliographic database, which contains the title, abstract, source information, and other metadata about scientific journals articles in biomedicine.) Even though most of the articles referenced in MEDLINE are from commercial publishers and not freely accessible, NLM delivers users to the publishers' electronic doorsteps. The NLM and its talented scientists and developers have pushed the envelope in many other areas as well, from genomics to imaging to public health. The NLM serves not only researchers and clinicians, but also consumers and policy makers.

Another critical role of the NLM is its scientific leadership in the field of biomedical and health informatics. The NLM funds research in informatics as well as the training of future scientists and leaders. While not the only federal agency involved in the use of information technology in health and biomedicine, it is clearly the foundational leader that facilitates the basic research to inform others who apply it.

No small part of the NLM's success is due to its excellent leadership in Donald AB Lindberg, MD, who has guided the Library for over two decades, longer than I and many others have been in the field. Dr. Lindberg has been remarkably prescient over the years. I remember him touting the virtues of the Human Genome Project when I was an NLM informatics trainee in the late 1980s. Subsequently he has been spot on in his seeing the development of new venues for publishing as well as the desire for patients and consumers to access health information online.

The NLM also has longevity. It has an illustrious history, dating back to its inception as the The Library of the Office of the Surgeon General of the Army, led in its early days by John Shaw Billings, MD. This year is the NLM's 175th year anniversary.

I have a great deal of gratitude for the NLM personally. Like many who work in informatics, my career would not be what it is without the help of NLM. I entered the field in a postdoctoral fellowship directly out of my medical training in 1987. The three years of fellowship funded by NLM allowed me to gain knowledge and skills as well as prepare for an academic career in the field. After completing my informatics training, I landed a faculty position at Oregon Health & Science University (OHSU), funded by a grant to OHSU under the Integrated Advanced Information Management Systems (IAIMS) program, an NLM initiative to develop the informatics human and technology infrastructure at academic medical centers. (In the 21st century, these activities are a normal part of doing business at academic medical centers.) The director of the OHSU IAIMS program, who recruited me to that first job, J. Robert Beck, MD, also obtained an NLM informatics training grant at OHSU, of which I now serve as PI and Director.

The NLM has also funded my research over the years, not only providing the resources for my own scientific contributions to the field but also giving me the experience and latitude to develop other aspects of my career. My first grant ever was a First Independent Research Support & Transition (FIRST) Award (also known as an R29). Since then I have had a number of subsequent grants both for research and education of trainees. These projects, from research to teaching, have enabled me to touch the life of countless others who have also achieved success in their careers in the field.

While it is obvious that the US government needs to make some painful decisions about long-term debt control, discretionary expenditures such as those on NLM have been beneficial to many people, not to mention the health of Americans and others around the world. When politicians and policy makers are deliberating, I hope they will consider the value and impact that government agencies like the NLM have made to so many people. I will always be grateful for what the NLM has done for me.

Friday, June 24, 2011

Public Rollout of the ONC Health IT Curriculum

This week was a major milestone for the Office of the National Coordinator for Health IT (ONC) Health IT Curriculum project. The curricular materials that were developed for the 82 community college programs to rapidly expand the health IT workforce were released to all educators and the public at large. In this posting, I will provide the context for this project and describe what it is not before delving into the details of what the curriculum contains.

The ONC Health IT Curriculum is one of four programs in the overall ONC Workforce Development Program. The overall program was specified by Section 3016 of the Health Information Technology for Economic and Clinical Health (HITECH) Act, the portion of the American Recovery and Reinvestment Act (ARRA), also known as the federal stimulus bill. ONC operationalized the program by designating 12 workforce roles, with six to be educated in the six-month community college programs and six to be educated in 1-2 year programs in universities. The primary audience for the curricular materials are the community college programs.

Five universities were funded under the $10 million project as Curriculum Development Centers: Oregon Health & Science University (OHSU), Columbia University, Duke University, Johns Hopkins University, and University of Alabama-Birmingham. Each center prepared four components each. One university, OHSU, was additionally funded to serve as the National Training & Dissemination Center (NTDC), given the additional tasks of developing the dissemination Web site, training community college faculty in use of the materials, capturing feedback, and providing technical support. The curricular materials are now available for download by the public on the NTDC Web site, although the feedback and support functions are limited to the 82 community colleges.

