Annual Reflections at the End of 2012

It has been somewhat of a tradition for me with this blog to post a reflection at the end of each year. I did so in 2009, 2010, and 2011. So here goes for 2012.

I am pleased at the success of this blog, closing in on 90,000 page views and having 315 followers (as I write this). Of course, the success is not really a matter of page views and followers, but rather the substantive knowledge and insights that the blog contributes. To that end, I am pleased that others re-post, tweet, and/or respond to some of my postings. This also reinforces my decision to not post every train of thought, but rather to only do so when I believe I have something important to say. This is my 40th post of 2012. That is the most postings for any of my four years, but still reflecting my decision only to write when I have something I consider meaningful to say, and not just posting because I feel like I must on a given day.

This past year has been another successful one for myself and the field. Much of it, of course, revolves around work related to the HITECH Act, which has defined the last few years of our informatics careers for many of us in the field. The coming year will mark a transformation, as least for me, as the major ONC projects that have consumed much of our time and thinking will be drawing to a close. The curriculum project is already winding down, as we transition from a development role to a support role, with ONC funding slated to cease at the end of March. As noted in a recent update on the project, I do hope there will be a way to sustain the updating and enhancement of the curriculum. At this time, however, there is no funding source that has been identified to do that. By the same token, the University-Based Training (UBT) program is also starting to wind down. While we will have students wending their way through their UBT program studies for most of 2013, the funding for this project will be completed by next year at this time.

Of course, I did accomplish a great deal more in 2012 than just efforts related to HITECH. The department I lead at Oregon Health & Science University (OHSU), the Department of Medical Informatics & Clinical Epidemiology, continues to thrive, with the renewal of our evidence-based practice center as well as several new informatics-related grants and projects. Student enrollment in our informatics educational program above and beyond UBT remains strong. I am grateful to have a position that allows me to provide leadership and vision while still enabling me to pursue my own intellectual activities in teaching and research.

On a personal level, this year saw a number of accomplishments. Here are some of the accolades and achievements of 2012:

• Served as General Conference Chair of the ACM SIGIR 2012 Conference
• Served as Scientific Program Committee Chair of the AMIA 2012 Annual Symposium
• Named as Course Director for the AMIA Clinical Informatics Subspecialty Board Review Course
• Named among the Top 25 Clinical Informaticists by Modern Healthcare magazine for the third year in a row
• Named an "EHR Game Changer" by Health Data Management magazine (slide show and article)
• Appointed to the Workforce Subgroup of the Certification and Adoption Workgroup of the ONC Health IT Policy Committee
• And, on a lighter note, named as a Fellow of the American College of Medical Informatimusicology (ACMImimi)

Despite the winding down of the major HITECH infrastructure investments over the next year (or in some cases, but not in the workforce program, more), there is much interesting and important work yet to come. Now that HITECH has established the foundation of data in healthcare organizations, we will hopefully be able to start doing important things with that data, such as improving health and healthcare delivery. Informatics professionals, some certified in new specializations (not only physicians), will provide the leadership to facilitation the collection, analysis, and use of the that data. New technologies will also continue to provide excitement, but we must never lose sight of the purpose of our primary role in informatics, which is to put that data, information, and knowledge to optimal use for individuals and society.

Let me close this posting by noting that anyone and everyone can also contribute to the Department of Medical Informatics & Clinical Epidemiology. We launched a major philanthropic drive this year, and any support you are willing to give will greatly help our current and future programs. I hope you will consider a gift to our program on our department giving page.

In the meantime, I look forward to another exciting year for informatics and this blog in 2013, and wish everyone a healthy and happy New Year.

Knowns and Unknowns About the Health IT Workforce

I have had the opportunity over the last few months to serve on a Federal Advisory Committee (FACA) workgroup focused on health information technology (HIT) workforce policy recommendations for one of the two main HIT advisory committees to the Office of the National Coordinator for Health IT. It has been a pleasure to interact with a diverse cross-section of people who have interest in workforce issues.

One of my pleas to the group has been to seek more data to inform our (at this point potential) policy prescriptions. I am a person who prefers to make decisions based on data. I know that we cannot always get the data we need or want to make a decision, and sometimes we are not able to get data at all. But everything else being equal, I prefer to have my decisions driven by facts that have some basis in evidence.

