More on the Clinical Informatics Subspecialty: News Report and Some (But Not All) Questions Answered

The newly approved medical subspecialty of clinical informatics is sure getting a lot of press! It was certainly one of the hot topics at the recent AMIA Annual Symposium 2011. And now the iHealthBeat news site has an audio report featuring three leaders, including myself.

At the AMIA meeting, AMIA President and CEO Ted Shortliffe commented that it seemed as if 90% of his email lately consisted of questions about the subspecialty. While the percentage of my email on the topic has not been quite that high, I do get plenty of questions, especially from current, former, and prospective students of the Oregon Health & Science University (OHSU) biomedical informatics educational program.

To answer questions about the subspecialty, AMIA has developed a Web page, which it plans to build out over time, that answers specific questions. Shortliffe addressed some of the questions in his President’s Column in the November/December, 2011 issue of JAMIA [1].

This much we know for sure about the subspecialty that has been approved by the American Board of Medical Specialties (ABMS): In a first for American medicine, the subspecialty will be available to all physicians who have a primary board certification, whether internal medicine, surgery, radiology, etc..  Although the subspecialty board will be administrated by the American Board of Preventive Medicine (ABPM), any physician with primary board certification will be eligible for this subspecialty.

The initial certification of subspecialists will proceed as it has for all new subspecialties, with those having prior practice experience in the field being able to “grandfather” in on the training requirements in a “practice track” and be board-eligible, i.e., able to sit for the certification exam. Although ABPM will have the final say on what the practice-track requirements will be, the proposal to ABMS stated this track would be available to those practicing in the field a minimum of 25% time over three years or who have completed a non-accredited training program. The latter could be a National Library of Medicine (NLM) Informatics Fellowship or an educational program of a certain level, such as the OHSU Graduate Certificate or one of its master’s degree programs. But the final determination will be at the discretion of the ABPM. In the past, new subspecialties have tended to be more inclusive than exclusive with regards to practice-track requirements, but in this case, the ultimate decision-maker will be the ABPM. After five years, the practice track will no longer be available and formal training will be required in a fellowship program accredited by the Accreditation Council for Graduate Medical Education (ACGME).

A related question is when those who are board-eligible will be able to take the exam. ABPM has indicated a hope to be able to offer the exam initially in late 2012 or early 2013.

Another common question is what opportunities for practice will be available for those who are not board-certified. Again, as with all new medical specialties, it will likely be that physicians who are not certified will still find employment in the field, at least for many years to come. I cannot imagine a battle-tested Chief Medical Informatics Officer (CMIO) losing his or her position because he or she is not board-certified. On the other hand, it could be harder going forward for those aspiring to be CMIOs to break into the field without formal training and certification.

Related to the opportunity questions are capacity questions. Will there be enough positions for those seeking training or, on the other hand, will positions go unfulfilled? The demand for training will remain to be seen. A related capacity issue is how training will be funded. At the present time, most informatics programs are offered via graduate-level education, with funding coming mainly from students paying tuition (or from a training grant, such as the NLM training grant or the University-Based Training [UBT] from the Office of the National Coordinator for Health IT [ONC]). Those in physician-training fellowships, however, are usually paid a stipend, often via the graduate medical education subsidy from the Centers for Medicare and Medicaid Services (CMS) of the US government. Clearly these physicians will be able to generate some revenue by practicing medicine, but whether it will be enough to cover the cost of fellowship training will remain to be seen.

Another educational issue is how much a tradition-bound organization like ACGME will allow fellowship programs to incorporate distance learning and other non-site-based forms of training. As we have learned at OHSU (and as I noted in the iHealthBeat report), distance learning programs are very popular for physicians and other mid-career professionals who seek to shift their careers into informatics without having to leave their job or geographical location. We have demonstrated that even practicum and internship experiences can be managed via distance, giving learners real-world experience on the ground in operational informatics settings near where they live.

I have also been asked if OHSU plans to get involved in board review courses and a clinical informatics fellowship. The answer is easier for board review; of course! Our existing curriculum has a great deal of overlap with the core curriculum for the subspecialty that was published in JAMIA in 2009 [2]. Related to this, I have been asked by physicians already in clinical informatics positions and hoping to take the exam whether they should pursue board review or traditional education, i.e., graduate education. This one is tough to answer generally, since there is a substantial knowledge base of clinical informatics, and those learning it for the first time may not learn optimally in a board review type of format. (You have to master the knowledge before you can review for the test!)

As for developing a fellowship, I certainly hope we do so, although that will require the partnership of our institution’s clinical enterprise. I also see a role for our program providing educational content to institutions that wish to offer a fellowship but do not have the educational infrastructure to support it.

Also a common question is what physicians without a board specialty can do. Unfortunately there is not much, since a medical subspecialty requires that one have a primary specialty. The good news is that AMIA has launched an Advanced Interprofessional Informatics Certification Task Force to explicitly address certification of other informatics professionals with other doctoral degrees. Hopefully an alternative pathway will be developed for others to receive comparable professional recognition in clinical informatics.

There are still questions that ABPM and ACGME must answer going forward. Like all major developments, there will likely be unanticipated consequences. But in the long run, formal recognition of informatics professionals will be positive not only for the informatics field but also for healthcare and the health of society.

(Postscript: In early 2012, AMIA posted a page of frequently asked questions about the subspecialty: http://www.amia.org/faq-clinical-informatics-medical-subspecialty.)

References

[1] Shortliffe, E. (2011). President's column: subspecialty certification in clinical informatics. Journal of the American Medical Informatics Association, 18: 890-891.
[2] 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.