Eligibility for the Clinical Informatics Subspecialty

(Postscript: This posting was originally published on January 11, 2013. Thanks to two colleagues, Ted Shortliffe and Ben Munger, a few minor corrections and clarifications have been made, and it is being re-posted on January 13, 2013.)

One of the most common email messages I receive these days is an inquiry from a physician about his or her eligibility for the clinical informatics subspecialty. I am writing this posting in part to have a link to send to people in reply to those emails. But before I go further, let me make one vital disclaimer clear: I am not the decision-maker! That will be the exclusive role of the American Board of Preventive Medicine (ABPM), which is the administrative home for the subspecialty. I can give educated guesses based on what the ABPM has said and written, but ultimately it is their decision whether or not someone is eligible.

Shortly before the end of 2012, the ABPM released a one-page document on the clinical informatics subspecialty certification exam and qualifications for eligibility. The first exam will be available during a two-week window between October 7-18, 2013, with registration opening in March. The registration process will include a determination of whether an applicant is eligible for board certification, i.e., be allowed to take the exam.

The next most common questions I am asked are (a) what educational programs at Oregon Health & Science University (OHSU) will make me eligible and (b) what educational programs at OHSU or elsewhere will best prepare me for the exam? I will address those questions after providing what I know about the primary question on eligibility.

The eligibility requirements are clearly laid out in the ABPM document, so those who want to determine if they are eligible should read them carefully. The first three requirements are relatively straight-forward. In short, they are:

1. Primary certification by one of the 23 member boards of the American Board of Medical Specialties (ABMS)
2. Graduate from a US, Canadian, or other medical school deemed acceptable by the ABPM
3. Unrestricted license to practice medicine in the US or Canada

The fourth requirement, which is the "pathway" by which one is eligible during the first five years of the subspecialty (also known as the "grandfathering" era), is more challenging to interpret. There are two pathways for eligibility in the first five years, after which only a formal clinical informatics fellowship accredited by the Accreditation Council for Graduate Medical Education (ACGME) will allow eligibility for certification. These pathways must be completed in the first five years to be eligible to take the certification exam under the "grandfathering" criteria.

The first of the two pathways is the "practice pathway." Those who have been working in informatics professionally for at least 25% time during any three of the previous five years, and can have a supervisory individual attest to it, are eligible for this pathway. "Working" in informatics not only includes "practice" (i.e., being a Chief Medical Information Officer), but also teaching and research.

The second pathway is the "non-traditional fellowship," which is any informatics fellowship of 24 or more months duration deemed acceptable by ABPM. At the November 4, 2012 panel at the American Medical Informatics Association (AMIA) Annual Symposium, Dr. William Greaves of ABPM stated this would be composed of informatics educational programs that were listed in the proposal submitted to ABPM by AMIA in 2009. This list, which has not been made public by ABPM or AMIA, included programs that were funded by training grants from the National Library of Medicine (NLM) or were members of the AMIA Academic Forum at the time the proposal was submitted by AMIA to ABMS in 2009. (I can say that OHSU was definitely on the list, since we were both NLM-funded and a member of the Academic Forum at that time and still are. both). Dr. Greaves also said that ABPM would review applicants trained in other fellowships for eligibility on a case-by-case basis.

The ABPM document also states that time spent in training in informatics could be applied to the practice pathway at one-half the value of practice time. In other words, someone in an educational program for at least 50% time during the previous five years would be eligible to take the certification exam. My interpretation of what he said (remember, I do not make the rules and they may change!) is that someone in a master's degree program that involves the equivalent of one and a half years of full-time study would thus be eligible. If my interpretation is correct, this would mean that completing the Master of Biomedical Informatics (MBI) Program at OHSU within a five-year time span would make one eligible, since it requires six academic quarters of full-time study. The OHSU Graduate Certificate Program, on the other hand, which is a subset of the MBI requiring about nine months of study if done full-time, thus would not be enough. Presumably one can mix and match to achieve eligibility, i.e., with some practice and some education.

As for the common question I get about which OHSU program would make one eligible, the answer then depends on how much practice pathway eligibility one has. If one completely meets the practice pathway criteria, then how much education is a moot point; they are eligible on the basis of professional work. But for those who have not worked in the field enough to quality by the practice pathway, it likely means they would need to complete the MBI or have enough education to make up for the "shortfall" in their practice time, perhaps with a Graduate Certificate.

The second common question I get asked is, what educational programs at OHSU and elsewhere will best prepare one for the exam? This answer is also part guess, as ABPM has not released any information about the exam content beyond saying it will likely reflect the core content outline that submitted with the ABMS proposal and published in JAMIA in 2009. Last year I created a matrix that mapped each element of the core content outline to an OHSU course. The sum of OHSU courses pretty much covered the outline, but the problem is that it required 23 courses to do so. This is about 50% more than required for the MBI. (Remember that OHSU is on an academic quarter system, so the number of courses is larger than programs on a semester system.) However, it is also clear from the matrix that a relatively constrained set of courses could cover a fairly large portion of the core content outline. Furthermore, we are undertaking a process to reorganize the curriculum with an eye to creating a set of courses that will be "core" for the core content, i.e., cover a substantial portion of the outline, while still maintaining the balance that we believe is important to learn in informatics. (The core content outline is likely to be fairly similar for the certifications that emerge for other healthcare professionals and PhDs that AMIA is now planning to propose. In fact, it is not very specific to "physician" informatics, and actually provides a good overview of the critical content necessary for mastery by all who work in clinical informatics.)