We are starting to some additional data emerge. Led by Dr. Susan Fenton, the state of Texas has carried out a series of focus groups of HIT employers in the state. The larger report of this work was recently distilled down to a journal article (Fenton S, Joost E, Gongora-Ferraez M. Health information technology knowledge and skills needed by HIT employers. Applied Clinical Informatics. 2012;3:448-61.). The emerging results present some interesting conclusions:

1. Employers report needing a diversity of skills and knowledge
2. The usual adage of needing knowledge of healthcare seems to be increasingly complemented by the need to understand and know how to work with data
3. In additional to skills and knowledge, ability to think critically and solve problems is key
4. There is no consensus on optimal career paths

The second point is borne out in some additional data that was presented to the group by Norma Morganti, another member of the workgroup who also directs the Midwest Community College Health Information Technology Consortium, one of the five ONC Community College Consortium programs. She convened a focus group in Ohio to ascertain competencies for the workforce involved in HIT aspects of health system transformation, particularly the primary care medical home. Among the critical competencies required are those requiring population management and data analytics.

These data support a shift we are noticing in our own program for skills of our graduates. While knowledge of healthcare is still key, there seems to be a growing preference among those who hire our graduates for those with strong data skills and understanding. This really is not surprising, given the shift I described earlier this year in the focus of the work of informatics from implementation (many healthcare organizations have already done that) to analytics (now they need to figure out what to do with the data).

It will be interesting to see how this trend evolves. I am fairly certain (though as always, will change my views if supported by the data!) that there will be a growing need among informatics professionals to know how to make use of data to improve health, healthcare, research, etc.. After all, that is the primary of purpose of informatics, to make use of data and information to improve all aspects of human health.

I Am a Runner

Every now and then, I take a break from informatics in my blog to write about other things. Let me take a detour in this posting and talk about running.

I am one of those people who is a runner. Running has been an important part of my life. I am not a fanatic, and keep running in the context of the rest of my life, but I one of those people who runs regularly no matter where I am or what the weather is, and feels uneasy when I am not able to do so.

Running is connected to major parts of my life. One is my devotion to personal health. Running keeps my heart strong, my weight under control, and my appetite in check. I can't claim that running will make me immortal, and as a physician I know that sometimes people get illnesses that have nothing to do with their personal health habits.

Do I run to extend to my life? I believe that running will probably extend my life, but I cannot be sure. And even if it did not, I would still run. Along with healthy eating, running makes me feel good today. Regular exercise and healthy eating give me more energy in my daily function, here and now.

There is some growing scientific evidence as to what is the proper amount of running. A recent paper by O'Keefe and Lavie, summarizing research they and others have done, was published Online First in the journal Heart [O'Keefe, J. and C. Lavie (2012). Run for your life ... at a comfortable speed and not too far. doi:10.1136/heartjnl-2012-302886]. The evidence seems to show a U-shaped phenomenon, where all-cause mortality is lowest at a running distance of 10-20 miles per week. Mortality goes up both for those who do not exercise as well as those who do so excessively. I am pleased to fall into the category of distance with the lowest mortality, but again I do not run primarily to extend my life.

Does running help my personal discipline? Perhaps not as much now as earlier in my life, but there is no question that my breaking out from being an underachiever in my early part of high school was due in part to the discipline I developed from running. That discipline certainly played a role in my future career and other life accomplishments.

Another aspect to running I enjoy is its "portability." That is, one can run anywhere. As someone who travels quite a bit, I enjoy being able to run. In fact, one of the enjoyments is getting to see parts of places I travel to around the world that I might not ordinarily see if I were just attending conferences or visiting the tourist sites. I have run on six continents (one of these days will do Antarctica!) and in countries as diverse as Cuba, Zimbabwe, Thailand, Slovenia, Egypt, and Brazil.

