Post-doctoral and Pre-doctoral Training in Biomedical Informatics - Positions Available at OHSU

Although our educational program seems to be getting much of its recognition these days from our online program that focuses on educating informatics practitioners, we are still very committed to more intensive full-time education on our campus, especially in the training of future researchers in the field. I am pleased to report that Oregon Health & Science University (OHSU) had its National Library of Medicine Biomedical Informatics Training Grant renewed this year for another five-year cycle, with additional funding and opportunity provided by another institute of the National Institutes of Health, the National Institute of Dental and Craniofacial Research (NIDCR, which has a focus on oral and cranial health).

We are therefore seeking qualified applicants for our pre-doctoral and post-doctoral research training fellowship program in biomedical informatics for the 2013-2014 academic year. Additional support is available from the U.S. Department of Veterans Affairs and Kaiser-Permanente Northwest Region. By providing a structured research experience, with the option of course work and/or pursuit of a degree, the fellowship program prepares trainees to enter the academic community and undertake programs of independent biomedical informatics research, or to take leadership positions in the growing number of hospital and/or commercial efforts in biomedical informatics.

Our fellowship opportunities including the following:

NLM – Pre- and post-doctoral opportunities are available. The pre-doctoral positions are open to any qualified individual with a bachelor’s degree or higher, with the fellow expected to pursue a doctoral degree. The post-doctoral positions are open to any qualified individual with a doctoral degree. The fellow is expected to pursue a research project and is strongly encouraged to also pursue a master’s degree in biomedical informatics at OHSU.

U.S. Department of Veterans Affairs – The position is open to an MD and has a clinical practice component. The fellow is expected to work on a project with the VA’s advanced clinical information system and is strongly encouraged to also pursue a master’s degree in biomedical informatics at OHSU.

Kaiser-Permanente – This position is open to an MD and has a clinical practice component. The fellow is expected to work on a project with Kaiser-Permanente’s advanced clinical information systems and pursue coursework at OHSU.

NIDCR – Pre- and post-doctoral opportunities are available. Our goal is to prepare the fellow/trainee to enter the academic community and become an independent researcher, or to take leadership positions in the growing number academic and/or commercial efforts in oral health informatics. The pre-doctoral positions are open to any qualified individual with a bachelor’s degree or higher, with the fellow expected to pursue a doctoral degree. The post-doctoral positions are open to any qualified individual with a doctoral degree. The fellow is expected to pursue a research project and is strongly encouraged to also pursue a master’s degree in biomedical informatics at OHSU.

For more information about our biomedical informatics graduate program, visit our Web site. More detailed information about our fellowship programs is also available.

Program faculty and staff from OHSU will be present to meet with prospective students at the Career Expo of the AMIA 2012 Annual Symposium from November 4-7, 2012. Additional information is also available from Lauren Ludwig.

Health IT Workforce Policy: Roundtable with Rep. Susanne Bonamici

The First Congressional District of Oregon has a history of leadership in health information technology (HIT) workforce policy. As one who lives in the district, I am delighted that its Congressional representative, Susanne Bonamici, is holding a roundtable discussion on HIT workforce policy this week. I am honored to participate, especially in light of my role on the Workforce Group of the Office of the National Coordinator for HIT (ONC) HIT Policy Committee. Of course I also lead the informatics education program at Oregon Health & Science University (OHSU), an institution of which many employees are constituents of Rep. Bonamici and which is a well-known leader in HIT workforce development.

According to Rep. Bonamici, "As Oregon leads the nation in developing coordinated health delivery systems, the role of technology in managing information flow between patients, providers, and insurance companies will become increasingly important. The results of this roundtable discussion will inform legislative and oversight actions in the health IT field for the 113th Congress." She has further elaborated three topics for the roundtable:

• What can be done to better prepare practitioners to effectively use health IT and electronic health records?
• How can technology developers better design their products to fit with workflow in a medical setting?
• Does current curriculum adequately prepare technology developers and future medical service providers to meet industry and patient needs?

I heartily concur with her statement about Oregon's leadership in coordinated delivery systems and the importance of information in such systems. Regardless of one's political views, or the fate of "Obamacare" after next month's Presidential election, our healthcare system needs to become more coordinated, patient-centered, and focused on rewarding value over quantity of care. This vision is exemplified by the recent report from the Institute of Medicine, Best Care at Lower Cost: The Path to Continuously Learning Health Care in America, which makes a compelling case for a learning health care system infused with all aspects of HIT and informatics.

