Eligibility for the Clinical Informatics Subspecialty: 2016 Update

Some of the most highly viewed posts in this blog have been those on eligibility for the clinical informatics subspecialty for physicians, the first in January, 2013 and an update in June, 2014. I recently led a Webinar hosted by the American Medical Informatics Association (AMIA) on the eligibility that I am using as a segue here to provide another update, which may be my last one before the "grandfathering" period ends.

One of the reasons for these posts has been to use them as a starting point for replying to those who email or otherwise contact me with questions about their own eligibility. After all these years, I still get such emails and inquiries. While the advice in the previous posts is largely still correct, we have had the ensuing experience of three years of the board exam, who qualified to sit for it, and what proportion of those taking the test passed. There are still (only) two boards that qualify physicians for the exam, the American Board of Preventive Medicine (ABPM) and the American Board of Pathology (ABP). ABP handles qualifications for those with Pathology as a primary specialty and ABPM handles those from all other primary specialties.

The official eligibility statement for the subspecialty is unchanged from the beginning of the grandfathering period and is documented in the same PDF file posted then from the ABPM (and summarized by the ABP). One must be a physician who has board certification in one of the primary 23 medical specialties. They must have an active and unrestricted medical license in one US state. For the first five years of the subspecialty (through 2017), the "practice pathway" or completing a "non-traditional fellowship" (i.e. one not accredited by the Accreditation Council for Graduate Medical Education, or ACGME) will allow physicians to "grandfather" the training requirements, i.e., take the exam without completing a formal fellowship accredited by the ACGME. But starting in 2018, the only pathway to board eligibility will be via an ACGME-accredited fellowship.

In the Webinar, I made some observations about who was deemed eligible for the exam, although as always, I must provide the disclaimer that ABPM and ABP are the ultimate arbiters of eligibility, and anyone who has questions should contact ABPM or ABP. I only interpret their rules.

We have now learned from the experience of having the exam offered over three years. As I noted in the Webinar, there are now 1107 physicians who have achieved certification in the subspecialty. The exam pass rate has been high but has declined each year, starting at 91% in 2013 and falling to 90% in 2014 and 80% in 2015. While we cannot be sure that the exam has not changed, the declining pass rate most likely reflects highly experienced individuals taking the exam initially and those with less experience taking it in subsequent years.

I (and a number of others) have been somewhat surprised at the high pass rate in all years, given the vast body of knowledge covered by the exam and the lack of formal training, especially "book" training, of many who took the exam. It is not uncommon for pass rates for those grandfathering training requirements into a new subspecialty to be much lower. We will have to see how the pass rate changes going forward, and it will be especially interesting when those completing ACGME-accredited fellowships start taking the exam.

One bit of advice I definitely give to any physician who meets the practice pathway qualifications (or can do so by 2017) is to sit for the exam before the end of grandfathering period. After that time, the only way to become certified in the subspecialty will be to complete a two-year, on-site, ACGME-accredited fellowship. While we were excited to be the third program nationally to launch a fellowship at OHSU, it will be a challenge for those who are mid-career, with jobs, family, and/or geographical roots, to up and move to become board-certified.

But starting in 2018, board certification for physicians not able to pursue fellowships will become much more difficult. There are many categories of individuals for whom getting certified in the subspecialty after the grandfathering period will be a challenge:

• Those who are mid-career - I have written in the past that the age range of OHSU online informatics students, including physicians, is spread almost evenly across all ages up to 65. Many physicians transition into informatics during the course of their careers, and not necessarily at the start.
• Those pursuing research training in informatics, such as an NLM fellowship or, in the case of some of our current students, in an MD/PhD program (and will not finish their residency until after the grandfathering period ends) - Why must these individuals also need to pursue an ACGME-accredited clinical fellowship to be eligible for the board exam?
• Those who already have had long medical training experiences, such as subspecialists with six or more years of training - Would such individuals want to do two additional years of informatics when, as I recently pointed out, it might be an ideal experience for them to overlay informatics and their subspecialty training?

Fortunately, one option for physicians who are not eligible for board exam will be the Advanced Health Informatics Certification being developed by AMIA. This certification will be available to all practitioners of informatics trained at the master's level and higher. It will also provide a pathway for physicians who are not eligible for the board certification pathway. I am looking forward to AMIA releasing its detailed plans for this certification, not only for these physicians but also other practitioners of informatics.

However, I also hold out hope for the ideal situation for physician-informaticians, which in my opinion will be our own specialty. The work of informatics carried out by physicians is unique and not really dependent on their initial clinical specialty (or lack of one at all). I still believe that robust training is required to be an informatician; I just don't believe it needs to be a two-year, in-residence experience. An online master's degree or something equivalent, with a good deal of experiential learning in real-world settings, should be an option. The lack of these sorts of options will keep many talented physicians from joining the field. Such training would also be consistent with the 21st century knowledge workforce that will involve many career transitions over one's working lifetime.