An additional fun aspect to my running in recent years has been my acquisition of a Garmin global positioning system (GPS) watch, which enables me to track my distance and speed as well as plot my route after a run (or bike ride) on a Google or Bing map. I do not track all of my runs, but I enjoy being able to see where I have run, especially when traveling in distant places. These include Buenos Aires, Argentina; Singapore; San Francisco; Washington, DC; my old high school (New Trier West) area; Honolulu; Oaxaca, Mexico; Bangkok, Thailand; Gabarone, Botswana; and Cape Town, South Africa (among others!).

Of course, the GPS watch is the only technology I use while running, which gets to another advantage of my running time. This is the ability to disconnect from all my other devices - computers, tablets, smartphones, etc. - and have some time for solitary thinking. Sometimes I come up with my best ideas for research, teaching, or even things unrelated to work while running (including many of the thoughts in this blog entry).

A common adage among sports medicine physicians is that runners don't know when to stop. I do usually stop when I get sick (e.g., a cold or the flu) or injured. In fact, my running has been somewhat impacted over the last couple years by some knee problems. Fortunately, the pain is not exacerbated by running (in fact, running and movement tend to make it feel better), but it has led me to reduce my mileage somewhat. I no longer run races, though occasionally like to participate for the thrill of doing so.

I will continue to run for as long as I can in my life. I believe it is contributing to my health and well-being, not only in the future but most importantly in the present.

If MOOCs Are the Answer, What is the Question?

I have written about massive open online courses (MOOCs) before, once wondering whether disruptive innovation was finally coming to higher education and then further noting that a colleague was creating a MOOC from the materials of the ONC Health IT Curriculum. (I am pleased to report that the MOOC is making good progress.) MOOCs also have attained quite a bit of discussion as part or all of the solution to the problem of runaway costs of higher education in the United States. The New York Times has called this year the Year of the MOOC, while others wonder if this is finally the time that Silicon Valley-style disruptive innovation will come to higher education.

I have skin in this game in a number of ways. One is that I direct a large graduate program in a public health science university that has minimal government financial support, i.e., the program is mostly dependent on tuition, training grants, and other sources of funding. This graduate program is in an academic department that I chair that is likewise being asked to achieve increasing fiscal self-sufficiency in all its activities. I am also reaching the end of a well-funded project to develop a health information technology (HIT) curriculum for colleges and universities. In addition, I am the parent of two children, one of whom recently completed a bachelor's degree and the other who is still in undergraduate studies but planning further education beyond her bachelor's degree, both in public state universities. And of course, I am a US citizen concerned about my country's long-term fiscal solvency while maintaining economic competitiveness through a highly educated populace.

To some, MOOCs are seen as a way to reduce the costs of higher education, which is under increasing scrutiny to demonstrate its value. Based on my own experience with distance learning, I am optimistic that online education can be efficient and scalable. Although I do not find myself in agreement with many of the political positions of Texas Gov. Rick Perry, I admit to having sympathy for his challenge to higher education to create a $10,000 bachelor's degree.

That said, I recognize that online courses alone do not an education make, especially a college education. College is also about maturation, participating in non-academic activities, and developing skills beyond just mastering of knowledge, such as leadership, mentorship, volunteerism, and more. I have no doubt that MOOCs can replace the kind of large lecture classes I took as an undergraduate at the University of Illinois, i.e., the "101" classes. But I am less convinced they can replace the smaller courses, the hands-on experiences, the volunteer activities, and so forth.

As enthusiastic as I am about the use of educational technology, I do not see online courses alone comprising the entire educational experience. Even in our online graduate program, we encourage networking and participation in professional organizations among our students. We have created a practicum and internship program that allows even our remote students to get real-world experience. A "distance education" in our program is not just a succession of online courses. Our students are engaged in a virtual community with us.

At the same time, I also worry that low-cost college education may create a two-class system, one of children of parents with the means to afford a four-year in-residence college education and all of its benefits, and the other of students whose college experience is mostly impersonal. I believe we need a balance.

Another interesting aspect about MOOCs and other online repositories of educational materials is the notion of "openness." I was prodded into thinking about this by some from the Office of the National Coordinator for Health IT (ONC) who want to see the curriculum be maintained in some open, perhaps crowdsourcing, project. This made me realize that MOOCs and similar initiatives are open in the sense that they are accessible to many people. But the openness is only one-way, i.e., the rest of the world cannot alter the "open" materials.