I also agree with the importance of the topics she raises. Namely, how do we prepare healthcare professionals to work in a data-driven healthcare system that strives for value and coordination of care? Likewise, what sort of professional workforce do we need to optimize information systems and their use? How do we best train that workforce and do so in a cost-effective manner? How do we nurture the industry in which they work? How do we advance the science, practice, and innovation?

What advice do I have for Rep. Bonamici concerning HIT workforce development? Since her first topic mentions the training of clinicians, I will begin there. In this realm, we need to insure that 21st century healthcare professionals are knowledgeable and savvy in their use of HIT to deliver optimal care, not only to individual patients, but entire populations. Current practitioners will need to be brought up to date through continuing education, while students will require their curricula to be updated to reflect what it takes to provide care in a data-driven learning healthcare system. Probably the best way to deliver this care is through the growing push for "interprofessional" education that brings all future healthcare professionals in the same classroom, preparing them to work in the future care system that is increasingly coordinated and team-based.

Delving further, all current and future healthcare professionals need to learn about tools that capture data and transform it into information and knowledge that can be used for both individual and population-based care. As such, these clinicians need to have competency in the following:

• Understanding the importance of the efficient and accurate collection of data not only for the electronic health record (EHR) of their delivery organization, but also how that data will populate other sources, such as personal health records (PHRs), health information exchange (HIE), and the public health system
• While not needing the detailed knowledge of informaticians, healthcare practitioners must learn the informatics basics of data standards, interoperability of clinical data systems, and clinical decision support
• Understanding the critical need to protect patient privacy and confidentiality
• Have skills in finding pertinent and reputable sources of knowledge to be applied to patient care, i.e., being expert in searching knowledge sources, from scientific literature (e.g., Pubmed) to summary textbooks and related sources
• Being able to deliver care in teams, using data and information to plan and guide care
• Mastering the concepts of healthcare quality measurement and improvement, i.e., understanding the rationale but also the limitations of quality measures, and how electronic data systems will facilitate them
• Being able to look forward and see other changes coming to healthcare in the future, such as personalized medicine, based on genomics and bioinformatics, and the role that it will play in the delivery of healthcare
• Understanding the ways that care is delivered over telecommunications networks, i.e., telemedicine and telehealth
• Be competent in the use of a wide variety of information devices, from computers to tablets to smartphones and the networks to which they connect

Implementing this vision and putting the technology and skills to use it will not come without the help of HIT and informatics professionals. The future HIT workforce must be ready to develop, implement, and evaluate HIT systems. These professionals will certainly need to be savvy with technology, but they will also need to be highly knowledgeable in the science and best practice of informatics to make sure these tools serve clinicians, patients, and the healthcare system. They must also be cognizant of the concerns of how HIT impacts workflow and patient safety. We must also adapt the curricula of our educational programs for future HIT professional workforce needs by increasing our experiential learning and preparing for "big data," predictive analytics, and advanced forms of clinical decision support.

Also, in settings like the First Congressional District, with its Silicon Forest, we will need to train additional individuals who will innovate and lead in industry. Our informatics program at OHSU has been working for some time to increase its collaboration with the HIT industry. It must be remembered that not only does HIT have the potential to improve health and healthcare, but in places like the First Congressional District, it can also contribute to economic development.

There must also be a cadre of academic informaticians who perform research and develop the future. In addition to education, a wide variety of innovative informatics research takes place at OHSU. Examples of the areas addressed include:

• Care coordination - the Integrated Care Coordination Information System (ICCIS) project led by Dr. David Dorr collects data and it makes available for analysis to enhance coordination of care.
• Secondary use of clinical data - my own research involves the development of data sets to augment the development of systems and algorithms to allow re-use of data in clinical systems.
• EHR simulation for patient safety - working with intensive care physician Dr. Jeffery Gold, we are developing realistic simulations to improve both users of EHRs and the systems themselves.

As in most scientific fields, government has funded the basic research that industry does not. Exemplary government agencies that support this research include the National Library of Medicine (NLM) and the Agency for Healthcare Research and Quality (AHRQ). I encourage Rep. Bonamici to continue her support for NLM and AHRQ, and encourage her to be in the lead in making sure to maintain and consider increasing their funding.

