Sunday, December 29, 2013

Annual Reflections at the End of 2013

It has become a tradition for this blog for my last posting of the calendar year to be a message reflecting on the past year and looking ahead to the following one. As such, this marks my fifth annual message, dating back to 20092010, and 2011, and 2012. I continue to enjoy writing this blog, with it serving as a venue to discuss issues of importance to myself and the biomedical and health informatics field.

This past year of 2013 was another gratifying year, as well as a transitional one, as the work and funding under the Health Information Technology for Clinical and Economic Health (HITECH) Act, at least for myself and our program at Oregon Health & Science University (OHSU), drew to a close. Indeed, this blog has paralleled the HITECH Act since the inception of both, getting its start in early 2009 around the time of the passage of the American Recovery and Reinvestment Act (ARRA), the economic stimulus legislation passed in 2009 in the early days of the Obama Administration. HITECH itself is now transitioning, as the most of its grant funding has ended and its incentive payments for EHR adoption are tapering off.

HITECH has certainly been a career-defining era for many of us working in informatics. As with many large initiatives, especially government ones, it has had its successes and failures. It is interesting to read my postings from the early days, after the legislation was passed but prior to it being implemented, followed by the reality that not everything in HITECH, nor the Obama Administration, has gone as we might have hoped. Nonetheless, I do feel comfortable that the government and the taxpayers received their money's worth for the work that our informatics program was funded to do. We created a useful new curricular resource and trained a number of people that resulted in new informatics careers being launched. But going forward, HITECH will increasingly be seen in the rear-view mirror.

In this transitional year, a number of other new initiatives came about, which point the direction of the future for myself and our program. For myself, 2013 is ending with my becoming a "board-certified" clinical informatician. While the new subspecialty is still a work in progress, I was pleased to be part of 450 or so individuals who passed the first offering of new board exam. I was also proud that 40 of those who passed received at least part of their informatics education in our program at OHSU. It was also great to see the press postings from OHSU as well as AMIA, with the former picked up by a local business magazine and the latter described in the health IT press.

For our department, one of the most important new initiatives of the last year was the launch of the Informatics Discovery Lab (IDL). I had the opportunity to give a talk about the IDL in an interesting format of 5 minutes total with exactly 15 seconds per slide at a local forum called IgniteHealth. The IDL was also described in an interview with its leader, faculty member Dr. Aaron Cohen, in Oregon Business, a local business magazine. We also received a good deal of notice about one of the first tangible outcomes of the IDL, which is our partnership with EHR vendor Epic to use their system for research and educational purposes. This initiative too made it into the HIT press: Healthcare IT News, Healthcare Informatics, and HIT Consultant.

Despite the end of the HITECH funding and the modest decline in enrollment expected after it, we are still moving forward and innovating with our educational program. A number of new initiatives are in the works and likely to reach fruition in 2014. Recognizing the need to stay relevant, we are forging ahead in new directions where we believe the field is headed. One of these initiatives is to add coursework in data analytics, with the eventual likelihood of an entire track in this area. In the meantime, we are also developing plans for a clinical informatics fellowship that will complement our other fellowship programs. We are also pleased to be working with other programs developing clinical informatics fellowships, being able to provide coursework and related expertise to them.

Another opportunity for our department has been to become involved in the curriculum transformation process for OHSU medical students. OHSU was also one of 11 medical schools receiving grants from the American Medical Association to accelerate change in education. My role in the grant is to develop competencies and curricula for the data-driven future of medicine that will be forthcoming as care delivery models change. The new OHSU curriculum will also feature more informatics than it ever has before.

Finally, I had the opportunity to weigh in on the year in review for the California Health Care Foundation iHealthBeat year in review.

As for what lies ahead in 2014, I believe it will mainly be built on the foundation of new post-HITECH activities started in 2013. The clinical informatics subspecialty will be important, although I also hope we will see more progress in professional recognition and certification for the larger majority of non-physician (and even non-clinical) informatics professionals. There is a large and important role for all who work in informatics, not only those in clinical (healthcare) areas, but other areas of the field as well. This will be especially so, for example, as advances in clinical research informatics enable other areas, from translational bioinformatics to public health informatics, disseminate their progress into healthcare and individual health spheres. Although each subarea of informatics is distinct, I expect their work to increasingly overlap going forward. For example, as bioinformatics and genomics have more impact in health and healthcare, the underlying informatics will necessarily become more similar.

