Saturday, November 15, 2014

Continued Concerns for Building Capacity for the Clinical Informatics Subspecialty - 2014 Update

The first couple years of the clinical informatics subspecialty have been a great success. Last year, about 450 physicians became board-certified after the first certification exam, with many aided by the American Medical Informatics Association (AMIA) Clinical Informatics Board Review Course (CIBRC) that I directed. This year, another cohort took the exam, with many helped by the CIBRC course again. In addition this year, the Accreditation Council for Graduate Medical Education (ACGME) released its initial accreditation guidelines, and four programs (including ours at Oregon Health & Science University [OHSU]) became accredited, with a number of other programs in the process of applying.

Despite these initial positive outcomes, I and others still have many concerns for how we will build appropriate capacity in the new subspecialty. In particular, many of us are concerned that the number of newly certified subspecialists will slow to a trickle after 2018, once the "grandfathering" pathway is no longer available and the only route to certification will be through a two-year, on-site, full-time clinical fellowship. Indeed, the singular bit of advice I give to any physician who is currently "practicing" clinical informatics is to do whatever they can to get certified prior to 2018. It will be much more difficult to become certified after that, since the only pathway will be an ACGME-accredited fellowship.

I previously raised concerns about these challenges in postings last year and the year before, and this one represents an update leading into the annual AMIA Symposium. Colleague Chris Longhurst, whose fellowship program was the first to achieve accreditation, has expressed similar concerns in interviews by CMIO Magazine and HISTalk.

Looking forward, I see four major problems for the subspecialty. I will address each of these and then (since I am a solutions-oriented person) propose what I believe would be a better approach to the subspecialty.

The subspecialty excludes many physicians who do not have a primary specialty

When the AMIA leadership starting development a proposal for professional recognition of physicians in clinical informatics around 2006, they were advised that creating a new primary specialty would be a lot more difficult to sell politically and instead to advised to propose a new subspecialty. This would be unique as a subspecialty of all medical specialties. I am sure that advice was correct, but we have unfortunately excluded those who never obtained a primary clinical specialty or whose specialty certification has lapsed. These individuals can still be highly capable informaticians, and in fact many are. The alternate AMIA Advanced Interprofessional Informatics Certification being developed may serve these physicians, but it would be much better as a profession to have all physicians under a single certification.

The clinical fellowship model will exclude from training the many physicians who gravitate into informatics well after their initial training

The majority of physicians who work in clinical informatics did not start their careers in the field. Many gravitated into the field long after they completed their initial medical training, took a job, and established geographic roots and families. The distance learning graduate programs offered by OHSU and other universities have been a boon to these individuals, as they can train in informatics while keeping their current jobs and not needing to uproot their families. Many of these individuals have great experience, and many passed the initial board exam. They are clearly capable.

After 2018, the "grandfathering" pathway will no longer be an option, and the only way to achieve board certification will be via a full-time two-year fellowship. It is interesting to note the recent advice I heard expressed by Dr. Robert Wah, President of the American Medical Association. He noted that many physicians have moved beyond direct clinical care to have an impact in medicine in other ways. But he advised that every physician should establish their clinical career first and then move on to other pursuits. This too is at odds with the clinical fellowship model that almost by necessity must come during one's primary medical training.

In a similar vein, a number of colleagues who are subspecialists in other fields of medicine express concern that a clinical informatics subspecialty fellowship would add an additional two years of training on to the already lengthy training required of most highly specialized physicians. As much as I am an advocate of formal informatics training, I also recognize, and would even encourage, such training being integrated with other clinical training, especially in subspecialties.

The clinical fellowship model also is not the most appropriate way to train clinical informaticians

Even for those who are able to complete clinical informatics fellowships, the classic clinical fellowship training model is problematic, as those of us applying to ACGME have learned. I likened this process a few months ago to fitting square pegs into round holes.

Clinical medicine is very well suited to episodic learning and hence rotations. A patient comes in, and their current presentation is a nice segue into learning about the diseases they have, the treatments they are being given, and the course of their disease(s). Even patients being followed longitudinally in a continuity clinic have episodes of care with the healthcare system that provide good learning.

But informatics is a different kind of topic. Informatics is not an activity that takes place in episodes. You can't really learn from episodic exposure to it. Good informatics projects, such as a clinical decision support implementation or a quality improvement initiative, take place over time. In fact, learning is compromised when you jump in and/or leave in the middle. Informatics projects are also carried out by teams of people with diverse skills with whom the informatician must work. I would assert that better learning takes place when the informatics trainee encounters specific informatics issues (standards, security, change management, etc.) in the context of long-term projects.

