Toward Sustainable Funding for Clinical Informatics Fellowships

I have written before that one of the key challenges facing the new clinical informatics subspecialty is the funding of training fellowships. This is just one of the many "square pegs into round holes" problems of clinical informatics training not meshing with the traditional approach to clinical subspecialty fellowships.

The major problem is that most clinical subspecialty fellowship training in medicine is funded in part, even if only indirectly, by the service contributions that fellows make to the clinical unit in which they are training. A cardiology fellow, for example, is providing cardiology service to his or her department, which can either be billed or, if billed by the attending physician, allowing that attending physician to extend his or her capacity. This is in distinction to how most advanced education is funded, where a tuition model (either directly paid by the student or subsidized by someone else, such as a state government or training grant) pays the cost.

While a clinical informatics fellow will hopefully make contributions to the health system in which he or she is training, it is a bit of a stretch to believe they are providing monetary value for their service. At best, the health system is investing in these fellows because they are building informatics capacity in their organizations, which may translate into cost savings as value-based reimbursement models are undertaken (e.g., accountable care organizations).

If we are going to require physicians being trained in clinical informatics to do so via the traditional fellowship model, how are we going to pay the cost of their training? Some health systems might find value and foot the bill, as some already are. But it is not clear how sustainable this model is. If a health system comes on hard times financially and needs to cut costs, the clinical informatics fellowship might be an area that is reduced or eliminated.

Therefore a clinical informatics fellowship model must include a means for fellows to generate revenue for at least part of the their training. One obvious way to do this is allowing these fellows to practice in their primary medical specialty and bill (or otherwise be remunerated) for their work. Accreditation Council for Graduate Medical Education (ACGME) rules actually require clinical informatics fellows to maintain active practice in their primary specialty during their fellowship time (i.e., not moonlighting). Their work in clinical informatics will usually be distinct from their clinical practice, as clinical informatics work is likely to be applied to the entire health system and not just the fellow's primary specialty.

A problem with the fellowship trainee billing, however, is that it comes up against Center for Medical and Medicaid Services (CMS) rules that do not allow clinical trainees to "double dip." That is, most health systems with graduate medical education programs (i.e., residency and fellowship training) receive a subsidy from CMS Medicare funding to pay for physician training. Most health systems interpret this to not allow residents and clinical fellows to bill for their patient care work. But clinical informatics, like a number of other emerging subspecialties that emanate from multiple primary specialties, is truly different from the clinical practice component of the primary specialty.

To this end, I have recently collaborated with several of my colleagues leading clinical informatics fellowship programs to publish an open letter to CMS asking for guidance on clinical fellows being able to bill for their work so that clinical informatics fellowships can achieve financial sustainability [1]. We published this letter in the journal Applied Clinical Informatics and will be engaging with other medical subspecialties to achieve clarification from CMS on this issue. In addition, the leadership of the American Medical Informatics Association (AMIA) is working with other subspecialties in a similar situation to provide a larger picture of the problem, which we have learned is not unique to clinical informatics. The hope of clinical informatics fellowship leaders is that fellows will be allowed to function as attending physicians for their clinical practice in their primary specialty, and that this will allow a more sustainable funding model for clinical informatics fellowships.

References

1. Lehmann, CU, Longhurst, CA, et al. (2015). Clinical informatics fellowship programs: in search of a viable financial model - an open letter to the Centers for Medicare and Medicaid Services. Applied Clinical Informatics. 6: 267-270.

Accolades for the Informatics Professor: Leadership Award at HIMSS and Other Notables

Time for one of my periodic postings on accolades for the Informatics Professor. Probably the major one concerns next week's Healthcare Information Management Systems Society (HIMSS) conference, where I will be receiving the HIMSS Physician IT Leadership Award. I am honored to receive this award and to be among so many other special award winners. Others have also picked up on the award, including MedTech Boston and HITECH Answers.

The HIMSS Award is not my only recent accolade. I was quoted in a story in the Portland Business Journal about the role of our program in the IBM-Epic bid to replace the Department of Defense military electronic health record system.