From a program standpoint, I am equally certain that initiatives such as the IDL will be drivers of our research directions. While government sources of research support will still be important and form the bedrock for advancing the science, it will be equally critical to collaborate with industry and other partners to disseminate the fruits of that research. Academia is unexcelled for making discoveries but industry is just as critical to making them available to a wide audience. The era of "home-grown" informatics systems is receding, with the need to build and study on top of commercial platforms in widespread use becoming more critical.

As for this blog, I plan to continue in the same manner as in the past, with postings only when I have something I believe is interesting to write about, and not serving as my stream of consciousness. I have nothing against the latter types of blogs, but my preferred approach (and time availability!) is the former. I hope to maintain the focus on the issues in informatics that are most core to me, but not hesitating to branch out when appropriate.

Sunday, December 22, 2013

A Student Who Helped My Educator Aspirations

I believe that one of things that separates a good educator from a great one is that the latter is unafraid to have students who (a) know more about some or many topics than they do, (b) do not hesitate to point out errors in the teacher's content, or (c) are not afraid to speak their minds, including when they disagree with the teacher. I aspire to be a great teacher, and the attributes of trying to be one were reinforced to me this past fall when Keith Boone, aka @motorcycleguy, became a student in my introductory informatics course (and our Master of Biomedical Informatics program at Oregon Health & Science University).

I had been following Keith's health information technology (HIT) standards blog for a number of years when I started to get to know him. I always enjoyed and found value for my teaching in his explanations of HIT standards and related areas. Keith is one of those people who has a wealth of experience, providing knowledge and even wisdom, but without (until now) formal training. He is an excellent writer, not only in his tweets and blog, but also his book on CDA (Clinical Document Architecture). When Keith decided to pursue a formal education in informatics, I was thrilled when he chose our program.

In addition to being a diligent and successful student, Keith blogged and tweeted his way through his first term of courses this past fall. Some of his posts described his decision-making around going back to school and finding tools that worked for him. Others represented his reactions to discussion I try to elicit in the virtual classroom (which are manifested in threaded discussion forums), in particular on payment for physician-patient online communications, consumer health-related access to the Internet, and payment issues around telehealth. I replied to all of his posts in the class and to some of them on his blog.

Naturally some of his postings revolved around his area of expertise, namely standards. I thoroughly enjoyed his posting on noting the difficulty of using Pubmed to find information on standards, which also raised some issues around the academia-industry dichotomy in the standards community. I also got a chuckle out of his tweeting of my mentioning a new standards activity that is generating a great deal of interest and enthusiasm, which is the Fast Healthcare Interoperability Resources (FHIR, pronounced "fire"). I have to admit I felt a little anxiety going into the module on standards with Keith. He was already among my sources for expertise for the lecture, and naturally I wanted to make sure I had everything right. I am pleased to report that he provided some excellent corrections and feedback, mostly on the finer details, and this will benefit future students in having more precise explanations about the nuances of standards. (I also feel a little relief that I did not get anything wrong in a major way!)

I also enjoyed Keith's mid-course comments on what he was getting out of being a student and his wrap-up posting reflecting back on his first term in the program. While I cannot report his grade in the course due to FERPA (Family Educational Rights and Privacy Act, the educational equivalent of HIPAA), I can note that he did extremely well!

One of the most satisfying aspects of my work as an educator is seeing those I have taught go on to achieve great things. While the education I contributed to is never the sole reason for their success, it usually does contribute. Keith has already achieved a tremendous amount in his career, but I am confident I will feel even greater satisfaction when he achieves even more due in part to the education he received in our program.

Thursday, December 19, 2013

The Informatics Lessons of Healthcare.Gov

The debacle of the Web site rollout will serve as a case study in curricula of business, political science, informatics, and other fields of study for years to come. It is unfortunate that the toxic politics of healthcare reform obscure other interesting lessons to be learned about large-scale IT initiatives applied to complex problems, such as trying to match individuals to health insurance plans available in their area and determining who is eligible for federal subsidies.

I count myself among those who have waited years for healthcare reform, seen an imperfect (but better than the status quo) plan signed into law, and then observed its rollout botched from both a technical as well as a communications standpoint. My views on the Affordable Care Act (ACA, aka Obamacare), not the focus of this post, are that it was the best that could be achieved politically at the time, and that it will hopefully be improved over time. The goal of providing healthcare to all Americans, including those who are not insurable by market-based mechanisms, is still a laudable goal. I am also dismayed by those who want to see the ACA fail at all costs, almost as if the fact that real people will be losing real healthcare coverage (or not having it in the first place) did not matter. I also agree with those who note we cannot attribute blame of everything bad happening about health insurance to the ACA, i.e., health insurance costs continue to rise for reasons unrelated the ACA and employers would likely continue scaling back health insurance benefits regardless of whether or not the ACA were repealed. Well, maybe I did want to get some commentary in about the ACA after all, but the bottom line is that the pre-ACA status quo was not sustainable.