Another policy challenge going forward will be to maintain the investment made through the HITECH Act. Educational institutions associated with the First District were highly successful in competing for funding provided through the HITECH workforce development programs. OHSU has delivered on the work it was funded to do under the two programs for which grants were awarded to it:

• Development of national HIT curriculum, which focused initially on community colleges but then generalized to all institutions of higher education. OHSU served as one of five curriculum development centers as well as served as the National Training and Dissemination Center (NTDC) that distributed and supported the curriculum.
• Educating its share of students in the University-Based Training (UBT) Program. Most of our graduates have been highly successful in fulfilling the roles envisioned for them in the expanding HIT workforce.

Now, of course, the HITECH funding is winding down, ending in early 2013 for the curriculum project and mid-2013 for the UBT program. While student tuition and other sources of funding will fill in some of the declining federal investment, there is still a case for investing in the common good of educating not only the HIT workforce, but also clinicians who use HIT in a more coordinated and learning healthcare system.

I hope that Rep. Bonamici can spur the entire community, from academia to industry to healthcare organizations, to work together to improve healthcare delivery as well as advance the HIT industry. Both are vital to the future health and economic well-being of Oregonians.

Improving Patient Safety Through Electronic Health Record Simulation

Most tools used in medicine require knowledge and skills of both those who develop them and use them. Even tools that are themselves innocuous can lead to patient harm. For example, while it is difficult to directly harm a patient with a stethoscope, patients can be harmed when improper use of the stethoscope leads to them having tests and/or treatments they do not need (or not having tests and treatments they do need). More directly harmful interventions, such as invasive tests and treatments, can harm patients through their use as well.

To this end, health information technology (HIT) can harm patients. The direct harm from computer use in the care of patients is minimal, but the indirect harm can potentially be extraordinary. HIT usage can, for example, store results in an electronic health record (EHR) incompletely or incorrectly. Clinical decision support may lead clinician astray or may distract them with unnecessary excessive information. Medical imaging may improperly render findings. Search engines may lead clinicians or patients to incorrect information. The informatics professionals who oversee implementation of HIT may not follow best practices to maximize successful use and minimize negative consequences. All of these harms and more were well-documented in the Institute of Medicine (IOM) report published last year on HIT and patient safety [1].

One aspect of HIT safety was brought to our attention when a critical care physician at our medical center, Dr. Jeffery Gold, noted that clinical trainees were increasingly not seeing the big picture of a patient's care due to information being "hidden in plain sight," i.e., behind a myriad of computer screens and not easily aggregated into a single picture. This is especially problematic where he works, in the intensive care unit (ICU), where the generation of data is vast, i.e., found to average about 1300 data points per 24 hours [2]. This led us to perform an experiment where physicians in training were provided a sample case and asked to review an ICU case for sign-out to another physician [3]. Our results found that for 14 clinical issues, only an average of 41% of issues (range 16-68% for individual issues) were uncovered.

While this rate of error is alarmingly high, it must be remembered that the physicians reviewing the case were new to it, i.e., not taking direct care of the patient. It is also important to remember that paper-based information management in the ICU has always had its problems as well. Nonetheless, there clearly needs to be improvement both in the presentation of information as well as the training of users to access it.

As we were completing this work, a new round of funding was announced for a grant program, Improving Patient Safety Through Simulation Research, by the Agency for Healthcare Research and Quality (AHRQ). I am pleased to report that we have been awarded a three-year, $1 million grant to pursue this work. Dr. Gold is Principal Investigator of the project and several faculty in our informatics program, including myself, are Co-Investigators. Our efforts will focus on continuing the development of the simulation through development of new cases, aiming to improve both the user interface as well as user training, and disseminating our results. Of course, we are not the only research group evaluating improved methods to find and use data in the EHR, our simulation approach is novel and will hopefully add additional insights to improving the use of HIT in the clinical setting.

References
1. Anonymous (2012). Health IT and Patient Safety: Building Safer Systems for Better Care. Washington, DC. National Academies Press. http://www.iom.edu/Reports/2011/Health-IT-and-Patient-Safety-Building-Safer-Systems-for-Better-Care.aspx.
2. Manor-Shulman, O., Beyene, J., et al. (2008). Quantifying the volume of documented clinical information in critical illness. Journal of Critical Care, 23: 245-250.
3. Steiger, D., March, C., et al. (2012). Use of simulation to assess and improve electronic medical record usage. American Journal of Respiratory and Critical Care Medicine, 185: A2890. http://ajrccm.atsjournals.org/cgi/reprint/185/1_MeetingAbstracts/A2890.