I also gave a Future Talk at New Relic, Inc., a Portland-based software analytics company on March 9, 2015. Entitled, Big Data in Healthcare and Biomedicine: Opportunities and Challenges, the talk, with links to my slides and a video, was written up in their company blog.

HITECH and Meaningful Use at a Crossroads

It is hard to believe that the Health Information Technology for Economic and Clinical Health (HITECH) Act was passed into law five years ago, in 2009, and at the end of the year, the massive legislation was shaped into a program that has profoundly altered the informatics world, not to mention all of healthcare. Like most large undertakings, especially when infused with politics, the results have been mixed. Clearly the goals of EHR adoption have been substantial in hospitals and by physicians, even if the resulting systems have not achieved the ideals we held out for them. Perhaps as much depending on your political views as much as your informatics views, the glass is either partially empty or partially full.

On the positive side, a large proportion of US physicians [1] and nearly all US hospitals [2] now use an electronic health record. While many have argued that there should have been a much greater focus from the start on data interoperability, we are seeing progress with the rapid coalescence behind the FHIR, ReST, and OAuth2 standards in the Argonaut Project of HL7.

On the negative side, the systems we have implemented have been driven by meaningful use criteria. While no one would argue against these criteria generally (e.g., problem lists, electronic prescribing, etc.), many have argued that healthcare organizations have had to devote too much effort to meeting the criteria rather than innovating and leading with the beneficial aspects of technology. By the same token, the focus of vendors has had to be on certification to insure their customers can meet the meaningful use criteria with their products. On top of this is the toxic political environment in the US, with one's views' on HITECH and the Affordable Care Act being a sort of political Rorschach Test, making it even more difficult to have a meaningful conversation.

I tend to be glass-half-full kind of person, although I certainly acknowledge the limitations of the situation we are in now. It is easy to find critics of the current situation, but I tend to prefer to read and converse with those who present a balanced view that recognizes the problems in paper-based healthcare that led us to adopt the (still not achieved) promise of information technology (IT)-enabled healthcare. I give a special call-out to my colleagues Bob Wachter [3] and Jacob Reider [4] for their recent writings, and the former for his book that was just released [5], which I am enjoying but admittedly not done reading yet.

The real question is how we can get from here to where we want to be. This is especially so with the release of the Notice of Proposed Rule Making (NPRM) for Meaningful Use Stage 3 as well as the legislation to solve the Sustainable Growth Rate (SGR) problem (the "doc fix") of Medicare, which contains a proposal to roll the Meaningful Use Program into a more coalesced approach to incentives for quality in the Medicare Program.

My own view is that we should be focusing on data standards and interoperability, aiming to allow innovation to flourish on top of it. We also need to be open and critical of current failings, but also willing to move beyond negativity and linking the current situation to politics and/or greed. Not that both of these are not present, but that we need to come together as a community so those negative attributes are held in check by the greater community working toward more positive goals.

References

1. Charles, D, Gabriel, M, et al. (2014). Adoption of Electronic Health Record Systems among U.S. Non-federal Acute Care Hospitals: 2008-2013. Washington, DC, Department of Health and Human Services. http://www.healthit.gov/sites/default/files/oncdatabrief16.pdf.
2. Hsiao, CJ and Hing, E (2014). Use and Characteristics of Electronic Health Record Systems Among Office-based Physician Practices: United States, 2001–2013. Hyattsville, MD, National Center for Health Statistics, Centers for Disease Control and Prevention. http://www.cdc.gov/nchs/data/databriefs/db143.htm.
3. Wachter, B (2014). Meaningful Use. Born, 2009, Died, 2014? Wachter's World, November 13, 2014. http://community.the-hospitalist.org/2014/11/13/meaningful-use-born-2009-died-2014/.

4. Reider, J (2015). Spring Deliveries from Washington. The Health Care Blog, March 22, 2015. http://thehealthcareblog.com/blog/2015/03/22/spring-deliveries-from-washington/.

5. Wachter, R (2015). The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age. New York, NY, McGraw-Hill.