Nonetheless, what can we learn from the rollout from an informatics standpoint? One problem is clear, which is the federal procurement process for IT, about which even President Obama joked. This is issue is addressed well in context in a blog posting by Dr. David Blumenthal, the former Director of the Office of the National Coordinator for Health IT (ONC) who was appointed shortly after the first election of President Obama. Dr. Blumenthal noted the major differences between a typical large-scale federal IT procurement and the selection of an electronic health record (EHR) system for the large and venerable Partners Health System, which is anchored by two of the large Harvard Medical School teaching hospitals.

For the federal IT procurement, the agency (in this case, ONC) provides the specification and then in essence turns the process over to a separate contracting office in the government. This is in contrast to the Partners EHR decision, which was reached by a process that involved leadership guided by diverse expertise within the organization. This sounds to me like an informatics approach, from gathering the needs of the organization and giving voice to different stakeholders within it, to then seeing the entire selection process through to making a decision. Whether or not we call it "informatics," implementing a large complex IT project "takes a village" within organizations.

Another insightful blog posting comes from Clay Shirky, a well-known Internet commentator. He noted how the planning and rollout process defied well-known best practices for undertaking large, complex IT projects. Political necessities cannot bypass the reality of the incremental requirements gathering, setting reasonable timelines, and testing. Part of the problem, of course, is that the ACA needed to roll from a political standpoint in October, 2013. Delaying longer would push implementation into the middle of the 2014 elections, which would make those elections potentially more unpredictable.

But political timelines aside, everyone with knowledge of complex IT projects knows that no amount of political or other wishful thinking can make a project happen faster than is possible. John Halamka, a well-known informatics blogger, rightly pointed out that few people remember a project launching somewhat late, whereas more people remember for a longer time when projects go poorly and caused disruption, as has. I myself have always believed that one of the major limitations of the HITECH program was its highly compressed timeline, mostly related to its being funded by a short-term federal economic stimulus. This was certainly true for many of the grant-funded activities under HITECH, such as the regional extension centers (RECs) and the workforce development program. The RECs, which were funded at about the same as the workforce development programs, needed trained personnel immediately. Yet the workforce development training programs needed some lead time to be developed, and even furthermore the curriculum for those programs should have had enough development time before those.

In conclusion, while not everyone uses the word "informatics" in their descriptions of what happened and what should have been properly done with, it is clear that the type of approach advocated by most who are trained in informatics would be more likely to achieve the outcome resembling the Partners EHR implementation than the debacle. This is not to say that projects led by informatics experts never fail. However, the involvement of stakeholders, glued together by informaticians who understand healthcare, IT, and their interactions, would likely have a probability of greater success. I acknowledge the previous sentence is not evidence-based, since one cannot carry out randomized controlled trials in these sorts of complex interventions. But there is plenty of accumulated knowledge and wisdom on the best practices that emanate when sound informatics principles are applied [1-4], and these should guide any type of complex health IT implementation.

I am sure there will be more lessons that emerge from the experience, and hopefully honest scholars will be able to peel back the toxic politics and truly allow learning to take place. I also hope we can achieve sensible answers in our quest to provide basic, high-quality, and affordable healthcare to everyone in the United States.


1. Barnett, GO (1979). The use of computers in clinical data management: the ten commandments. Society for Computer Medicine Newsletter. 4: 6-8.
2. Bates, DW, Kuperman, GJ, et al. (2003). Ten commandments for effective clinical decision support: making the practice of evidence-based medicine a reality. Journal of the American Medical Informatics Association. 10: 523-530.
3. McDonald, CJ, Overhage, JM, et al. (2004). Physicians, information technology, and health care systems: a journey, not a destination. Journal of the American Medical Informatics Association. 11: 121-124.
4. Sittig, DF and Singh, H (2012). Rights and responsibilities of users of electronic health records. Canadian Medical Association Journal. 184: 1479-1483.