Health IT Jobs Growth Outpacing Qualified People to Fill Them?

I recently wrote about the substantial growth in health information technology (HIT) employment that has exceeded all predictions. That is the good news. The less-good news is that healthcare organizations still face substantial challenges in meeting their HIT staffing needs. This was borne out by a recent survey of the College of Healthcare Information Management Executives (CHIME), which assessed HIT workforce staffing issues and found that the shortfalls of needed HIT staff still persist [1]. Perhaps this is not surprising, given the growth in the use of HIT and overall employment as noted in my previous post.

A total of 163 out of CHIME's 1400+ members, mostly chief information officers (CIOs), responded to the survey during July, 2012. A similar survey had been administered in 2010. All sizes (from 0-99 to 1000+) and types (academic, community, and multi-hospital) of healthcare provider organizations responded.

About 67% of respondents reported that their organizations were experiencing shortages. This was compared with 59% in 2010. The highest category having unmet needs was academic centers, reported by 82%. About 12% of organizations reported 15% or more positions being open.

The survey asked about skills most often in demand, which included:

• Clinical software implementation and support staff (e.g., EHR, CPOE) - 74%
• Infrastructure staff - 47%
• Business software implementation and support staff - 45%

About 71% said IT staff shortages could jeopardize an enterprise IT project, while 58% said they would definitely or possibly affect meeting meaningful use criteria for incentive funding. About 85% also expressed concerns about being able to retain current staff.

The survey also assessed awareness of the HIT Workforce Programs of the Office of the National Coordinator for Health IT (ONC) [2]. Only 67% were aware of the ONC workforce programs, with 12% of those respondents reporting that they had hired graduates from them. (Unfortunately the survey did not distinguish knowledge of and hiring from community college versus university-based programs.)

The respondents reported their chief strategies for coping with IT staff shortages, which included:

• Hiring third-party consultants - 28%
• Hiring from within the organization and retraining - 20%
• Other (multiple strategies) - 18%
• Using recruiters to find and place qualified staff - 15%
• Depending on HIT vendors to provide implementation staff - 8%
• Other kinds of outsourcing - 6%
• Developing a pipeline of students by collaborating with local colleges and universities - 2%

The most important attributes and competencies deemed to be needed by HIT professionals included:

• Actual experience in a health IT shop
• Clinical informatics experience
• Education in IT theory and practice in a real-world setting

The most important attribute or competency that was least likely to be mentioned by respondents was:

• Coding knowledge
• Willingness to start “at the bottom” in an IT shop
• Education in IT theory and practice in a classroom setting

Those surveyed were also asked what competencies or areas of knowledge were generally lacking in candidates being considered for IT staff positions. The most frequently mentioned were:

• Lack of knowledge of healthcare and related IT applications
• Lack of practical experience
• Lack of experience with an organization’s system
• Inability to interact successfully with front-line users

Overall, the CHIME survey demonstrates that adequate numbers of HIT professionals with appropriate skills are a bottleneck to HIT implementation in healthcare organizations. The highest unmet needs for staffing are in clinical areas, with individuals most sought after being those with healthcare and/or HIT experience, applied education in both theory and practice, and good people skills. Knowledge of ONC workforce programs is by no means universal, and even those with knowledge of the programs are hiring relatively few graduates, although the survey did not distinguish levels of knowledge or hiring from community college versus university-based programs. Clearly while job opportunities in HIT are strong, many organizations are experiencing challenges fulfilling their HIT hiring needs. There is also onus on educational programs to train individuals with adequate skills as quickly and efficiently as possible.

References

1. Anonymous (2012). Demand Persists for Experienced Health IT Staff. Ann Arbor, MI, College of Healthcare Information Management Executives. http://www.cio-chime.org/chime/press/surveys/pdf/CHIME_Workforce%20_survey_report.pdf.

2. Hersh, W. (2012). Update on the ONC for Health IT Workforce Development Program. HIMSS Clinical Informatics Insights. July, 2012. http://www.himss.org/ASP/ContentRedirector.asp?ContentId=80559&type=HIMSSNewsItem;src=cii20120709.