That is not necessarily a bad thing. Phenomena like Wikipedia not withstanding, I believe there is a role for materials that have authorship and authority. The Web facilitates their annotation, but not their underlying alteration. Even Wikipedia and the myriad of open-source software projects have found a need for governance. I relish the idea of everyone in the world annotating the ONC HIT curriculum, but I am less enthusiastic about everyone in the world updating the source materials.

Notwithstanding my concerns, I am excited to play a small role in the disruptive innovation of higher education through my own work. But I also know that MOOCs are not the complete solution. I envision a future where students are wedded to an educational institution, but have the flexibility of online learning and the ability to have some of their learning come from other teachers and institutions. Perhaps that is why initiatives like Semester Online, where ten universities are sharing courses among each other, with appropriate transfers of academic credit and tuition money, will survive if MOOCs turn out to be a passing fad. We can probably learn from systems like the European Credit Transfer System (ETCS), which standardizes credits for higher education and allows their transfer across educational institutions.

I hope we can achieve a happy middle ground of making the best use of the dissemination and collaboration afforded by the Internet while still recognizing the value attachment to a real institution of higher learning. I also believe the cost of higher education can be reduced, but as former Harvard President Derek Bok used to say, If you think education is expensive, try ignorance.

Update on the ONC Health IT Curriculum

In my previous posting, I noted the end was in sight for the Oregon Health & Science University (OHSU) University-Based Training Grant (UBT) grant from the Office of the National Coordinator for Health IT (ONC). This is even more so the case for our other major ONC workforce project, the ONC Curriculum Development Centers (CDCs) program, as the ONC funding portion of this project will end in March, 2013. This program has produced three successive versions of the health information technology (HIT) curriculum for community college programs, and it has had broad use beyond those programs, including our own informatics graduate program at OHSU.

Since the first version of the curriculum, the materials have been available for download from the National Training and Dissemination Center (NTDC) web site. Since the second version, anyone in the world has been able to create a login and download up to the entire curriculum. Technical support has been available for the faculty of the community college consortia.

Even though the ONC funding will be ending, the materials will live on. While there is no funding as of now to support and update the materials, options are being explored. In the meantime, the NTDC web site will be maintained by OHSU for at least one year after the ONC funding ends. In addition, ONC plans to incorporate the materials into its developing National Learning Consortium. Others have moved the materials on to other sites, including one that is turning them into a massive open online course (MOOC).

As the ONC funding is winding down, we are producing the final deliverables of the project. The major last deliverable we are most excited about is a new version of the VistA for Education (VFE) environment that is used as a fully function electronic health record (EHR) for the lab-based components of the curriculum. Based on the VistA EHR of the US Veteran's Administration (VA), the learning curriculum provides both learning to use as well as configure the VistA system for computers running the Microsoft Windows operating system. One of the limitations of this EHR has been the use of a version that requires the commercial Intersystems Cache environment (as is done in operational settings by the VA itself). A new version of VFE has been developed that is based on the open-source GT.M environment (with help from the WorldVistA community). As GT.M runs only in the Linux environment, we have had to develop a virtual machine approach in order for VFE to run on Windows. But we have succeeded at developing this, including an installer that takes the user through all the required steps. The exercises based on VistA from Components 7 and 11 of the curriculum have been revised to run properly with this new version of VistA.

Other project-end deliverables include updating of various materials, including revising the last unit of Component 1 to include coverage of Stage 2 of meaningful use. We were planning to update the materials for the new HIPAA regulations that were supposed to be released in 2012, but those have not come out yet, so will not be in this version of the curriculum.

Overall, the reception of the materials has been gratifying. The NTDC download site has nearly 10,000 registered users. We are currently conducting a survey of those users that we hope to publish in the near future.

Clearly these materials represent a highly worthwhile product funded by the American Recovery and Reinvestment Act (ARRA). Even if they do become out of date, they will continue to be directly useful for some time to come, and serve as a foundation for other educators to develop their own curricular materials using ours as a foundation for some time to come.