Monday, December 9, 2013

Consider Giving a Gift to the OHSU Informatics Program

It is time for the annual giving drive of the Oregon Health& Science University (OHSU) Biomedical Informatics Program and I hope that those of you looking for good causes to support will consider giving a philanthropic gift to support the program. While our program is as strong and innovative as ever, philanthropic gifts enable us to accelerate and expand our research as well as provide support for our students.

This past year has been a transitional year for us, as we have completed our work funded by the Office of National Coordinator for Health IT (ONC) and moved on to new activities. While we have made this transition successfully, and continue to be known for innovation and leadership in the field, we still face challenges ahead.

Our ONC funding provided tuition support the enabled about 130 people to launch new careers in clinical informatics and health information management. We also wrapped up our work on the national health IT curriculum that will be a resource for years to come.  In addition, our bioinformatics and computational biology program continued to grow and thrive.

We have also been able to maintain some of the programs started by the ONC funding and roll them out to all the tracks of the program. One is our practicum and internship program that enables students to obtain real-world experience to augment their academic studies. (If you have possible practicum or internship experiences for our students, please let us know.) Another program we have maintained is our career development specialist, whose expertise has likewise been rolled out to all tracks of the program. Our major challenge for continuing these programs is finding sources of funding to keep them fully deployed.

As you may have read or seen, we have also undertaken new initiatives this year. The most visible of these efforts was the launching of our Informatics Discovery Lab (IDL). We aim for the IDL to address the important challenges that are facing healthcare and biomedical research and that require a combination of informatics innovation and commercial collaboration. The first fruit of the IDL is our new partnership with Epic Systems Corp. that will enable us to use the Epic electronic health record both in our teaching and in our research. We are in dialogue with a number of other industry partners to also participate in the IDL.

We have a number of other new initiatives underway. One is to address the need for informaticians of all backgrounds to acquire more skills in data analytics. We hope to fulfill this through developing new courses and other educational activities, and possibly a new track in the program. We are also recruiting for new junior faculty to keep the program fresh and vibrant. Finally, we plan this coming year to begin streaming our Thursday lunchtime research conferences live, which will augment the recorded videos that we have been posting after each event for several years. While we will not able to deliver the pizza we serve locally to remote sites, we do hope those participating remotely will be able to participate interactively via tweeting questions and comments.

The ability to carry out these activities will be augmented and accelerated with additional help that philanthropy can provide. I hope you will consider providing a gift that will allow us to reach our new goals more quickly and successfully. I give myself through a weekly deduction from my paycheck, and that is another option as well. Giving in any manner will help our students, faculty, and others associated with the program.

Saturday, December 7, 2013

I'm a Clinical Informatics Subspecialist!

I received notification this weekend that I passed the clinical informatics subspecialty certification exam, which means I can now proudly call myself a subspecialist in clinical informatics. I am delighted that the years of effort initially undertaken by the American Medical Informatics Association (AMIA) have culminated in this outcome.

What does this make me a specialist/expert in? I like the recent definition of the subspecialty by the Accreditation Council for Graduate Medical Education (ACGME): "Clinical informatics is the subspecialty of all medical specialties that transforms health care by analyzing, designing, implementing, and evaluating information and communication systems to improve patient care, enhance access to care, advance individual and population health outcomes, and strengthen the clinician-patient relationship."

I took the exam, administered by the American Board of Preventive Medicine (ABPM), in October. I was no doubt well-prepared by my prolific teaching of informatics, including being the Director of the AMIA Clinical Informatics Board Review Course. The exam covered the material of the core content outline of the field in a representative manner, even if the multiple-choice format somewhat limited the kinds of questions that could be asked.

I am also pleased to report that all OHSU faculty who sat for the clinical informatics subspecialty board exam passed it, which means that we have 6 clinical informatics sub specialists at OHSU. In addition to myself, this includes:
  • Eilis Boudreau, MD, PhD
  • Michael Chiang, MD, MA
  • Michael Lieberman, MD, MS
  • Vishnu Mohan, MD, MBI
  • Thomas Yackel, MD, MS
It is also interesting to browse the (small amount of) statistical data that ABPM provided in the letter announcing the exam results. If the minimum passing score is 450, then that would mean 91% of all who took the exam passed it. This means a total of 444 people passed the exam.

The work of building the specialty will now continue. We are doing our part at OHSU by continuing to develop our fellowship program we hope will be accredited by the ACGME when its rules are finalized next year. OHSU will likely offer continuing medical education (CME). And of course, OHSU will continue to be a leader in educating the rest of the informatics field as well in our graduate educational programs.