The curricular materials are not a certificate or degree program out of the box. Rather, the content should be thought of more like a library (or, to use the words of ONC Chief Science Officer Charles Friedman, PhD, a "buffet") from which educators can pick and choose content for their courses. The materials alone will not substitute for formal education, as good education still requires teachers, mentors, and fellow learners with whom to interact (whether in-person or on-line). However, the matierlals will be a valuable resource for a wide variety of educational activities in health IT. As the director of a graduate program in biomedical informatics, I know that OHSU will adopt some of these materials in its own graduate-level educational program (just as some of the curricular content came from our existing program).

The curricular materials consist of 20 components, each of which is comparable in depth to a college course. The components are subdivided into 8-12 units, each of which contain a variety of activities appropriate to the topic, including voice-over-Powerpoint narrated lectures, references, suggested readings, exercises, and more. The topic areas of the components are: 
  1. Introduction to Health Care and Public Health in the U.S.
  2. The Culture of Health Care
  3. Terminology in Health Care and Public Health Settings
  4. Introduction to Information and Computer Science
  5. History of Health Information Technology in the U.S.
  6. Health Management Information Systems
  7. Working with Health IT Systems
  8. Installation and Maintenance of Health IT Systems
  9. Networking and Health Information Exchange
  10. Fundamentals of Health Workflow Process Analysis & Redesign
  11. Configuring EHRs
  12. Quality Improvement
  13. Public Health IT
  14. Special Topics Course on Vendor-Specific Systems
  15. Usability and Human Factors
  16. Professionalism/Customer Service in the Health Environment
  17. Working in Teams
  18. Planning, Management and Leadership for Health IT
  19. Introduction to Project Management
  20. Training and Instructional Design
ONC and the Curriculum Development Centers also developed a “set table” consisting of a matrix of curriculum components and workforce roles to guide community college programs in using components to train for particular workforce roles. The matrix specified the core set of components for each workforce role for two types of student backgrounds, healthcare and information technology.

Each component also contains a blueprint document that provides an overview of the learning objectives and content for each unit. All of the components also have an instructor's manual that provides more detailed information, including listing of authorship and teaching information. The full set of blueprints have been rolled into a single PDF portfolio and are available on the ONC Web site.

Three of the components are "lab" components that make use of an educational version of the Veteran's Administration (VA) VistA EHR. A version of VistA that runs under various versions of Microsoft Windows is provided on the Web site, courtesy of the VA. However, this version will not be usable by everyone, as it requires a license for the Intersystems Cache environment, which is freely available to academic institutions but not others. Nonetheless, the materials will still be valuable to others who can adapt the exercises for other EHR systems.

All told, the curricular materials are a comprehensive resource. The entire collection of material is 7.5 gigabytes in size (6.75 gigabytes compressed) in 12,339 files. The 20 components contain 213 units, 460 lectures (some units have more than one lecture), 8913 slides, and 125.9 hours of lecture audio. In the collection are 460 Powerpoint files, 460 MP3 files, 465 PDF files, and 1346 Microsoft Word files.

We call this publicly available version of the curricular materials Version 2. It has been available to the ONC Community College Consortium for two months, and supersedes the original Version 1 provided to consortium members last year. The materials are distributed under a Creative Commons Attribution-NonCommercial-ShareAlike 3.0 Unported License. This means that all users of the curriculum can use, share, and adapt the materials but must attribute the originator of work, use the materials only for non-commercial purposes, and share any changes made under same license. Per the ONC, universities own the intellectual property for their components.

The support for the public rollout of the curricular materials will be minimal. This is in part because the funding does not have the resources to provide that support but also because these materials are aimed at educators who will adapt them into their own courses and other educational activities.