There are other concerns that have arisen about various aspects of the ACGME accreditation progress. One program was declined accreditation because a program director was not in the same primary specialty as the Residency Review Committee (RRC), despite the fact that clinical informatics is supposed to span all specialties. ACGME also requires any fellowship program, no matter how small, to have 2.0 FTE of combined director and faculty time. This may make sense in a clinical setting where faculty are simultaneously engaged in care of the same patient, but does not fit well when a trainee is working on single aspects of a larger project. Another ACGME requirement is for all faculty who teach to be named, and for those who are named to be board-certified clinical informaticians. This again does not make sense in the context of informatics being an activity with participants from many disciplines outside of medicine, some even outside of healthcare. Finally, ACGME requires fellows to be paid. This is easier to do when fellows are actively involved in the clinical operations of the hospital. Even if these trainees cannot bill, they do make it easier for attending physicians and hospitals to bill.

The funding model for fellowships creates challenges for their sustainability

A final challenge for clinical informatics fellowships is their funding and sustainability. Most subspecialty training in the US is funded by academic hospitals, and part of the "grand bargain" of such training is that clinical trainees provide inexpensive labor, which "extends" the ability of their teachers to provide care. The various clinical units have incentive to do this because it increases the ability of the units to provide and bill for services. Clinical informatics is different in that fellows will be unlikely to provide direct capacity benefit to academic clinical informatics departments. Our department at OHSU, for example, does not have operational clinical IT responsibilities.

Furthermore, these fellows will be doing their clinical practice in their primary specialties, and not their clinical informatics subspecialty. The primary specialties will include the full gamut of medical specialties such as internal medicine, radiology, pathology, and others. Even if fellows will be able to bill, it will be challenging within organizations for units to divide up the revenues.


In last year's post I proposed a solution addressing last year's description of these problems, and what follows is an updated version. There are approaches that could be rigorous enough to ensure an equally if not more robust educational and training experience than the proposed fellowship model. It would no doubt test the boundaries of a tradition-bound organization like ACGME but could also show innovation reflective (and indeed required) of modern medical training generally.

A first solution is to provide a pathway for any physician to become certified in clinical informatics, whether having a primary board certification or not. Informatics as a subspecialty of any medical specialty is a contortion. I do not buy that one cannot be a successful clinical informatician without having a primary board certification. I and likely everyone else in the field know of too many counter-examples to that.

Moving on to specifics of training, last year I noted that there should be three basic activities of clinical informatics subspecialty trainees:
  • Clinical informatics education to master the core knowledge of the field
  • Clinical informatics project work to gain skills and practical experience
  • Clinical practice to maintain their skills in their primary medical specialty
How can we insure that these three general areas are met without requiring a trainee to be in a fixed location or to train over a fixed period of time? The first activity area is easy. There is no question any more that essentially any learning experience can be delivered using online learning. There are many educational programs in informatics, including ours at OHSU, that have a strong track record in successfully imparting knowledge to students remotely.

Next, how would trainees get their practical hands-on project work? Again, many informatics programs, certainly ours, have developed mechanisms by which students can do internships or practicums in remote location through a combination of affiliation agreements, local mentoring, and remote supervision. While our program currently has students performing 3-6 months at a time of these, I see no reason why the practical experience could not be expanded to a year or longer. Strict guidelines for experience and both local and remote mentoring could be put in place to insure quality.

Lastly, what about clinical practice? As noted above, I disagree that this should even be a requirement. But if it were, requiring a trainee to perform a certain volume of clinical practice, while adhering to all appropriate requirements for licensure and maintenance of certification, should be more than adequate to insure practice in their primary specialty. Many informatics distance learning students are already maintaining their clinical practices to maintain their livelihood. Making clinical practice explicit, instead of as something requiring supervision, will also allow training to be more financially viable for the fellow. Any costs of tuition and practical work could easily be offset by clinical practice revenue.

There would need to be some sort of national infrastructure to set standards and monitor progress of clinical informatics trainees. There are any number of organizations that could perform this task, such as AMIA, and it could perhaps be a requirement of accreditation. Indeed, ACGME and the larger medical education community may learn from alternative approaches like this for training in other specialties. One major national concern these days is that number of residency positions for medical school graduates is not keeping up with the increases of medical school enrollment or, for that matter, the national need for physicians. It is possible that alternative approaches like this could expand the capacity of all medical specialties and subspecialties, and not just clinical informatics.

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