Update on the OHSU ONC University-Based Training Grant

It seems like yesterday that the Office of the National Coordinator for Health IT (ONC) HITECH Program was starting up and the funding of the ONC Workforce Development Programs occurred. Now, however, those programs are winding down after nearly three years. In this posting, I will provide an update of OHSU's University-Based Training (UBT) Grant.

As I noted in my last update on the program, we had committed all of our training slots by last summer. For the rest of the grant, we have been and will continue to be leading the students through the program and aiming to launch as many as we can into successful informatics careers.

OHSU was one of nine universities (or consortia of universities) awarded a UBT grant in April, 2010. We were funded to educate 148 students, 135 in the Type 1 (one year) category and 13 in the Type 2 (longer than a year) category. Since we already had existing programs, we ran our grant essentially as a financial aid program for our existing Graduate Certificate (GC, Type 1) and Master of Biomedical Informatics (MBI, Type 2) programs. Because of the time constraints imposed by the ONC funding, we made a condition of admission being completion of the GC program as an accelerated part-time student in one year and of the MBI as a full-time student in one and a half years.

Although both the GC and MBI programs are available online, we chose to require the ONC Type 2 students to be full-time on-campus students. But our GC students have been from all over the US, paralleling the national distribution of all of our online students.

The figure below shows graphically how students have flowed through the program as of this time. A total of 493 students applied for funding, of which we were able to accept 178, meaning a 36% rate of acceptance. It was a challenge to have to turn down so many qualified applicants applying for funding, although all of them had the option of enrolling in the program as self-funded (tuition-paying) students. In fact, 65 (21%) of those who applied but were not funded did enroll in that manner.

Probably the single biggest challenge of the program has been a relatively high rate of student attrition. For most students, this has been due to their underestimating the time commitment of the programs. Even the accelerated part-time commitment to the GC program has been challenging for many students, especially those working full-time or with other (e.g., family) commitments. As a result, 41 students have withdrawn from the program after starting it, although 13 of them have continued as self-funded students on a more part-time basis.

With the fall academic quarter of 2012 winding down, we will likely have a total of 97 graduates (66%) by the end of this term. There are 38 students still progressing through the program. Combined with the 13 who have moved to self-funded status, this should enable us to hit our target of 148 graduates overall for the grant.

Of course, the UBT students have not been the only students in the OHSU informatics program during this time. Even if we were to slightly fall short of our UBT program goals, we have contributed many other people to the informatics workforce. Since the UBT program started, a total of 228 other students have enrolled in the GC or MBI programs, and 96 have graduated.

The UBT grant has also had other benefits to our program. Recognizing that informatics is not a "spectator sport," we developed practicum and internship programs for the GC (one quarter or 11 weeks) and MBI (two quarters or 22 weeks) programs respectively. These experiences have give all of our UBT students real-world experiences in a variety of settings, from healthcare organizations to companies to others. We have even developed a process for our online students to find opportunities and pursue them. Our alumni and other networks have been helpful in identifying these experiences. A second important benefit to the program has been the ability to hire a career development specialist, providing career counseling for the first time in the history of our program.

One of the challenges as the UBT grant winds down is how to sustain these additional benefits. One way we are trying to sustain them is to roll them out to all other (i.e., non-UBT) students in the program. So now, for example, self-funded students can pursue practicum and internship experiences as well as avail themselves to our career development specialist. In the long run, however, we will need the base of enrollment provided by something comparable to the UBT grant to maintain all of these services.

My hope going into the UBT grant was that enrollment in our and other informatics programs would increase initially from the UBT funding and then be sustained by increased interest and career opportunities in the field. As I have noted in another recent posting, there is plenty of data to indicate that the opportunities are there. But as we have always noted, getting out the word about informatics careers has always been a challenge, especially among younger people without much experience in the healthcare system (and knowing why informatics is so important to it). To that end, we are planning to ramp up a marketing campaign to attract more interest in all of our educational programs, which I will detail in a subsequent posting.

As the UBT program winds down, I am confident in its success. I believe it has demonstrated the need for more informatics professionals and provided a foundation for educating them, even if the results might take longer than was hoped to meet the acute needs of the meaningful use program. I am also confident there will continue to be need for professionals working at that interface between healthcare and its information.