Another program in the ONC Workforce Development Program related to the project is the Competency Examination, a project led by Northern Virginia Community College. There are six exams, with one for each of the six community college-trained workforce roles. Each exam consists of 125 multiple-choice questions, to be taken in three hours and graded on a pass-fail basis. At least 80% of exam questions come from the curriculum components. Beta versions of the six exams became available on May 20, 2011, with the final versions to be ready in September. The exam is free to consortia member college graduates through their schools.

The final program in the is the University-Based Training (UBT) program, which funds training in the other six workforce roles deemed to require longer training at the university level. Nine universities or consortia thereof, including OHSU, were funded under this program. As noted elsewhere, OHSU recently had its first graduates from its UBT program, with many more in the pipeline.

The Curriculum Development Centers and ONC do not plan to rest on our laurels. We know there are many areas where Version 2 can be improved, and fortunately the two-year project includes additional funding to provide for a Version 3 that will be delivered in 2012. A planning process is underway to improve the content and technical aspects of Version 2, along with reducing its gap and overlaps.

It has been gratifying to be part of this project, which has consumed a great deal of my life since the project began in April, 2010. I have enjoyed all of the roles I have played, as Director of the NTDC, Director of the OHSU Curriculum Development Center, and author of several units. I will look forward to feedback about Version 2 and suggestions for enhancements in Version 3. How to sustain the curriculum once the ONC funding ends is also a key concern.

Tuesday, June 21, 2011

Informatics Destination: Buenos Aires

I spent part of last week with my friends and colleagues at Hospital Italiano de Buenos Aires (HIBA) in Argentina. The HIBA Department of Health Informatics is truly an international leader in the field, with an internally developed electronic health record (EHR) that serves the needs of the hospital's clinicians, patients, and researchers. HIBA is a large academic medical center in the heart of Buenos Aires and also has a large health maintenance organization (HMO), Plan de Salud, that serves nearly half a million people. It also has a young but growing university.

The HIBA EHR has been in development for over a decade. At a time when the "conventional wisdom" of informatics is to acquire and implement commercial systems, HIBA has built a system tailored to its organization and workflow. Their success is a testament to the vision and leadership of the program's founder, Fernan Gonzalez Bernaldo de Quiros, MD. Dr. Quiros started HIBA's Department of Medical Informatics a decade ago to provide leadership in developing and implement the system, called ITALICA. He has now assumed the role of Vice President for Strategic Planning of HIBA, while Daniel Luna, MD has stepped in to head the department. Now called the Department of Health Informatics, they oversee all aspects of IT at HIBA, including non-clinical applications. An excellent overview of all their work is provided in a Yearbook of Medical Informatics 2009 article: Quiros, F., Luna, D., et al. (2009). Experience in the Development of an In-house Health Information System and the Training Needs of the Human Resources at the Hospital Italiano de Buenos Aires, 147-152, in Geissbuhler, A. and Kulikowski, C., eds. IMIA Yearbook of Medical Informatics 2009. Stuttgart, Germany. Schattauer.

HIBA has also become an international leader in informatics education and training. When the department was established, they also launched a medical informatics residency program. This program has trained the human resources necessary for the success of ITALICA. An emerging leader in the educational program has been Paula Otero, MD.

I first met Dr. Otero in 2004. A year later, she enrolled in the very first offering of the OHSU-AMIA 10x10 course. After the course ended, she proposed to translate the course into Spanish to make it available to a Latin America audience. She and her team successfully translated the course and began offering it across Latin America. While the first version was mostly a direct translation, the course has since diverged from the US-based course to be more specific to health care in Latin America. (For example, very little HIPAA!) For more information, see: Otero, P., Hersh, W., et al. (2010). A medical informatics distance-learning course for Latin America - translation, implementation and evaluation. Methods of Information in Medicine, 49: 310-315.

This initial collaboration set the stage for other collaborative activities. Dr. Otero, Dr. Quiros, and I were involved in the Rockefeller Foundation workshop devoted to building human capacity in health informatics in the developing world in Bellagio, Italy in 2008. We subsequently worked together on the AMIA Global Partnership Program. Dr. Otero has become my Co-Chair in leading the International Medical Informatics Association (IMIA) Working Group on Education.