I believe that the eight courses required to obtain a Graduate Certificate can be fashioned in a way to prepare one well for the certification exam. Indeed, I can also see where the content of the Graduate Certificate program could form the basis of the didactic portion of a clinical informatics fellowship (perhaps allowing the practice time and fellowship project to add enough credits to qualify one for a master's degree).

I am also sometimes asked if the 10x10 ("ten by ten") course (which is the equivalent of one course, the introductory course, in our Graduate Certificate and MBI programs), or the AMIA Board Review course I will be directing, will cover enough to enable someone to pass the exam by just taking one or both. I believe it is unlikely that these courses alone, without any other formal training, would give one enough knowledge to pass the exam (although I suspect some will try, and perhaps succeed). It should be noted that achieving a sufficient grade of the optional final exam in the OHSU 10x10 course will provide credit to those eligible for study in the OHSU Graduate Certificate or MBI programs, which gets one course under their belt and gives them a trajectory for more.

(By the way, for those who are wondering: The AMIA Board Review course details will be announced in February. The current working plan is to offer the course three times between June and September, after the ABPM registration period opens but enough in advance of the actual exam. There will likely be East Coast, Midwest, and West Coast sites for the three offerings. The courses in the first year will be all face-to-face, although online versions will be developed for subsequent years. A brief interview of me about the course from the AMIA Symposium is available, as is an interview of Dr. Greaves.

Ironically, one activity for which there is no guarantee of being adequately prepared is a traditional research-oriented fellowship, such as those funded by NLM training grants. If one's course of study in one of these fellowships includes a course of study containing a good deal of practical clinical informatics courses, then that preparation should be excellent. However, not all informatics fellowships offer such coursework, as the primary purpose of the NLM-funded fellowships is to train future researchers. There may also be individuals in these fellowships who are extremely well-trained in other areas of informatics, such as bioinformatics or imaging informatics, who will technically be eligible for certification though not really well-prepared to pass an exam focused on practical clinical informatics. Indeed, even those who have a clinically oriented but highly theoretical curriculum may not be able to pass the exam that will have a very practical and applied focus.

I should also reiterate that this eligibility process only applies to the first five years of the subspecialty. After that time, the only way to achieve eligibility for certification will be in an ACGME-accredited clinical informatics fellowship. No details about these fellowships have been released, other than their proposed requirements in the ABMS proposal that was also published in JAMIA in 2009, and a statement by ABPM that such fellowships will be required to be 24 months (two years) in duration. I have previously raised some concerns about what these fellowships might look like, how they will be funded by healthcare organizations, and what will be the ramifications for the way many physicians train in informatics now, which is through graduate programs, often online. A lack of flexibility in these fellowships could limit clinical informatics training mainly to those at the beginning of their careers, which is currently not how most physicians train in informatics.

Let me summarize the answers to the questions of (a) am I eligible in the first five years of the subspecialty, (b) can OHSU make me eligible, and (c) can OHSU help me pass the certification exam?

• Any US or Canadian physician who has a primary board, has a license to practice medicine, and was education in an acceptable medical school is eligible.
• Further eligibility is required by either having "practiced" informatics for at least one-quarter time in three out of the last five years or who has completed an informatics fellowship at a to-be-released list of institutions.
• Although the rules are not clear, educational time in an approved informatics program will count at one-half the value of practice time, i.e., having been in an educational for at least one-half time in the last five years. This may allow those who have insufficient practice time to obtain eligibility through educational programs. (For those with no practice time at all, I interpret this to mean one could be eligible through the OHSU master's program but not the Graduate Certificate Program.)
• The curriculum of the OHSU Graduate Certificate Program as it now stands can be tailored to cover a substantial fraction of the core content likely to be on the exam, and will be reorganized in the next 1-2 years to allow it to do this even more efficiently.
• The 10x10 and AMIA Board Review courses are unlikely to enable one with no other formal training in informatics to pass the exam (though anyone is able to try!).

A final question I am sometimes asked is whether I will be eligible for the exam, and if so, whether I plan to take it? I believe I am eligible (although this is for the ABPM to decide!), since I was certified by the American Board of Internal Medicine (ABIM) at a time when there was lifetime certification granted by ABIM, i.e., re-certification will never be required, even though I would re-certify if I ever returned to patient care. In addition, while I have not seen patients for over a decade, I still maintain an "administrative" medical license in the state of Oregon, which makes me a licensed physician. I also have no trouble meeting the practice pathway time requirements, since I live, eat, and breathe informatics at least full time (some would say well more than that!). Therefore if I am indeed eligible, I certainly plan to sit for the exam, and hope later this year to be among those who are certified clinical informatics subspecialists.