Tuesday, April 28, 2015

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.


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.

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