The crowning achievement of our collaboration was the awarding of a grant from Fogarty International Center of the US National Institutes of Health (NIH). In 2009, we were awarded one of eight grants in Fogarty's Informatics Training for Global Health (ITGH) Program. The stated goal of our project under this funding was to extend our collaboration that had mostly been in clinical informatics into clinical research informatics. HIBA has a strong Institute of Basic Sciences and Experimental Medicine, which includes 31 basic research teams. Many are funded by grants, including some from the NIH.

We proposed in the grant, and have operationalized in the first two-plus years of the project, a plan for short-term, intermediate-term, and long-term training. The short-term training has been focused on clinical researchers, extending the Spanish 10x10 course with modules that teach them how informatics can augment clinical research.

The intermediate training has been more focused on informatics trainees, with a course in clinical research informatics developed by OHSU informatics faculty Judith Logan, MD, MS. This course was taught on-line in OHSU's spring academic quarter to both OHSU and HIBA informatics trainees. Dr. Logan also came on this trip to have an in-person meeting with the HIBA students.

The long-term training has focused on providing postdoctoral fellowship training to HIBA informaticians. At OHSU, we have treated these trainees as if they were fellows on our National Library of Medicine (NLM) training grant. The first two fellows - Damian Borbolla, MD and Vanina Taliercio, MD - have been at OHSU for over a year. A third fellow, Sonia Benitez, MD, will join them later this year. The goal for these trainees is for them to return to Argentina after their training to assume leadership roles in informatics and clinical research.

Dr. Logan and I also had the opportunity to give talks at HIBA (with more details and even an Elluminate recording of the slides and audio). Not only were there about 80 people present in person, another 25 or so listened in via Webcast. Some of the Webcast listeners even asked questions of the speakers. In my talk I provided an overview of the HITECH program for EHR adoption in the US. Dr. Otero translated my slides to Spanish and both the English and Spanish versions, with references, are available on my Web site. An interesting piece of trivia I learned on this trip is that the phrase meaningful use has no direct translation in Spanish. The closest translation is uso significativo. (Which is somewhat ironic, since HIBA is much closer to meaningful use of EHRs than most US hospitals!)

Although we have made substantial progress in our collaboration, the best is yet to come. We will look forward not to our trainees applying their new knowledge and skills to advancing healthcare and clinical research in Argentina, but also to new undertakings, such as a possible jointly developed master's degree.

Monday, June 6, 2011

Commencement Address Representing OHSU School of Medicine Graduate Studies Program

The Commencement & Hooding Ceremony of the OHSU School of Medicine, also known as Graduation, is always an enjoyable time for me. It is gratifying to see another year's class of graduates from our Biomedical Informatics Graduate Program receive their hoods and diplomas. This year we had largest graduating class ever, with six PhDs, 12 students in our two master's programs, and 20 Graduate Certificates. This brings our total number of degrees and certificates awarded up to 336 since the inception of the program in 1996. This commencement we more than doubled our number of PhD graduates (from five to 11), and also saw the first group of graduates from our ONC University-Based Training (UBT) Program.

This year I also was invited to give the Graduate Studies Program faculty address. I was honored to represent the faculty of all of the OHSU School of Medicine graduate programs and share my informatics-tinged wisdom and vision with the larger School of Medicine audience.

Below is the text of my remarks delivered on Monday, June 6, 2011:

After all these years of sitting down in the faculty section of this ceremony, I am honored to be asked to give this address representing the faculty in the graduate programs of the School of Medicine. As some of you know, I direct the graduate program in biomedical informatics, which is the field devoted to the use of data and information, usually but not always aided by computers, to improve personal health, clinical practice, biomedical research, and public health. Like all disciplines, biomedical informatics has a science and methodology that is carried out by its researchers and practitioners, and a new group of graduates are entering the field by completing their studies today.

As the faculty in my program know, Commencement is a very important event for me. With the exception of last year due to an unavoidable conflict, I have attended every Commencement since our biomedical informatics graduate program had its first graduates in 1998. We began with a handful of Master's degrees, but now as of this graduation have over 300 alumni who have attained not only Master's degrees, but also PhDs and Graduate Certificates. Despite 13 years of graduating students, my thrill of seeing graduates of our program has not worn off. I am sure that my fellow graduate program directors feel the same way.

So what advice can I give to those who are graduating with PhDs, Master's degrees, and Certificates in the School of Medicine? I will skip the usual advice, important as it is, to devote your life's work to your profession, to keep a healthy balance of activities outside of work with family and friends, and to act professionally in a world of instant gratification and 24/7 information flow. Instead, I will try to provide some perspective and wisdom from my discipline of biomedical informatics.

I probably do not need to tell graduates, faculty, or even members of the audience that the 21st century is a golden era at the intersection of health sciences with information and computer sciences. It is truly changing what we do as clinicians, researchers, and other professionals who deal with health.

One of the best statements of this vision comes the Institute of Medicine and is the notion of the learning health system. We now truly have the ability to track and measure what we do in health care practice and public health, and drive research questions and answers from it. Our substantial federal investment in electronic health records, along with the growing ability to sequence genes, measure their expression, and analyze the products they produce, is ushering in an unprecedented era to compare and then learn the best approaches not only to treating disease but also keeping us healthy.

It is also critical to remember that no matter from what discipline you are graduating, success in this new era will require skills to use and manage information in ways that did not exist even a decade ago. You must understand the meaning and the limitations that exist with the increasing types and volume of data you collect. You must adhere to data standards so others can build on your work. Those of you working with human data also cannot forget the importance of protecting the privacy of individuals who have graciously permitted you to borrow their data for your work. In addition to skills in managing data, you must also be an expert in searching and accessing the literature and other scientific resources of your field. As if that is not enough, critical thinking and analysis are essential to all of this voluminous amount of data and information.

Another critical challenge to emerge in the 21st century is the need to collaborate across disciplines. The truly vexing problems of health care and public health require an interdisciplinary approach. Basic scientists, clinicians, informaticians, and others must come together to translate basic science into clinical care, to bring the best clinical care to the entire population, and insure that care is delivered with the highest quality and safety. We also need to reform our health care system to provide incentive for coordination and efficiency, not only because it will cost less but also because it will result in better patient outcomes. This will in turn require critical investments in information systems to bring the right information to the right people at the right time.

In closing, no matter what graduate degree or certificate you are receiving today, there are unprecedented opportunities. There may be uncertainties about health care reform, federal research funding, and the economy in general. But there is now unprecedented opportunity to impact health. I wish all graduates here today the best as they embark on their new careers.

(Postscript: The text of this talk also appears on the OHSU School of Medicine Commencement 2011 site.)

Sunday, June 5, 2011

An Informatics Silver Lining to a Terrible Tragedy

Although the tornado in Joplin, Missouri was a terrible and unfortunate tragedy, there is an interesting little side story related to biomedical informatics. I don't want to make light of the tragedy, particularly the town having its hospital destroyed. However, an article on the St. Louis Today web site tells an interesting sidebar.

Apparently the destroyed hospital made its conversion to electronic health records (EHRs) just three weeks before the tornado. The EHR system did not miss a beat, and remained running during and after the storm. As such, people needing their records accessed were able to have that done when they obtained medical care elsewhere.

This situation brings memories of Hurricane Katrina, where just about all of the hospitals in New Orleans had their medical records rooms, typically in the basements of their facilities, destroyed by the ensuing flooding. The one exception was the New Orleans VA Medical Center, which was able to keep its records intact through the well-known VA EHR system.

Joplin also did have a health information security breach from the tornado. Although unlike most breaches we read about lately, this breach was purely due to non-electronic records, in particular paper records and x-ray films being blown up to 75 miles away.

This story does not alleviate the terrible tragedy of the tornado, nor does it rebut any of the serious challenges to implementing EHRs. It does, however, show one example of the value of electronic data systems in healthcare.